On April 27, 2016, the Department of Health and Human Services issued a Notice of Proposed Rulemaking (NPRM) to implement key provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), bipartisan legislation that replaced the flawed Sustainable Growth Rate formula for clinician payment from Medicare with a new approach to pay clinicians for the value and quality of their care.

The proposed rule would implement these changes through a unified framework called the “Quality Payment Program.” It includes two paths:
  • The Merit-based Incentive Payment System (MIPS) or 
  • Advanced Alternative Payment Models (APMs) 
Physician practices are to begin to report MIPS or to qualify for payment under APMs by Jan.1, 2017. Data reported in 2017 will inform a payment adjustment; either a bonus, penalty or zero incentive payment are awarded in 2019. See the timeline for the types of incentives and the reporting years in which they will be effective. 
 
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Under the MIPS payment system, physicians are required to report measures under 4 performance categories, each of which is assigned a certain number of earned points that can be earned to determine to composite performance score determining the adjustment. CMS also will provide each physician or group with a weighted score. The four categories are:

  • Quality Measures (50 points) – Six measures are required and less in specific areas with partial credit for small and rural practices.
  • Advancing Care Information (ACI) (25 points) – Formerly known as meaningful use. CMS wants practices to report on the use of electronic health records.
  • Clinical Practice Improvement Activities (CPIA) (15 points) – Awards for improvement of practice activities that improve care. There is a list of 90 activities. Radiology may qualify to report about 15 percent of them.
  • Cost (10 points) – This is not a category where measures are reported on the claim. Rather, CMS applies its own claims data which is linked to how many patients can be attributed to the physician or group.
CMS acknowledges that many specialties may not qualify to report data for some of these categories. In such cases, CMS proposed giving those categories zero points and heavier weight in the categories where physicians/groups can participate.

Alternatively, physicians or groups may qualify to gain a 5 percent bonus for participating in alternative payment models. CMS redefines APMs as Advanced Alternative Payment Models and proposes that they include the following existing models as of Jan. 1, 2017:
  1. Medicare Shared Savings Program – Tier 2 and 3
  2. Comprehensive Primary Care Plus
  3. The Next Generation Accountable Care Organization Model
  4. Comprehensive End Stage Renal Disease Care Model 
  5. The Oncology Care Model (two-sided risk arrangement)
Any physician or group that can attribute 25 percent of their Medicare payments to income from participation in a qualified Advanced APM will automatically qualify for a 5 percent bonus. This percentage of payments increases to 50 percent and then to 75 percent in future years.

On May 13, CMS issued a Flexibilities and Support for Small Practices fact sheet in response to many stakeholders’ concerns about the proposed rule that shows that 87 percent of solo practitioners and 69.9 percent of small groups (2-9 doctors) will see penalties under MIPS. This is in comparison to the projected 49.2 percent penalty and 50.4 percent positive scores for larger practices.

CMS acknowledges that the NPRM will have a negative impact on small practices, but it believes that the impacts based on 2014 data are artificially inflated. CMS’ rationale for this misperception is that it is based on 2014 data, which does not take into consideration special accommodations for small and rural practices in the rule. CMS also notes that few small practices were reporting measures in 2014. When these aspects of the data are taken into account, CMS predicts that actual impacts in 2019 will be much smaller.

In the proposed rule, CMS makes special accommodations for small and rural practices by:
  • Excluding practices from MIPS that generate a low volume of care from Medicare patients and bill less than $10,000 worth of claims annually.
  • Acknowledging the unique needs and challenges of being in compliance with the use of electronic health records (formerly known as meaningful use). CMS is promoting the use of technology that is meaningful and easy to use.
  • Allowing for flexibility in MIPS scoring so that fewer measures are required and partial credit is given to small and rural practice to qualify for bonuses in the quality measure and clinical practice and improvement categories.
  • Allowing for group reporting where the reporting of the group covers all individual physicians in the practice regardless of their level of individual participation or possible participation in a multispecialty virtual group.
  • Promoting the use of a single reporting mechanism, such as registries.
MACRA allows for $100 million over five years for technical assistance via organizations, such as Quality Improvement Organizations and Regional Extension Centers, to MIPS-eligible clinicians in practices with 15 or fewer clinicians to help small and rural practices receive education and training on how to qualify in the new payment programs.

CMS also developed the Transforming Clinical Practice Initiative and has awarded $685 million to 39 national and regional health care networks and supporting organizations to provide technical assistance to help equip more than an estimated 140,000 clinicians with tools and support. The ACR’s R-SCAN project was one of the 10 support and alignment networks that was awarded funding to help physicians transition into new clinical practice.

The ACR will comment extensively on the MACRA proposed rule and its effects on small and rural practice. Comments are due on June 27, 2016.