Small practices get relief in final MACRA rule

Fewer doctors will need to report quality data to the government next year, and the requirements for those who do report will be more flexible under the final version of the rule implementing Medicare payment reform.

The final rule for the Medicare Access and CHIP Reauthorization Act (MACRA), which was announced today, exempts from reporting requirements for 2017 practices with $30,000 or less in Medicare Part B charges or 100 Medicare patients or fewer, or who will be in their first year of Medicare participation. The earlier version of the rule set the exemption threshold for Medicare charges at $10,000 or less and 100 or fewer patients.

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MACRA provides medical practices two tracks-which the government refers to collectively as the Quality Payment Program-for Medicare reimbursements beginning next year: either as part of an alternative payment model, such as an accountable care organization or shared savings program, or through the Merit-based Incentive Payment System (MIPS), a fee-for-service model that rewards or penalizes a practice depending on its performance on a range of quality and outcome metrics. Practices choosing the APM track will get a bonus in 2019 equal to 5% of their Medicare reimbursements and are exempt from MIPS reporting requirements.

Practices will report data next year and begin receiving financial bonuses or penalties based on that data in 2019. 

Most small practices are expected to choose the MIPS track, and the final rule allows for more choices in how they report their data in 2017. They can either submit a minimum amount of information, such as an individual quality performance measure or clinical improvement activity; data covering 90 days or more and more than one quality measure or improvement activity; or a full year of data. The final rule also reduces by about half the number of required reporting measures.

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Using any of the three reporting options will enable practices to avoid a penalty in 2019 and may earn a bonus. Practices that don’t participate at all will see a 4% hit to their Medicare reimbursements.

Next: Making MACRA transition as simple as possible

In announcing the final rule Andy Slavitt, acting administrator for the Centers for Medicare & Medicaid Services (CMS), said the agency received more than 4,000 comments during the rule’s development process. The comments could be summarized, he said, as “make the transition to MACRA as simple and as flexible as possible.” As part of its response, he said, CMS has launched a new website-qpp.cms.gov-to be a “one-stop shop” for helping physicians understand and participate in the quality payment program.

Slavitt noted that the final rule includes $100 million over five years to help practices with 15 or fewer providers or in underserved areas learn about MACRA and report their data. He added that CMS will continue to take comments on the rule, “so that we can make sure the program evolves as the healthcare system evolves."

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In another potentially significant change from the earlier version of the MACRA rule, CMS says it is mulling development of a new alternative payment model for launch in 2018. The new model, called ACO Track 1+, would entail less risk than the alternative models that currently qualify for the quality payment program.

CMS predicts that the increased flexibility in reporting options of the final rule as compared with the earlier version, along with other policy changes will lead to small practices participating in the quality payment program at rates close to those of larger practices-a significant change from its earlier estimates.

In addition, the agency is forecasting that about 90% of MIPS-eligible providers, and 80% of those in solo or small practices, will either see no change in their Medicare reimbursements or receive a bonus. 

Next: Industry reacts

Medical societies generally greeted announcement of the final rule with cautious optimism. Nitin Damle, MD, president of the American College of Physicians, said in a written statement that the college “will review the rule in greater detail, but expects to be asking for improvements in several areas.  In particular, we would like to see CMS provide multiple pathways for medical homes, beyond CPC+ within the advanced APM pathway.”

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 John Meigs Jr., MD, president of the American Academy of Family Physicians said in a written statement the academy is pleased with the low-volume exclusions, the funds targeted to training for clinicians in small practices, and the ability of practices to choose their own reporting timeline during 2017. The latter, “will be of particular value to small and solo medical practices,” Meigs said.

Boyd Buser, DO, president of the American Osteopathic Association, said in a statement that the final rule gives its members “the certainty needed to plan their approach to the new payment system and the rule addresses many of our physicians’ concerns with the transition.”

Buser added, however, that the AOA is disappointed that the patient-centered medical home model does not qualify as an APM under the rule.