Medicare & Medicaid

Jump-start the new year with MACRA: Looking ahead to 2018

David O. Barbe, MD, MHA , Former President

This time of the year is one for both reflection and anticipation. As our profession looks back on the issuance of the first Quality Payment Program (QPP) final rule a year ago and celebrates our collective progress toward adoption of the Medicare Access and CHIP Reauthorization Act (MACRA), so too must we look ahead to the program’s future.

The Centers for Medicare and Medicaid Services (CMS) issued the 2018 QPP final rule in November, and the American Medical Association (AMA) has been working to digest the full impact of the 1,600-page bill and arm physicians with resources to successfully navigate the program next year.

The AMA worked diligently and collaboratively to help shape a number of the policies, including those offering more flexible Advancing Care Information (ACI) measures that benefit physicians in small practices. We estimate more than 97 percent of eligible clinicians will avoid a penalty in 2020 based on their QPP participation in 2018. The policies in the rule recognize year two as a timeframe for further preparation and learning in advance of a more robust program in 2019.

The AMA’s QPP final rule highlights are available online, and I’m pleased to offer just a few below to help inform your MACRA participation in 2018:

  • Adds up to five bonus points to the final Merit-based Incentive Payment System (MIPS) score for clinicians who treat complex patients.
  • Begins measuring improvement in the Quality and Cost performance categories in 2018.
  • Under ACI, allows the continued use of 2014 edition Certified Electronic Health Record Technology (CEHRT) and finalizes exclusions for electronic prescribing and health information exchange measures.
  • Under the Quality category, adds no additional cross-cutting measure requirements in 2018 and maintains the number of Quality measures a physician must report for full participation in the category.
  • Under Improvement Activities (IAs), allows physicians to report through simple attestation, broadens existing IAs and develops new IAs (including activities related to diabetes prevention programs and the use of digital health tools) and increases the number of IAs eligible for the ACI bonus.

A number of policies related to Alternative Payment Models (APMs) are very positive. These include allowing the revenue standard for more than nominal financial risk to remain at 8 percent of revenues for an additional two years. CMS has requested information to assist in increasing opportunities for APM participation, and the AMA is looking forward to providing input.

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Finish your 2017 QPP checklist before ringing in the new year

Small practices have much to look forward to in 2018, including a policy that significantly expands the low-volume threshold to $90,000 or less in Medicare Part B allowed charges or 200 or fewer Medicare Part B patients. Previously the threshold was $30,000 in allowed charges or 100 patients. Further, the new rule adds five bonus points to the final MIPS scores for practices of 15 or fewer clinicians.

As expected, physicians belonging to practices with 10 or fewer employees may create virtual groups beginning in 2018. The CMS offers a virtual group (ZIP download) toolkit, including a fact sheet that further summarizes the related policies finalized in the 2018 QPP final rule.

CMS reversed a few positive proposals that were included in its 2018 proposed rule and that AMA had supported, many related to the Cost category. CMS replaced their initial proposal to weight Cost at zero in the 2018 performance/2020 payment year with a 10 percent weight. As a result, the Quality performance category weight will fall from 60 to 50 percent. The Cost category weight will rise to 30 percent in 2019/2021. Cost scores will be based on two AMA-opposed carry-over measures from the value-based payment modifier—total per patient cost and total spending around a hospital admission.

However, 10 previously-finalized episode-based cost measures will be replaced in the future with measures developed with more input from clinical experts and stakeholders. The AMA will continue to advocate alongside our partners to limit the weight of the Cost category and to represent the interests of our profession going forward.

I look forward to the AMA’s continued development of resources around the QPP final rule and more broadly related to MACRA participation in 2018 and beyond. Visit the AMA’s MACRA Page to learn more about the organization’s involvement in Medicare payment reform policy and for viewpoints on the various components of MACRA.

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