On Friday, Oct. 14, 2016, the Centers for Medicare & Medicaid Services (CMS) published the Final Rule to implement the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which the agency is referring to as the Quality Payment Program (QPP). To get to a Final Rule, CMS solicited and reviewed over 4,000 public comments and had over 100,000 physicians and other stakeholders attend its outreach sessions, so they could listen to concerns and educate the community on the direction for the new program.
CMS intends for QPP to reward the delivery of high-quality patient care through two avenues: Advanced Alternative Payment Models (Advanced APMs) and the Merit-based Incentive Payment System (MIPS) for eligible clinicians or groups under the physician fee schedule (PFS).
The nearly 2,400-page regulation is complex, but included below are some initial thoughts on what’s in the rule.
CMS Is Attempting to be Flexible in QPP Implementation
The agency emphasized that it wanted to develop a program that is flexible, instead of one-size-fits-all, so clinicians could choose to participate in a way that is best for them, their practice, and their patients. For example, CMS presented the idea of 2017 as a “transition year” for QPP. Calendar year (CY) 2017 (January 1, through December 31, 2017) is confirmed as the first performance period, with CY 2019 as the corresponding first payment year, but CMS envisions that it will take a few years to reach a steady state in the program, and it anticipates a ramp-up process and gradual transition with less financial risk for clinicians in at least the first two years.
The focus of the program in its initial years is on encouraging participation and educating clinicians, all with the primary goal of placing the patient at the center of the healthcare system.
Details on “Pick Your Pace of Participation” for Clinicians
Eligible clinicians will have three flexible options to submit data to MIPS and a fourth option to join Advanced APMs in order to become qualifying APM Participants (QPs), which would ensure they do not receive a negative payment adjustment in 2019. The four options are
- Clinicians can choose to report to MIPS for a full 90-day period or, ideally, the full year, and maximize their chance to qualify for a positive adjustment.
- Clinicians can choose to report to MIPS for at least 90 days, but less than the full performance period, and report more than one quality measure, more than one improvement activity, or more than the required measures in the advancing care information performance category in order to avoid a negative MIPS payment adjustment and to possibly receive a positive MIPS payment adjustment.
- Clinicians can choose to report one measure in the quality performance category; one activity in the improvement activities performance category; or report the required measures of the advancing care information (ACI) performance category and avoid a negative MIPS payment adjustment.
- MIPS eligible clinicians can participate in Advanced APMs, and if they receive a sufficient portion of their Medicare payments or see a sufficient portion of their Medicare patients through the Advanced APM, they will qualify for a 5 percent bonus incentive payment in 2019.
It should be noted that MIPS eligible clinicians who are exceptional performers in MIPS, as shown by the practice information that they submit, are eligible for an additional positive adjustment for each year of the first six years of the program. There is an additional $500 million for exceptional performance payments to MIPS eligible clinicians whose performance meets or exceeds a certain final threshold score.
In addition, the Final Rule confirms that if MIPS eligible clinicians choose to not report even one measure or activity in 2017, they will receive the full negative 4 percent payment adjustment in 2019.
CY 2018 Is also a Transition Year
As the community moves toward a steady state of QPP implementation, CMS anticipates that the iterative learning and development period will last longer than the first performance period of the program (2017). The agency envisions CY 2018 to also be transitional year to provide a ramp-up of the program and of the performance thresholds. More details on the parameters of this second transition year will be accomplished through rule-making in 2017.
Advanced APM Determinations Not Yet Finalized
CMS is completing an initial set of Advanced APM determinations that will be released in the coming weeks, but before January 1, 2017. The agency anticipates that the following programs will qualify as Advanced APMs in 2017:
- Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO) Track 2;
- MSSP ACO Track 3; Next Generation (ACO) Model;
- Comprehensive Care Plus (CPC+); and
- Comprehensive End-Stage Renal Disease (ESRD) Care (CEC) Large Dialysis Organization (LDO) Two-Sided Risk Model.
In addition, CMS announced that it expected additional new Advanced APMs to become available for participation in 2017 and 2018. The agency is exploring including a Medicare ACO Track 1 Plus (1+) to begin in 2018. The model would be voluntary for ACOs currently participating in Track 1 of MSSP or ACOs seeking to participate in the Shared Savings Program for the first time. It would test a payment model that incorporates more limited downside risk than is currently present in Tracks 2 or 3 of the Shared Savings Program but sufficient financial risk in order to be an Advanced APM.
Final Rule Provides Additional Flexibility in Certified EHR Technology Surveillance Provisions
The Final Rule includes the requirement that providers—including eligible professionals (EPs), eligible hospitals (EHs), and critical access hospitals (CAHs) under the Medicare and Medicaid EHR Incentive Programs and eligible clinicians under the ACI performance category in MIPS—
must cooperate in good faith with requests relating to Office of the National Coordinator for Health IT (ONC) direct review of certified health IT. The rule emphasizes that ONC direct review is designed to mitigate potentially serious risk to public health and safety and to address practical challenges in reviewing certified health IT by ONC-Authorized Certification Bodies (ONC-ACBs).
However, the rule modifies the requirement to cooperate with a request relating to ONC-ACB surveillance, which is different from ONC direct review. The modification to the ONC-ACB surveillance provisions will allow providers to choose whether to participate in Supporting Providers with the Performance of Certified EHR technology (SPPC) activities supporting ONC-ACB surveillance of certified EHR technology.
The Rule finalizes a two-part attestation that splits the SPPC activities into two parts and draws a distinction between cooperation with ONC direct review and cooperation with ONC-ACB surveillance requests. As it relates to ONC direct review, the attestation is required. As it relates to ONC-ACB surveillance, the attestation is optional.
Final Rule Requires Attestations in Support of Health Information Exchange and the Prevention of Information Blocking
EPs, EHs, and CAHs under the Medicare and Medicaid EHR Incentive Programs and eligible clinicians under the ACI performance category in MIPS are required to attest that they acted in good faith to implement and use certified EHR technology in a manner that supports interoperability and the appropriate exchange of electronic health information. Attestations will cover EHR reporting periods and MIPS performance periods beginning on or after January 1, 2017.
The Final Rule does include the caveat that the focus of the attestations is to address knowing and willful actions to prevent the exchange or use of electronic health information. CMS and the Department of Health and Human Services (HHS) emphasize that this good faith standard takes into account health care providers’ individual circumstances and does not hold them accountable for consequences they cannot reasonably influence or control.
Help Is on the Way—Technical Assistance Coming for Small Practices and Other Clinicians
CMS is in the process of selecting contractors to implement a technical assistance program to educate clinicians on how to succeed with QPP. Congress provided funding ($20 million per year for five years) in MACRA for technical assistance to small practices, rural practices, and practices in medically underserved health professional shortage areas (HPSAs). The awards for contractors should be made in the coming weeks and allow small providers to become better prepared to implement MACRA in 2017.
In addition, for 2017, many small practices will be excluded from new QPP requirements due to the low-volume threshold, which was finalized at less than or equal to $30,000 in Medicare Part B-allowed charges or less than or equal to 100 Medicare patients.