MACRA 2018 Proposed Rule Reflects New CMS Flexibility

In proposed changes to Medicare's new value-based payment system for physicians, federal officials want to delay mandatory data reporting for another year and lower implementation burdens for small physician practices.

The 2018 proposed rule for Medicare's new payment system for physicians is consistent with the relatively flexible regulatory approach at the Centers for Medicare & Medicaid Services (CMS) under the Trump administration.

Next year's proposed changes to the Quality Payment Program (QPP), which were announced Tuesday afternoon, feature continuation of "pick your pace" for the new payment system's data reporting and expands exemption of physicians from mandatory participation.

The QPP was established under the Medicare Access and CHIP Reauthorization Act (MACRA), which gives physicians two service-reimbursement tracks: the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) such as Medicare accountable care organizations (ACOs).

"The most significant proposed changes for 2018 intend to ease the administrative burden for physicians, especially those who are in small practices and rural settings," Christopher Stanley, MD, MBA, director at Chicago-based healthcare consultancy Navigant, said this morning.

In the 1,052-page proposed rule, he says there are three prime examples of CMS regulatory flexibility, including a financial sweetening of MIPS for physicians in small practices who are struggling to adopt the new payment system:

• More physicians will be exempt from MIPS as the threshold for inclusion is increased from 100 patients or $30,000 in Part B payments to 200 patients or $90,000 in payments.
• Physicians will be able to participate in MIPS through Virtual Groups—working with other small practices to combine their administrative costs.
• Physicians in small practices will receive extra "bonus" points within the Composite Performance Score for MIPS to recognize their value to communities where they practice.

The proposed rule eases reporting requirements significantly, but small and rural practices still face daunting QPP implementation challenges, Stanley says.

"Readiness will still require investment in technology such as healthcare IT, people such as care coordinators and data support, and process such as establishing a Virtual Group. The proposed rule does not give a pass to rural providers—it simply opens the door that they will still need to walk through."

In the proposed rule, there are several other examples of planned changes to QPP designed to give physicians more flexibility in operationalizing the new payment system:

• Continuation of the "pick your pace" option for implementation of MIPS data reporting in 2018. There are four MIPS data-reporting categories: quality, improvement activities, advancing care information, and cost.
• Continuing to allow the use of 2014-edition Certified Electronic Health Record Technology.
• Adding the option for physicians to use facility-based scoring for facility-based clinicians such as hospitalists.
• For physicians at small practices, adding a new hardship exemption for the advancing care information data-reporting category.

In a prepared statement Tuesday afternoon, CMS Administrator Seema Verma underscored her agency's commitment to regulatory flexibility during the QPP rollout.

"We've heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient. That's why we're taking a hard look at reducing burdens. By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork."

Tom Nickels, executive vice president of the Chicago-based American Hospital Association (AHA) praised the proposed QPP changes in a prepared statement on Tuesday.

"[The] proposed rule continues the incremental, flexible implementation approach called for by hospitals, health systems and the more than 500,000 employed and contracted physicians with whom they partner to deliver care. We are encouraged by CMS's proposal for a facility-based clinician reporting option that may promote better alignment and collaboration on efforts to improve quality among hospitals and clinicians," Nickels said.

More details about the QPP proposed rule are available in a CMS Fact Sheet.

The deadline for submitting public comments on the proposed rule is Aug. 18. The QPP 2018 final rule is expected to be released in the fall.