10 things physicians need to know about MACRA in 2018

On November 2, the Centers for Medicare & Medicaid Services (CMS) released its final rule governing its Medicare Quality Payment Program in 2018.

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The program, enacted under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), will affect participating physicians’ payment in 2020. This means physicians have about two months to prepare for what they need to report when the calendar turns to 2018, especially in performance categories that require full calendar year data reporting.

The final rule did not deviate much from a proposed rule released in June. In a statement, CMS Administrator Seema Verma said during visits with U.S. clinicians, she and colleagues heard numerous concerns about the agency’s “burdensome regulations” and the effect on patient care.

“These rules move the agency in a new direction and begin to ease that burden by strengthening the patient-doctor relationship, empowering patients to realize the value of their care over volume of tests and encouraging innovation and competition within the American healthcare system,” Verma said.

Here are the top things physicians need to know about the 2018 rule for the Quality Payment Program:

Greater exemptions

CMS notes as a way to extend flexibility, physicians or groups eligible for participation in the Merit-based Incentive Payment System (MIPS) with $90,000 or less in Medicare Part B allowed charges or 200 or fewer Part B beneficiaries will not be required to participate in quality metric reporting. This is the same as the proposed rule released in June.

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This expands the current $30,000/100-patient threshold and is projected to exclude an additional 134,000 physicians participating in Medicare, raising the total to 926,000 clinicians nationwide who do not have to report data under the Quality Payment Program as of January 1, 2018. That's 40% of all eligable physicians.

Next: MIPS category percentages shift

MIPS category percentages shift

Beginning in 2018 the cost category-based on claims data-becomes 10% of eligible physicians’ final MIPS score. This represents a major change from the proposed rule, which kept it at 0% next year. CMS will calculate cost through Medicare Spending per Beneficiary (MSPB) and total per capita cost measures for 2018-carryovers from the Value Modifier program.

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The quality performance category shifts from 60% of a physician’s score this year to 50% in 2018. In 2019, quality drops to 30% of a clinician’s overall score. The advancing care information category (25%) and clinical improvement activities (15%) categories retain their percentages next year as well as the 90-day reporting period.

However, reporting for cost and quality categories will encompass the entire calendar year and CMS has noted that will continue in 2019 (affecting 2021 reimbursement). This will likely be opposed by physician groups because of the length of the reporting period.

New clinical improvement activities

In addition to changing 27 previously adopted clinical improvement activities, CMS is finalizing 21 new activities for 2018. These include achieving health equity via participation in clinical trials, research alliances or community-based research, providing education opportunities for new clinicians and sharing EHR systems between primary care and behavioral health practices.

MIPS performance threshold raised

The scoring system performance threshold increases to 15 points in 2018 to avoid a penalty, up from three points this year. This means eligible clinicians will need to report data to qualify for a minimum of those 15 points from the various MIPS categories to receive a neutral payment adjustment (neither a penalty nor a bonus). An additional performance threshold remains at 70 points for exceptional performance.

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For the current year, payments will be adjusted up or down 4%. This rises to +/- 5% on 2020 payments (based on 2018 data).

No rush to switch EHRs

Originally, CMS wanted Medicare-eligible physicians to use 2015 Certified Electronic Health Record (EHR) technology. Seen as a burden for practices, especially smaller ones, CMS will allow use of 2014 Edition EHRs and instead provide a bonus to practices who have 2015 Edition systems.

Recognition of complex patients

There has been a lot of discussion since the Quality Payment Program was unveiled regarding how complex patients could drag down quality metric reporting as physicians struggle for adherence and/or care improvement. In 2018, CMS will award five bonus points in the MIPS program for treatment of such patients. This is seen as a move to appease critics who urged CMS not to water down standards and maintain their uniformity, while acknowledging adherence struggles for some patients.

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Complex patients will be determined by a combination of Hierarchical Condition Categories and the number of dually eligible patients a practice treats.

Relief for practices and patients affected by hurricanes

On the heels of offering relief to citizens whose enrollment in Medicare Part A or Part B for the coming year is affected by recovering from recent natural disasters, CMS is also offering relief to physicians. Evaluated on a case-by-case basis via hardship application for providers in areas declared an emergency or major disaster by the Federal Emergency Management Agency, CMS will count only the cost category for MIPS-eligible physicians. This affects physicians in the areas impacted by hurricanes Irma, Harvey, Maria and other recent natural disasters for both the current reporting year as well as 2018.

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MIPS-eligible clinicians who are able to report data for 2017 will be rewarded for their performance, but those who cannot report due to the natural disaster will not face a penalty in 2019. In addition to releasing the final rule for 2018, CMS issued an interim final rule for 2017 to address “automatic extreme and uncontrollable circumstance policy” for this year in the wake of all the natural disasters.

Furthermore, if a MIPS-eligible clinician’s certified EHR is unavailable in 2018 due to “extreme and uncontrollable circumstances” (such as a hurricane, natural disaster or public health emergency), practices can submit a hardship exemption application by December 31, 2017, for consideration. If deemed a hardship, the clinician’s advancing care information performance category weight would be readjusted.

Bonus for small practices

Small practices will get five bonus points on their MIPS final scores. These practices are defined as having 15 or fewer eligible clinicians. The bonus is awarded as long as the eligible physician (or group) submits data for at least one performance category.

In addition, as it is doing this year, CMS will continue to award small practices three points for measures in the quality performance category that don’t meet data completeness requirements for an entire patient panel.

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CMS also announced it will allow MIPS-eligible physicians to continue to apply for hardship exemptions in the advancing care information performance category regarding their EHR systems. This can include insufficient internet connectivity and lack of control over availability of certified EHRs.

Creation of virtual groups

Initially unveiled in the 2018 proposed rule in June, CMS will permit creation of “virtual groups” for solo practitioners and groups of 10 or fewer eligible clinicians. These professionals can partner with at least one other group to report MIPS quality metrics, regardless of location or specialty.

CMS has developed a Virtual Groups toolkit to assist eligible physicians in understanding the ins and outs of this new structure.

Easier Alternative Payment Model (APM) participation

Seeking greater participation in APMs, CMS is loosening some requirements for participation in 2018. This includes exempting initial Comprehensive Primary Care Plus participants from the 50-clinician limit for organizations that can earn incentive payments via medical home models. CMS is also easing the requirement for medical home models to the minimum required amount of financial risk assumed by practices.

CMS anticipates between 185,000 and 250,000 clinicians will participate in APMs in 2018, up from 70,000 to 120,000 this year.