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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  4. #4 by Chiropractor North York - June 23rd, 2020 at 08:25

    Good to know we are shining a light and putting rules in place for Merit-based Incentive Payment Systems. hopefully more emergency physician groups will participate in the near future.

  5. #5 by Appliances - July 7th, 2020 at 17:11

    It’s important that clear guidelines and rules are established for both Merit-based Incentive Payment Systems as well as the Advanced Alternative Payment Model.

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    I just hope that the MIPS will be implemented as stipulated here.

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