MACRA Final Rule Highlights

Provided by Barbara K. Tomar, ACEP’s Federal Affairs Director

The Medicare Access and CHIP Reauthorization Act (MACRA) Final Regulation was released Oct. 14. This rule – now designated by CMS as the “Quality Payment Program”- describes requirements for physicians to participate in the Merit-based Incentive Payment System (MIPS) and/or the Advanced Alternative Payment Models (Advanced APMs). Both begin January 1, 2017.

Former ACEP President Dr. Mike Gerardi appointed an APM Task Force that is developing some models that we hope will be reviewed and approved by CMS over the next year. Work of the Task Force was overseen this past year by Immediate Past President Dr. Jay Kaplan and current ACEP President Dr. Becky Parker has pledged to continue to support Task Force efforts.

It’s important to note that since few emergency physician groups have ever participated in various CMS bundled payment models/ACOs, etc. in the past, we expect most of the members to participate in MIPS for the next year or so.

We were pleasantly surprised in our early review of the 2,200-page rule, that CMS responded to ACEP’s comments on the timing and scope of some of the new programs.

Merit-based Incentive Payment System (MIPS):

  • Reduces timeframe for reporting. Instead of reporting quality measures (much like PQRS) for a full calendar year starting in January, members can report for as little as 90 days of their choosing and avoid the 4% penalty in 2019. (Similar to PQRS, there will be a 2-year lag between data reporting imposition of bonus/penalty.)
  • Doctors can report MIPS as individuals or through their groups. However, physicians must elect one or the other for all MIPS categories.
  • Quality measures reporting reduced from 9 to 6. Either 6 measures or a specialty measure set can be selected, 1 of which must be an outcome measure; if no outcome measures are available, a high priority measure.
    • Reporting thresholds reduced from 90% of patients (or 80% for claims reporting) to 50% in 2017.
    • Encourages the use of QCDRs and electronic sources through preferential scoring.
    • Increases quality percent of composite performance score: 60 percent of the composite performance score will be based on the quality performance category in 2017, due to the (requested) reduction of the cost performance category weight to zero next year. CMS was going to weight ‘resource use’ at 10% – a nearly impossible measure for EM due to current cost attribution methodology.
    • CMS working on patient condition and patient relationship codes to improve future cost attribution. (ACEP’s recent comment letter to CMS noted that none of the patient relationship codes fit EM practice so we will continue to work with CMS to change this).
  • (Clinical) Improvement Activities reporting burden reduced. Highly-weighted activities (20 points) reduced from 3 to 2 and medium-weighted activities or some combination of both need to equal 40 points. (Use of QCDR is highly weighted).
    • Allows 90-day reporting, also.
  • Advancing Care Information (previously known as Meaningful Use) reporting reduced.
    • EM has been exempt from reporting on EHR measures and may continue to be in spite of the burden placed by the hospitals.
    • Also reduced to 90-day reporting for 2017-2018

Advanced Alternative Payment Models (APM):

  • Reduces amount of losses that APMs must bear. CMS used the term “more than nominal risk” in the draft and proposed that qualified APMs pay of to 4% of Medicare spending. The final rule is based on physician/APM revenue which would be at risk for 5% of revenue losses instead.
  • Expanded the definition to include practitioners other than physicians so that models can address quality and costs of non-physician services.

Physician-focused payment model Technical Advisory Committee (PTAC):

Note: This brief description of PTAC is included as background as no changes to its role were made in the final rule.

  • MACRA created the PTAC (of outside experts) to assist physician groups who are creating APMs, providing a first line review of proposals to determine whether such proposed models meet the criteria established by the Secretary of HHS for PFPMs and offering some technical assistance. Based on its findings, PTAC can make recommendations to CMS as to whether the model should be refined, further studied, tested or implemented, but CMS makes the final decision through its own application process.

