With the issuance of its final rule on the Medicare Access and CHIP Reauthorization Act (MACRA), the Centers for Medicare and Medicaid Services has created a new Medicare payment system called the Quality Payment Program (QPP).

CMS issued its final rule last week and our initial review shows Acting Administrator Andy Slavitt was true to his comments, first made in January, that CMS would be listening to physicians as development progressed. I would like to thank him for being a sincere partner during the process.

Through comment letters and conversations with CMS, the AMA recommended many changes that would create a more flexible transition to the updated Medicare program, and CMS has adopted a majority of those recommendations in its final rule.

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There is still work to be done to improve the QPP, but it appears that we are off to a strong start. CMS’ revisions will allow for a reasonably paced progression into the program so that physician practices can learn and adjust over time.

The key elements of the proposed rule that CMS changed based on our recommendations are:

The proposed rule stated that physicians would have to successfully report in all four Merit-based Incentive Payment System (MIPS) categories to avoid a negative payment adjustment. The AMA advocated for a transition year with lower reporting burdens. In the final rule, the only physicians who will experience a negative 4 percent penalty in 2019, the first year of the program, are those who choose to report no data.

Participating in one of four options under “Pick Your Pace” will help you avoid penalties. At the very least, if you choose to report for only one patient on just one quality measure, one improvement activity, or the four required Advancing Care Information (ACI) measures you will avoid a negative payment adjustment.

We recommended that CMS create a transition period to allow enough time for physicians to prepare for the QPP. The final rule establishes a 90-day reporting period, a significant change over the proposed rule’s full calendar-year requirement for most reporting. If you report for at least 90 continuous days in 2017, you will be eligible for a positive payment adjustment. This revision allows you to start later so that you will have more time to prepare your practice.

An increase in the low-volume threshold

Initially, the proposed rule set the threshold for exemption for QPP participation for physicians with less than $10,000 in Medicare payments and fewer than 100 Medicare patients per year.

The AMA recommended increasing the threshold to $30,000 or fewer than 100 Medicare patients and CMS opted for that baseline in the final rule, estimating the provision will exempt 32.5 percent of eligible clinicians from MIPS reporting.

One of the leading causes of our frustration as physicians is Medicare’s overwhelming reporting burden.

For example, under the ACI category that replaces the electronic health record (EHR) Meaningful Use program, the number of required reporting measures was cut from 11 in the proposed rule to four in 2017 and five thereafter.

Further flexibility for small, rural, health professional shortage area (HPSA) and non-patient facing physicians

In the proposed rule, physicians who do not have bedside interactions with patients and doctors practicing in small, rural and HPSA settings were required to report two activities under the Clinical Practice Improvement Activities (CPIA) category. We called on CMS to create flexibility for these practice types—and CMS listened.

The final rule allows these physicians to report on just two medium-weighted or one high-weighted activity to achieve full credit in the CPIA category.

A zero percent weight for resource use

One of the four categories of the MIPS is resource use. The final rule sets resource use at a zero percent weight toward your score in the first year. However, CMS will provide feedback on how you performed on those measures.

A reduction in reporting thresholds

In the first year of the program, 2017, you will only have to report successfully on a measure on 50 percent of patients, and 60 percent of patients in 2018. This threshold was set in the proposed rule at 90 percent for those who report electronically and 80 percent for those who report via claims.

These are only a few of the changes that CMS made in the final rule based on our recommendations. As a physician who will be undergoing this transition at the same time as you, I want to do whatever I can to make sure we are all prepared, educated and set up to succeed under this new program.

There will be further developments as other provisions of MACRA are implemented and we will continue to work with CMS to make sure the QPP is positioned to work for all physicians.

Over the next few months, it is critical that all of us educate ourselves and prepare our practices for the first year of the program in 2017. The AMA’s Understanding Medicare Reform collection of educational materials, resources and tools will be continually updated as we learn more.

The AMA will be hosting two webinars on the QPP: Nov. 21, 7 p.m. Eastern Time and Dec. 6, 8 p.m. Eastern Time. We will also hold regional meetings Dec. 1 in Atlanta and Dec. 10 in San Francisco. The regional meetings can be attended in person or online. More details on how you can register will be available soon.

This is a monumental change to the practice of medicine. The repeal of the flawed Sustainable Growth Rate (SGR) was the first step. Based on the changes we have seen in the final rule, we know that CMS is listening to physicians. The AMA is in a unique position to make recommendations and will continue to do so. If you have not joined us already, now is the time to get off the sidelines and help us make sure this historic Medicare payment transformation sets us all up to provide the high-quality care we know our patients deserve and that we know we can give them. 

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