Nearly a third of physicians could be exempt from Medicare's new Merit-based Incentive Payment System under a final CMS rule for implementing the Medicare Access and CHIP Reauthorization Act. The CMS will also broaden the opportunities for physicians to join alternative models that carry bigger rate increases and bonuses.
In April, the CMS released the proposed rule on MACRA, which replaced the old and flawed sustainable growth-rate formula for physician pay with a new method meant to shift physicians away from the fee-for-service model and onto a value-based payment system. To avoid penalties under MACRA, physicians will participate in one of two reimbursement tracks: the Merit-based Incentive Payment System, known as MIPS, or advanced alternative payment models.
In MIPS, physician pay will be based on four performance categories: quality, resource use, clinical practice improvement and “advancing care information,” which is based on the meaningful-use program that rewards doctors for using electronic health records.
Heeding calls for more flexibility, the CMS in the final rule said it will move away from the “all or nothing” approach previously used in EHR incentive programs. The rule reduces the total number of required measures under the “advancing care information” category to five from 11 in the proposed rule. All other measures will be optional for reporting but could earn physicians bonus points toward their overall score. Required measures include security risk analysis, e-prescribing, sending patients a summary of care and requesting and accepting a summary of care.
“It's a return to the original intent, which was that future stages and the final stage of the health IT incentive program be about outcomes,” said Dr. Farzad Mostashari, former national coordinator for health IT and now CEO of Aledade, which establishes and operates physician-led ACOs.
Small practices also were spared. The CMS will exempt practices with less than $30,000 in Medicare charges or fewer than 100 unique Medicare patients per year. The draft rule set the threshold at $10,000 a year, which the American Medical Association found would affect about 16% of all MIPS-eligible clinicians. The threshold in the final rule would exclude 30% of physicians, according to the AMA analysis.
The CMS noted that more than 93% of Medicare Part B charges would still be subject to the incentive framework. The agency will provide $100 million in technical assistance to clinicians participating in MIPS who are in small practices, rural areas and in areas with a shortage of health professionals.
The final regulations also answer requests for lower minimum reporting thresholds. The agency originally wanted providers to report quality measures on 90% of their patients from all payers, and 80% of Medicare patients. Small providers argued they would have a harder time obtaining the information technology and data needed to meet that requirement. The final rule drops the Medicare threshold to 50%.
The agency estimates that more than 125,000 clinicians will participate in advanced APMs for the 2018 performance year. The agency expanded opportunities to participate in APMs.
Acting CMS Administrator Andy Slavitt said the CMS plans to develop more APMs through the CMS Innovation Center. “Ultimately, we believe that we're not looking to transform the Medicare program in 2017, we're looking to make a long-term program successful,” he said.