CMS gives more small practices a pass on MACRA

Story updated at 8:19 p.m. ET

The CMS wants to exempt more small providers from having to comply with MACRA.

Physician practices with less than $90,000 in Medicare revenue or fewer than 200 unique Medicare patients per year would be exempt under the new draft rule released Tuesday.

The move will exclude about 834,000 more clinicians from complying with the quality reporting program under the Medicare Access and CHIP Reauthorization Act of 2015. The original threshold was $30,000 or fewer than 100 Medicare patients.

"We've heard the concerns that too many quality programs, technology requirements and measures get between the doctor and the patient," CMS Administrator Seema Verma said in a statement about the rule. "That's why we're taking a hard look at reducing burdens."

Between alternative payment models and small practice exemptions, only 37% of 1.5 million Medicare clinicians now billing under Medicare will be complying with MIPS according to the CMS. Still, experts say the move should not be viewed as the CMS undermining value based care.

"This should not be taken a sign that physicians are going to go back to the fee for service way of doing business," said Christopher Stanley, director of the healthcare practice at consulting firm Navigant.

Large practices still care for the bulk of Medicare beneficiaries, according to John Feore, a director at healthcare consultant Avalere. The CMS in fact reports that 65% of Medicare payments would still be reported under methods that adhere to MACRA even if this draft rule were finalized.

To avoid penalties under the law that replaced the sustainable growth rate that was long considered flawed, physicians must follow one of two payment tracks: the Merit-based Incentive Payment System (MIPS), or advanced alternative payment models like accountable care organizations.

Small practices also can create "virtual groups" that would be evaluated under MIPS as one large entity. But so far, there's been little interest in that option.

Rebecca Altman, a managing partner with the consultant firm Berkeley Research sees the small practice exemptions as a way to ensure access for Medicare patients in underserved areas. She says providers in these areas warned her they would retire if they had to comply with all the MACRA requirements that could be costly and technologically burdensome.

Still, the CMS estimates that the number of clinicians participating in an APM will double next year, totalling anywhere from 180,000 to 245,000 clinicians. The CMS says that's because more doctors participate in ACOs and the Primary Care Plus Model.

Under MIPS, physician pay will be based on success in four performance categories: quality, resource use, clinical practice improvement and "advancing care information" through use of health information technology. The advancing care criteria is based on the government's meaningful-use program, which is used to decide whether doctors should be rewarded for using EHRs.

Provider groups were dismayed Tuesday that for the second year in a row the CMS would not be holding practices accountable if they reduced resource use under MIPS. Resource use compares what tools are used to treat similar care episodes and clinical condition groups across practices. The CMS is giving providers more time to get used to reporting under the quality system, despite some doctors saying they are ready and want the full bonuses they're eligible for.

The CMS estimates that providers could receive up to $1.4 billion in quality bonus payments under MIPS and APMs collectively in 2020 if the rule were finalized.

"If the CMS wants to transition to value-based payment for care, the program needs to be fully implemented," Chet Speed, AMGA's vice president, public policy said in a statement. "We recommend that the CMS revise its proposal to fully incentivize high performers in the Medicare program."

It's not just the Trump administration that's attempted to lessen the load of MACRA.

The Obama administration had also sought to ease compliance under MACRA. Last year, it introduced two "pick your pace" options for avoiding penalties for the first performance period that began Jan. 1, 2017. The first option allowed physicians to avoid penalties in 2019 as long as they submit some data to the program—but they will forgo any bonuses paid by the program for meeting certain quality measures. Physicians also could choose to submit data for part of the year and still qualify for a small positive payment adjustment.

Comments on the proposed rule are due Aug. 30.

An​ edited​ version​ of​ this​ story​ also​ appears​ in​ Modern​ Healthcare's​ print​ magazine​ published​ June​ 26.