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  1. #1 by R. B. Garelick - November 13th, 2016 at 22:21

    I greatly appreciate the information. I work 100% locums which has not yet been addressed in entirety by ACEP or ABEM and I recently received a letter that I did not comply with 2015-2016 reporting for “extra dollars” for the group’s I performed locums services. My charting is “impeccable” and I document efficiently whether with or without scribes as I often need to change their documentation, but appreciate their work product for efficiency sake in the world of “move the patients fast.”

    I am not sure why no bonuses for group I performed locums for and perhaps they did not report. Understand, I receive no benefit from this as hourly locums, but I am a strong advocate of effective ED management and patient care as past medical director and VP of a Democratic independent group.

    Can not tolerate wasteful ordering by protocol to meet a hospital or ED standard as when I arrive at patient bedside with triage orders, I often find most have NOTHING to do with patient chief complaint. Poorly documented. The study ordered in triage and no placement of c-collar in “I fell down” without proper neuro exam for C-Spine injury, so ED physician actually seeing and treating patient is having studies entered by someone who did not perform a PROPER triage assessment and is trying ot meet time goals, etc. We waste dollars. .

    So to my next point – ACEP needs to work on these “crazy” PIT doctor triage orders and demand some accountability for “useless studies” and ordering in defensible manner when PIT exam indicates no reason to order. PIT orders have wasted precious dollars. When I try to cancel – studies already completed. Perhaps we need a “guideline from ACEP” that when you “fall down and c/o neck pain or have risk factors – a c-collar is placed (some hospitals refuse cost and some EMS systems have stopped placing – can you imagine) in triage and if CT Cervical Spine ordered and no c-collar – then peer review.
    Or don’t order study.

    So we as ED docs are wasting money ad how do we change this perception. Are we trying to meet a CMS guideline dictated to us for CP that is not cardiac etiology, so to speak. I am not sure.
    In my opinion the sole purpose is to PUSH patients through and meet hospital guidelines and “times” as dictated by CMS.
    Where do we go from here. I often cancel studies after I see patient, chastised as locums for doing so and follow up on patient outcomes quite frequently (unlike most locums ABEM docs) and find NOTHING.

    Can we work on some protocols and practices at ACEP or guidelines as few exist for PIT and locums as well as expectations for those who have chosen to work 100% or PT locums?

    So many new grads coming out of residency, not knowing what they want and go FT locums. We SERIOUSLY need to address this at ACEP sooner than later and perhaps we need to study this in an organized manner so we can make an intelligent statement. Happening more than you realize. I work locums side by side with many new grads asking for guidance and assistance – perhaps a policy or recommendation of sorts. They have US skills I do not have based on my training and yet they cannot solve a simple problem. I often go and see their patients (upon request) like my previous teaching attending life and sit down and tell them my thoughts. They still order too much or too little. So let’s protect our “young one’s as best as we can even when we cannot dictate ther careers but can provide guidance.”

    I get frustrated by those who think, I am locums and move on as
    excellent patient care is their perception (wrong) and listening to the patient is so important which they do for less than 3 minutes. I watch and I pay attention. All patients can give you clues to their DX if you pay attention and LISTEN.

    So I am most certainly welcome to become involved to stop useless spending, guide our residents who graduate and work LOCUMS only and help to shape the PIT process and review articles and information as well as protocols we should be following when properly studied. We are a mess and our own worst enemies currently. I am not an academician but seriously concerned.

    So will wait to hear form anyone interested in my perception of completely wasted healthcare dollars in the ED and a[appropriate training and research that is far behind the times by ACEP.


  2. #2 by Samuel N. Mark - December 1st, 2016 at 06:54

    Excellent. I agree with this comment 100%

  3. #3 by Adrian A. Cordovi - January 6th, 2017 at 23:59

    Well stated. Most hospitals in my area have significant locum tenens providers.

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    I love this new Merit-based Incentive Payment System. Such an innovative, effective idea.

  34. #34 by Petey - April 1st, 2020 at 17:55

    Props to Dr. Mike Gerardi for getting this together.

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