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Go Ahead: MACRA My Day

by Jackie Lichwell, RN, BSN, MSHMI , Senior Manager, Quality Performance

CMS’ final MACRA rule is here, landing on our desks with a 2,000 + page thud nearly two weeks ahead of schedule.  Unlike with the draft version, where reception was almost universally negative, reactions to the final rule have been largely positive. 

MACRA as now written will bring gradual, rather than sweeping, change to the way physicians are reimbursed under Medicare.  For once, those changes have been informed and guided by physicians. Officials spent much of the summer after releasing its proposed rule listening to and learning from clinicians, who asked for flexibility to pick their own pace. The final rule reflects a shared advocacy for letting doctors be doctors, and minimizing the heavy-handed bureaucracy that has plagued CMS programs to date.

The final rule also pulls back from the high bar set for performance in the spring but doesn’t eliminate it entirely. Many providers originally forecast to be penalized in the first year will, mercifully, be spared.  Providers must submit only a nominal amount of data in 2017 to avoid a penalty in 2019--regardless of how they perform.   If this reminds some of Meaningful Use or PQRS, they’re not alone.  By providing physicians with “pick their own pace” options and delays in negative payment adjustments, CMS is effectively delaying the MACRA program as Congress envisioned. 2017 will be a “transition year,” according to CMS, and many of the 2018 requirements will remain uncertain until the comment period closes.  This isn’t exactly the line in the sand many anticipated.

While some have raised questions about the future of the program in its watered-down state, CMS has doubled down on its commitment to reach full implementation in the coming years. It has also provided assurances that it will leave no providers behind, as long as they make the effort to participate. So while it will be easy for providers to avoid 2019 penalties, the bar for success remains.  

Eventually, everyone will be expected to shift to value-based care, and providers who want to succeed should start thinking about the future now.  

Here are five things providers need to know about MACRA, in 2017 and beyond:

One: Make Sense of the MACRA Word Salad 

The MACRA legislation establishes the Quality Payment Program, or “QPP,” which includes two tracks: Merit Based Incentive Payment System, or “MIPS,” and Advanced Alternative Payment models, or “AAPM.” Based on CMS’ estimates, ~600,000 providers will be eligible for MIPS in 2017, while only 70,000-120,000 will be eligible for AAPM.

MIPS combines existing quality programs—Meaningful Use, PQRS, and Value Modifier--with a new category, Improvement Activities, to form a single program with more complex scoring requirements. Physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups that include these clinicians qualify as “eligible clinicians” if they 1) Bill more than $30,000 in Medicare Part B, or 2) See more than 100 Medicare patients.  Providers must not be considered ‘new’ Medicare enrolled clinicians.  Eligible clinicians’ scores will determine whether they receive positive or negative adjustment to their Medicare Part B Fee Schedule in future payment years. Payment years lag two years behind performance; 2017 performance will be reflected in 2019, and so on. (Refresh yourself on athenahealth's MIPS Guarantee here.)

Eligible clinicians are considered to be part of an AAPM if the individual clinician or group has at least 25% of Medicare part B covered professional services through AAPM’s or if at least 20% of their total Medicare Part B patients are attributed to 1 of 6 eligible AAPMs. These clinicians are excluded from MIPS and receive a 5% bonus adjustment. Over time, CMS expects that more clinicians will be eligible for the AAPM track and will not need to meet MIPS requirements. This aligns with Health & Human Services’ payment reform goals to link 50% of Medicare payments to quality and value via APMs by 2018.

Two: Plan on Reporting MIPS in 2017

Given that the vast majority of clinicians will not be eligible for the AAPM track in 2017, it’s in most clinicians’ best interest to prepare for MIPS—at least as a short term plan.   Assess and establish a plan for whom in your practice needs to be educated, trained, and performance monitored for MIPS success.  As a practice leader, you also need to determine your organizational readiness to move into the AAPM track and qualify for the 5% bonus adjustments so you don’t have to expend resources on meeting the MIPS requirements in future years.

Three: Start Taking Action Now, and Avoid the Path of Least Resistance

Practices will ultimately do themselves a disservice by selecting the minimum ‘pick your pace’ option.  2017 may be a “transition year,” but we can safely assume that requirements will grow more strenuous in 2018 after the comment period for the Final Rule closes.  Much of the work practices accomplish in MIPS will help them succeed in an APM.  

Participate in MU and PQRS today (if you’re not already) to familiarize yourself with the requirements to perform in MIPS 2017. Completing a Security Risk Analysis can often be the most time intensive task to completing MU programs, so start that today!

Access your practice’s Quality Resource Use Report (QRUR). This is the only report available to practices regarding their practice’s cost data. Although the cost category will not be reflected in the performance score in 2017, driving down costs at your practice will become increasingly important as the category weight increases each year in MIPS and also for APM.

Four: Partner With a Vendor That’s Got a Stake in the Game

At athenahealth, we want our practices to be successful under any payment model because our revenue is at stake, just like yours.  We’ll ensure that we’re optimizing athenahealth practices for success so they can meet the minimum requirements and perform at a pace that enables them to gain the positive adjustments they deserve.

CMS has not yet defined many of the 2018 requirements for its final rule and is seeking comment in several areas, particularly in the implementation of virtual groups. You can bet athenahealth will continue working with CMS to ensure they hear our point of view around interoperability, data transparency and enabling vendors to assist practices with actionable insight.  We will take on work for providers wherever we can, leveraging the cloud and providing web-based performance and reporting capabilities, as well as submitting data on their behalf.  Proactive performance monitoring and coaching will ensure that practices are optimizing their performance across categories so they can receive full credit for their work.  These are just some of the ways we’ll help practices thrive through MACRA.

Five: Keep Interoperability in Mind

In the end, CMS had to water down its initial proposal, in part because our healthcare system still does not have the infrastructure—or health information backbone—necessary to support value-based care. The sad reality is that most doctors are using EHRs that aren’t designed for cross-continuum information exchange—an imperative for adequately managing quality and reducing cost.

As a result, for most vendors and their clients, the impact of MACRA will initially be small, restricted to a gutless interoperability standard easily achieved for recertification. Any vendor whose revenue model relies on the success of their clients, however, has a lot of work to do: learning the complexity of MACRA, and ensuring its services will satisfy MACRA’s measures now and in the future as requirements for information sharing grow, particularly in the Resource Use and Improvement Activities categories.  Perhaps better than any other aspect of the program, MACRA’s interoperability (dis)incentives illustrate the difference between what you get when you buy software, or join a network.

And now, for the good news: athenahealth has been working for years to create the information flow that is critical to longterm MACRA success, and there are glimmers of hope that the rest of our industry is catching up. Our strategy has always been to connect across the continuum because we believe that’s what will fix healthcare in the long term, not just satisfy the check-the-box requirements of government programs. Sadly, those check-the-box requirements will continue to live on for a few more years under the current iteration of MACRA. We’ll be ready when the industry decides to catch up, and our clients will be, too.

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