CMS Releases MACRA Proposed Rule

On Wednesday, April 27, the Centers for Medicare & Medicaid Services (CMS) published a proposed rule on implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The proposed rule provides details on the new Merit-Based Incentive Payment System (MIPS) for MIPS eligible clinicians by consolidating components of three existing programs: the Physician Quality Reporting System (PQRS); Physician Value-Based Payment Modifier (VM); and, the Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals (EPs) or groups under the physician fee schedule. The proposed rule also establishes incentives for participation in certain alternative payment models (APMs).

In the rule, the Department of Health and Human Services (HHS) and CMS identified three central priorities for MACRA:

  • Improved interoperability and the ability of physicians and patients to easily move and receive information from other physician’s systems
  • Increased flexibility in the Meaningful Use program
  • User-friendly technology designed around how a physician works and interacts with patients

The major provisions of the proposed rule include:

The Focus of MACRA is on the Medicare Clinician Community

It is important to note that many changes in the MACRA proposed rule focus on Medicare payments for the clinician community, and do not directly impact hospitals and Medicaid providers. However, there are provisions of the proposed rule discussed below that do focus more generally on the Meaningful Use (MU) Program, which would impact all MU eligible professionals, eligible hospitals, and critical access hospitals.

Under MIPS, the MU component has been proposed to change to “Advancing Care Information” (ACI), which is intended to signify support for the vision of simpler, more connected, less burdensome technology

CMS is attempting to usher in a new era in health IT with the introduction of the ACI performance category score under MIPS. The agency is proposing to move to a system that allows physicians and other clinicians to choose to select the measures that reflect how technology best suits their day-to-day practice. CMS is also proposing to simplify the process for achievement, provide multiple paths for success and align with the Office of the National Coordinator for Health Information Technology’s (ONC’s) 2015 Edition Health IT Certification Criteria. The rule also emphasizes interoperability, information exchange, security measures, and requires patients to have access to their health information through use of APIs. Moreover, the rule intends to simplify reporting by no longer requiring all-or-nothing EHR measurement or quality reporting, reduce the number of measures to 11 measures and no longer require reporting on the Clinical Decision Support and the Computerized Provider Order Entry measures.

The First MIPS Performance Period is Proposed to Start on January 1, 2017

CMS is proposing that the MIPS performance period would be the calendar year (January 1 through December 31) two years prior to the year in which the MIPS adjustment is applied. With the first MIPS payment year scheduled to begin in 2019, the proposed rule includes a January 1, 2017, start date.

In order to be a Qualifying APM Professional (QP) and avoid a MIPS adjustment, eligible clinicians need to meet certain MACRA criteria for Advanced APMs

This proposed rule is intended to expand the opportunities for participation in APMs, maximize participation in current and future Advanced APMs, create clear and attainable standards for incentives, promote the continued flexibility in the design of APMs, and support multi-payer initiatives across the health care market.

APMs that meet the criteria to be Advanced APMs provide the pathway through which eligible clinicians can become QPs and earn incentive payments for participation in APMs.

This rule proposes two types of Advanced APMs: Advanced APMs and Other Payer Advanced APMs. To be an Advanced APM, an APM must meet three requirements: require participants to use certified EHR technology; provide payment for covered professional services based on quality measures comparable to those used in the quality performance category of MIPS; and, be either an expanded Medical Home Model or bear more than a nominal amount of risk for monetary loses. The requirements for an Other Payer Advanced APM are virtually the same, but these APMs are intended to be a commercial or Medicaid APM. In addition, CMS is proposing to notify the public of which APMs will be Advanced APMs prior to each QP Performance period.

CMS is Adding the Surveillance of Certified Health EHR Technology to the Attestation Requirements Under MU, the ACI performance category score under MIPS, and reporting under the APM Track

CMS is proposing to require eligible professionals, eligible hospitals, and critical access hospitals to attest (as part of their demonstration of meaningful use under the Medicare and Medicaid EHR Incentive Programs) that they have cooperated with the surveillance of certified EHR technology under the ONC Health IT Certification Program. Moreover, CMS is proposing to require such an attestation from all eligible clinicians under the ACI performance category of MIPS, including eligible clinicians who report on the advancing care information performance category as well as participation in an APM for the MIPS calculation.

This proposed rule expects these efforts to strengthen surveillance and other oversight of certified health IT, including through expanded in-the-field surveillance and ONC direct review of technology and capabilities, will be critical to the success of HHS programs and initiatives that require the use of certified health IT to improve health care quality and the efficient delivery of care.

CMS is Also Requiring Providers to Attest to Facilitating Health Information Exchange and Not Blocking Information

CMS is proposing that MU eligible professionals, eligible hospitals, and critical access hospitals, and ACI as well as some APM participants demonstrate their adherence to model interoperability and exchange practices.

The three-part attestation consists of the following questions: the eligible provider did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology; eligible providers implemented technologies, standards, policies, practices, and agreements reasonably calculated to ensure, to the greatest extent practicable and permitted by law, that the certified EHR technology was, at all relevant times: connected in accordance with applicable law and implemented in a manner that allowed for timely access by patients to their electronic health information as well as other requirements; and, eligible providers responded in good faith and in a timely manner to requests to retrieve or exchange electronic health information, including from patients, health care providers and other persons, regardless of the requestor’s affiliation or technology vendor.

MIPS is Intended to be a Budget-Neutral Program

The rule discusses how under MACRA’s requirements, MIPS would distribute payment adjustments to between approximately 687,000 and 746,000 eligible clinicians in 2019. Payment adjustments would be based on MIPS eligible clinicians’ performance on specified measures and activities within the four performance categories. CMS’ initial estimate is that MIPS payment adjustments would be approximately equally distributed between negative adjustments ($833 million) and positive adjustments ($833 million) to MIPS eligible clinicians, to ensure budget neutrality.

MIPS would also distribute approximately $500 million in exceptional performance payments to MIPS eligible clinicians whose performance exceeds a specified threshold. These payment adjustments are expected to drive quality improvement in the provision of MIPS eligible clinicians’ care to Medicare beneficiaries and to all patients in the health care system. However, this distribution could change based on the final population of MIPS eligible clinicians for calendar year 2019 and the distribution of scores under the program.

In addition, CMS estimates that between approximately 30,658 and 90,000 eligible clinicians would become QPs through participation in Advanced APMs, and are estimated to receive between $146 million and $429 million in APM Incentive Payments for CY 2019. As with MIPS, CMS expects that APM participation would drive quality improvement for clinical care provided to Medicare beneficiaries and to all patients in the health care system.

Look for updated information from HIMSS in the coming days with more details on the MACRA proposed rule.