The CMS has finalized a proposed rule to exempt more small providers from complying with MACRA. It also reversed course on plans to give providers a pass on gauging whether they are cutting costs under the Merit-based Incentive Payment System, or MIPS.
Physician practices with less than $90,000 in Medicare revenue or fewer than 200 unique Medicare patients per year would be exempted under the rule finalized Tuesday
The move will exclude about 134,000 providers. The original threshold for exemption was $30,000 in Medicare revenue or fewer than 100 Medicare patients.
Providers must follow the new rule in 2018 and will see payments affected in 2020.
Officials with the CMS said they were responding to many practices' concerns that they didn't have enough Medicare patients to justify the cost of overhauling their electronic health record systems or buying new ones to track and report quality measures.
With the revised threshold, a total of 934,000 providers will be exempt from MACRA's Merit-based Incentive Payment System.
Between alternative payment models and small practice exemptions, only 39% of 1.5 million Medicare clinicians now billing under Medicare will be complying with MIPS, according to the CMS. But experts say the CMS isn't undermining value-based care.
Large practices still care for the bulk of Medicare beneficiaries, according to John Feore with healthcare consultant Avalere. The CMS reports that 65% of Medicare payments would still be reported under models that adhere to MACRA.
To avoid penalties under the law that replaced the much maligned sustainable growth rate, physicians must follow one of two payment tracks: MIPS or advanced alternative payment models like accountable care organizations.
The agency expects approximately 185,000 to 250,000 providers will be in an APM next year. That's up from between 70,000 to 120,000 in 2017. The CMS estimates that in 2020, providers could receive up to $1.5 billion in bonuses for improving quality under MIPS and APMs.
The rule also said that providers will need to prove they are saving money under the program.
Under MIPS, providers can be rewarded or penalized based on their performance, including evidence of quality improvement, cost reduction or maintaining current levels of spending; efficient use of electronic health records; and clinical improvement activities such as later office hours and greater use of care coordination
MACRA allowed the CMS to judge providers on cost in incremental improvements, with cost-cutting accounting for 30% of a provider's MIPS score by the third year of MACRA. The law allowed the CMS to waive the cost measure for two years, but by the third year it has to kick in at the 30% rate, creating a steep cliff .
In the proposed rule, the CMS said it was considering waiving
the policy for the second year in a row. Providers had worried there were not enough cost measures. On Thursday, the CMS announced cost-cutting will account for 10% of a provider's MIPS score in the second performance year. The agency said that will make more gradual the cost performance category in the third performance year.
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