Datashop Blog

MACRA 2018: The Final Rule and What it Brings You

Transforming from the deeply-rooted fee-for-service model and basically changing every bit of it is not an easy task. Gradually sloping up to value-based care, the Centers for Medicare and Medicaid Services (CMS) released its final rule for the 2018 Quality Payment Program (QPP) under the Medicare Access and CHIP Reauthorization Act (MACRA), on November 2.

Providing clinicians several flexibilities on reporting on quality measures with over 270 measures, the 1,653-page long rule also comes with an array of implications for the ways physician practices make use of health IT in 2018. After having some time to take in and comprehend the final rule, here are the most important takeaways from the rule:

1.) Pick your own pace:

CMS maintains the 2017 reporting flexibilities for another year to ease providers into MIPS reporting requirements. For quality and cost, providers must report for the entire day but for the other categories, a reporting of 90 days will suffice. Even 3 points to small practices will be provided if they happen to submit quality measures below data completion standards. However, as CMS plans to quadruple the reporting period to a full calendar year and bring up the level of data completion up to 60 percent, providers need to prioritize their efforts in 2018.

2.) Easing the transition to Value-based care with Cost:

Going along with gradual implementation, CMS concluded it best to keep 10 percent of the MIPS final score for MIPS Cost performance category. The final score would be composed of 50 percent quality, 25 percent for Advancing Care Information and 15 percent for clinical improvement activities. The Costs will be assessed based on the total spending for beneficiaries and specific episodes of care will determine the feedback.

3.) The final QPP rule increases the low-volume threshold of participation:

In 2017, CMS exempted providers who billed Medicare less than or equal to $30,000 a year or had less than or equal to 100 Medicare part B patients a year. This year, considering the difficulties small practices had while participating in MIPS, CMS brought up the threshold to $90,000 Medicare Part B revenue or less than 200 patients a year- hence reducing the number of eligible providers to 622,000 for 2018.

4.) Hardship exceptions to practices:

Aimed primarily at the small practices and groups that deal with a significant share of complex patients, CMS also plans to award some bonus points and included an interim final rule allowing for a hardship exemption. The hardship exemption is aimed at small practices affected by extreme and uncontrollable circumstances like hurricanes Harvey, Irma, and Maria. The rule also provisions automatically keeping the Quality, Advancing Care Information, and Improvement Activities at 0 percent of the final score for such practices impacted.

5.) Avenues for bonuses:

One of the biggest provisions CMS has made is allowing the use of 2014 Edition and/or 2015 Certified EHR Technology in Year 2 of QPP. Although, CMS will be awarding a 10 point bonus to the practices that make the leap to 2015 CEHRT. Also, CMS will award bonus points to small practices with 15 clinicians or fewer and can earn 5 points in addition to their MIPS final score if they submitted data on at least one performance category. Additionally, if the patients are deemed complex, based on a combination of the HCC risk scores and the number of dually eligible patients treated, CMS will award the providers a maximum of five bonus points.

6.) CMS goes ‘virtual’:

CMS went ahead and created ‘virtual groups’ to bring in more individual practitioners and small practices. These groups can include individual practitioners and small practices with 10 or fewer clinicians with no specialty or location limitations. If any provider in a practice with a TIN participates in a virtual group, all the providers of that practice will be attributed in that virtual group.

7.) Advancing with Advanced Payment Models:

To enhance the number of Qualified Practitioners to participate in Advanced APMs, CMS extended its criterion of 8 percent generally applicable revenue-based nominal amount standard for two more years, until 2020. This threshold is applicable to advanced APMs, except the Medical Home Model where the cutoff is 2.5 percent of all Medicare revenue in 2018.

8.) All Payer Combination Option

Starting in 2019, providers can participate in Advanced APMs managed by payers other than Medicare. Known as the “All Payer Combination Option,” these alternatives would require more than nominal financial risk, comparable quality measures as MIPS and utilization of certified electronic health records.

All these changes are expected to bring CMS an equal distribution of $118 million in positive and $118 million in negative, along with the $500 million available additionally under “exceptional performance.” The final QPP rule provisions may start off slow and gradual, but it will help providers get off on the right foot with value-based care. The lower thresholds and the abundance of measures will definitely help clinicians understand and succeed under MIPS and work towards delivering value-based care: the ultimate goal.

To know more about our work with MIPS and APMs and how we could assist you in traversing through the Quality Payment Program, get a demo.

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Abhinav Shashank

Abhinav Shashank

Chief Executive Officer & Co-Founder - Innovaccer.

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