Final MACRA Rule Released by CMS

Following ASCRS Advocacy CMS Provides Flexible Performance Period, Reduces Quality Reporting Threshold to 50%, Reduces Resource Use Category Weight to 0% for First Year, and Eases Requirements for Advancing Care Information

Earlier today, the Centers for Medicare and Medicaid Services (CMS) released the Quality Payment Program Final Rule, which implements the Merit-Based Incentive Payment System (MIPS) and Advanced APMs. The provisions of this final rule with comment period are effective January 1, 2017. There is a 60 day comment period for this proposed rule. ASCRS will be submitting comments. Following advocacy from ASCRS and the medical community, CMS has made major changes from its original proposed rule. The new policies include: a flexible performance period for the first transition year (2017); reducing the Resource Use, or cost, category weight to 0% for the first year payment determination in 2019, and reducing the quality reporting thresholds to 50% of eligible patients. Full details on the program are below.

CMS also released several new resources on the Quality Payment Program, including an executive summary of the rule, a new website, and a fact sheet.

Performance Period Timing

As CMS had previously announced, the final rule includes several different options for providers to choose their participation level and time period for the first performance year of 2017. Specifically, CMS has finalized that, in 2017, providers may choose one of the following options:

  • Choose to report to MIPS for a period of time less than the full year performance period of 2017, but for a full 90-day period at a minimum, and report more than one quality measure, more than one clinical practice improvement activity, or more than the required measures in the Advancing Care Information performance category to avoid the MIPS payment adjustment and to possibly receive a positive MIPS payment adjustment.
  • Choose to report one measure in the Quality performance category; report one activity in the Clinical Practice Improvement Activity category; or report the required measures of the Advancing Care Information performance category and avoid a negative MIPS payment adjustment.
  • If a MIPS-eligible clinician does not report even one measure or activity in 2017, he or she will receive the full negative 4% payment adjustment in 2019.
  • MIPS eligible clinicians who participate, and meet the required revenue or patient thresholds, in Advanced APMs will receive a 5% bonus.

MIPS Categories

Quality - 60% of MIPS Score

Reporting Threshold: Following ASCRS and medical community advocacy, CMS is lowering the reporting threshold for the Quality performance category to 50% of eligible patients depending on the reporting method. Therefore, for claims reporting, physicians are required to report on 50% of Medicare Part B Patients, and for registry reporting, physicians would be required to report on 50% of all patients, not just Part B. Previously, CMS proposed to require reporting on 90% of all patients through registry and 80% of patients via claims, and ASCRS had recommended that the threshold be dropped to 50% of Part B patients for both methods.

Measure Requirements: CMS finalized its proposal to require physicians to report on at least six quality measures, with at least one being an outcome measure. CMS did not finalize the proposal that at least one measure be cross-cutting. ASCRS urged CMS to reinstate its previous PQRS measures groups, such as cataract and diabetic retinopathy, but CMS did not include them in the final rule. We will continue to push for their inclusion. CMS retained the existing ophthalmology measures from the proposed rule, which are also currently available for PQRS reporting. In addition, CMS is not finalizing the proposal to include ASCRS-opposed global and population measures in the quality score; however, CMS will calculate the measures based on claims for informational purposes.

Measure Benchmarks - MIPS Quality component scores will be based on whether a provider achieves pre-set benchmarks for each specific measure. CMS did not include the benchmarks in the final rule, but will publish them before the beginning of the performance period.

Resource Use - 0% of MIPS Score

Following advocacy from ASCRS and the medical community, CMS lowered the category weight for Resource Use, or cost, to 0% of the overall MIPS score for the 2017 performance period. Due to the flawed attribution methodology CMS proposed to use to calculate the cost measures and lack of risk-adjustment, ASCRS and the medical community recommended the category weight be lowered to 0% so that physicians are not penalized for the cost of care they did not provide. CMS will calculate the proposed cost measures based on the 2017 performance for informational purposes. The weight for this category will increase in future years to 10% in 2020, based on 2018 performance, and 30% for payment year 2021 and beyond.

CMS finalized a list of 41 episode-based resource use measures, including one for cataract and lens procedures. Since the overall category weight has been lowered to 0% for the first year, these episode measures will not impact physicians' MIPS scores but will still be calculated for information purposes. These measures will be included in the score in future years.

Improvement Activities - 15% of MIPS Score

CMS has shortened the title of the proposed Clinical Practice Improvement Activities category to Improvement Activities. In addition, CMS modified its proposal to lower the number of activities that must be reported for full achievement. CMS is lowering the requirement to four medium-weighted or two high-weighted activities for 2017. For small practices, CMS reduced the requirement to only one high-weighted or two medium-weighted activities. CMS retained the 90-day reporting requirement for improvement activities and is requiring they be performed during the same MIPS performance period for which a physician is reporting.

Advancing Care Information - 25% of MIPS Score

CMS finalized its proposal to measure a provider's use of Certified EHR Technology (CEHRT) through the Advancing Care Information Technology Category by calculating a base and a performance score. However, CMS finalized a reduced number of measures to be calculated in the base score and moved certain measures to be calculated only as part of the performance score.

Base Score: The base score will include five measures: Security Risk Analysis, e-Prescribing, Provide Patient Access, Send a Summary of Care, and Request/Accept a Summary of Care. Providers must answer yes or have at least 1 in the numerator of each measure to achieve the full base score. The base score will count for 50% of the ACI score, and providers must complete the full base score to receive points under the performance score. 

Performance Score: Physicians can earn additional points toward their ACI score by achieving performance on additional measures in the Patient Electronic Access, Care Coordination, Health Information Exchange, and Public Health objectives. Achievement on each of the measures will count up to 10% of the performance score.

2014-Certified Technology: CMS finalized the proposal to require providers with 2014-certified technology to report on Modified Stage 2. 

MIPS Composite Score

CMS will determine a provider's composite score for the 2017 performance period by adding the weighted scores from the three categories: Quality, Improvement Activities, and ACI. Due to the flexible reporting requirements for the first performance year, any composite score above the performance threshold of 3 points will be eligible for a bonus. Composite scores above 70 qualify as "exceptional performance" and are eligible for an additional bonus.

Advanced APMs

CMS largely finalized its proposals regarding Advanced APMs. Advanced APMs must incorporate a quality measure component; 50% of participants must use EHR; and the model must have two-sided risk. In addition, CMS finalized the proposed payment and patient thresholds for providers to be considered Qualified Participants (QPs), and thus eligible for a 5% bonus. Due to these requirements, and the lack of models available to specialists, ASCRS still believes the majority of our members will not qualify as QPs and will participate in MIPS. CMS did include in the rule that it intends to include in the final list of Advanced APMs the new Medicare Accountable Care Organization (ACO) Track 1+, which is still under development, which will be posted by January 1, 2017.

Additional information will be detailed in upcoming editions of Washington Watch Weekly. For questions, please contact Allison Madson, manager of regulatory affairs, at 703-591-2220 or amadson@ascrs.org.