Doc Groups Mostly Pleased with Proposed MACRA Rule would exempt more practices from MIPS program

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WASHINGTON -- Physician organizations are generally pleased with the proposed rule for implementing the Medicare Access and CHIP Reauthorization Act (MACRA) issued Tuesday by the Centers for Medicare & Medicaid Services (CMS).

For one thing, the proposed rule would result in fewer physicians being required to report their practice data under the Merit-Based Incentive Payment System (MIPS) program. Currently, physicians are excluded from MIPS if they bill $30,000 or less to the Medicare Part B program, or if they see 100 or fewer Part B beneficiaries during a specified period. The proposed rule would change those thresholds to $90,000 and 200 beneficiaries, respectively, beginning in January 2018.

Making that change would "exclude more physicians from small groups from the MIPS program if they have a low number of either patients or revenue coming through the Medicare program," said Anders Gilberg, senior vice president for government affairs at the Medical Group Management Association, a trade organization for group practices, in a phone interview. On page 55 of the proposed rule, CMS noted that the changes in the thresholds would exclude an additional 134,000 physicians from being required to fulfill the MIPS reporting requirements.

In addition, the proposed rule would allow physicians to use either 2014 or 2015 certified electronic health record technology (CEHRT) in 2018; current rules require physicians to transfer to the 2015 CEHRT version in 2018 if they're not using it already. To encourage more use of the 2015 version, those who use only the 2015 CEHRT starting in 2018 would receive a bonus under the proposed rule.

And the rule would delay by a year the inclusion of a practice's cost data in determining its MIPS score for purposes of paying penalties and bonuses. Currently, cost would comprise 10% of a practice's MIPS score beginning in 2020; the proposed rule would set that figure at 0% in 2020 and 10% in 2021, but CMS said in a fact sheet that the agency is "soliciting feedback on keeping the weight at 10%."

Other provisions in the proposed rule include:

• Adding "virtual groups" as a payment option beginning in 2018. Virtual groups would be defined as "solo practitioners and groups of 10 or fewer eligible clinicians who come together 'virtually' with at least one other such solo practitioner or group to participate in MIPS for a performance period of a year."
• Adding more quality improvement activities for physicians to choose from when reporting in this area.
• Expanding the definition of a certified patient-centered medical home to include the Comprehensive Primary Care Plus alternative payment model.
• Giving bonus points to small practices who submit data on at least one performance category in a specified period.

The proposed rule "will improve the ability of family physicians to participate successfully in payment reforms envisioned by the bipartisan Medicare Access and CHIP Reauthorization Act," said John Meigs, Jr., president of the American Academy of Family Physicians, in a statement. "We will be thoroughly analyzing the proposed regulations, but a brief review indicates progress on several fronts."

The American Medical Association (AMA) agreed. "In proposing [this rule], the Administration has taken another step to make sure the promise of MACRA -- where physicians are rewarded for improvement and for delivering high-quality, high-value care -- will be fulfilled," AMA president David Barbe, MD, said in a statement. "Patients and physicians will benefit from the new MACRA approach, as flexibility is vital when implementing a wide-ranging reform."

The American College of Physicians (ACP) also praised the proposed rule. In particular, "ACP is encouraged by the proposal to incorporate a Complex Patient Bonus through the use of Hierarchical Condition Category risk scoring methodology," ACP president Jack Ende, MD, said in a statement. "The use of this type of risk adjustment model encourages physicians to take on more complex beneficiaries while removing the concern that these sicker patients will negatively affect their overall performance score."

Although MGMA is generally happy with the proposed rule, there are several areas of concern, Gilberg said. First of all, "it's still an incredibly complex program in terms of the scoring and formulas involved."

In addition, "CMS increased the quality data reporting period from any 90 days in the performance year to the full year -- so [although] this year, the physician has the option to report a snapshot of data over any 90-day period, they increased it to a full year of reporting on quality," he said. That might not be so bad if CMS was giving physicians actionable data in return, "but they are still on that 18-month lag" where they don't release the data back to the physician until the following year.

"Overall, this is not going to be successful as a quality improvement program until CMS implements an actionable feedback loop for doctors that can provide them with data on their patients, and other information, on at least a quarterly basis throughout the year," said Gilberg. "So [that way, practices] could do things to improve quality through the year, as opposed to being [in] a retrospective quality reporting program."

Gilberg seemed hopeful that his group's concerns would be taken into account before the final rule is issued. "We do think CMS and HHS [the U.S. Department of Health and Human Services] will be open to our comments. [HHS Secretary Tom] Price, MD, is very open to making it work."

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