2016 has been a banner year for implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (P.L. 114-10). The law, which revises Medicare Part B by replacing the existing system for Medicare payments to physicians and consolidating multiple programs designed to improve the quality of care provided, builds on measures created by the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). The year began with CMS’ plans for implementation of MACRA and the corresponding concerns aired by providers regarding the administrative burdens and costs of compliance. As the year progressed, CMS proposed regulations that included the creation of the Quality Payment Program (QPP) while Congressional committees held hearings about the transition from the existing system for Medicare payments to physicians to the new one created by MACRA. The Proposed rule received thousands of comments, especially with regard to small physician practices, culminating in a November 2016 Final rule that made participation in the QPP voluntary for 2017. This Strategic Perspective counts down the top five MACRA developments of 2016, and looks ahead to the next year.
Under MACRA and its regulations, new programs will have unfamiliar names that require an updated vocabulary. Participation in the QPP gives eligible professionals (EPs) two tracks: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). MIPS eligible clinicians will report certain quality measures and later receive a payment adjustment based on the data provided, while Advanced APM participants will receive an incentive payment. MACRA also required the establishment of the physician-focused payment model (PFPM) Technical Advisory Committee (PTAC). The good news, however, is that while MACRA created a bunch of acronyms, it made others obsolete. The sustainable growth rate (SGR) was ended by MACRA (see Ding dong, the SGR is dead!, April 15, 2015), and the Physician Quality Reporting System (PQRS), Physician Value-based Payment Modifier (VM), and EHR Incentive Program (known as Meaningful Use) will end, leaving only certain consolidated elements of each in the QPP.
5. 2016 was a year of MACRA planning and preparation
In January, CMS Acting Administrator Andy Slavitt shared the "themes" he was considering as the agency prepared for MACRA implementation (see It’s time to turn the tables on technology, end meaningful use, January 13, 2016). As part of the consolidation of Meaningful Use into QPP, HHS’ Office of the National Coordinator for Health Information Technology (ONC) began to determine how to define and measure EPs’ use of EHR, while EPs remained uncertain about what, exactly, they will need to do to participate (see Will MACRA bring more ‘Stage 3 blues’ or the ‘EHR Hunger Games’?, April 1, 2016). The ONC solicited input on EHR metrics, including how to prioritize data measures and whether it should use a single or multiple data sources (see ONC seeks help building interoperability metrics for EHR, April 8, 2016). A House Committee on Energy and Commerce hearing included testimony from a number of EPs and other stakeholders who hoped that MACRA implementation would streamline reporting measures and allow care improvements (see Hearing addresses physicians’ MACRA preparations, April 20, 2016). Proposed regulations announced the creation of the QPP and spelled out for the first time the quality measures that CMS was looking to use (see Physician reporting streamlined, less burdensome under flexible Quality Payment Program, April 28, 2016). Similarly, the Quality Measure Development plan spelled out the strategic framework CMS would follow for creating and implementing new quality measures (see CMS posts plan for transitioning to merit-based and alternative payment models, May 3, 2016). CMS then embarked on a "months-long listening tour" before finalizing its regulations (see below).
4. Progress made on data access, privacy protection.
In addition to payment reforms, MACRA includes provisions to increase access to and use of claims data, and improves beneficiary privacy by requiring the removal of Social Security numbers from Medicare and Medicaid cards. Section 105 of MACRA expanded an ACA program providing qualified entities access to standardized extracts of Medicare Parts A and B claims data and Part D drug data. Qualified entities can use the combined data and derivative information to conduct, provide, and sell nonpublic analyses. CMS published a Proposed rule in February (see CMS walks through the data access door opened by MACRA and ACA, February 1, 2016). The agency determined that states will need to review and update their Medicaid business processes and systems as part of the Social Security Number Removal Initiative (SSNRI) (see State action necessary to prepare for social security number removal initiative, May 6, 2016). In a Final rule, CMS required qualified entities and their contractors (including business associates) to execute a Data Use Agreement containing privacy and security protocols including the de-identification of data (see Qualified entity rule finalized, privacy concerns mandate de-identification process, July 6, 2016).
3. Small practices worried about MACRA participation
Small physician practices were particularly concerned with the QPP Proposed rule. It would have required participation in the QPP for all practices that exceeded a low-volume threshold—defined as billing Medicare for more than $10,000 and providing care for more than 100 Part B-enrolled Medicare beneficiaries in one year. To assist small and rural practices with the transition, HHS committed to providing $20 million over five years to be used for QPP training (see HHS provides funding for training small practices in Quality Payment Program, June 21, 2016). However, better training was only one of the concerns small practices raised. Other issues included the amount of time available for preparation (especially because "virtual" reporting groups, which will allow individual physicians to form groups to report together, will not be available in 2017), EHR requirements in rural areas, and the burden of reporting requirements (see CMS hears small practice MACRA concerns, pursuing compliance flexibility, July 13, 2016).
2. Flexibility is king
As CMS continued toward issuing final regulations, the agency announced planned changes from the Proposed rule. The biggest change was making participation in QPP for 2017 voluntary, rather than mandatory. EPs may choose between no participation, nominal participation, partial participation, or total participation. This change was announced before the final regulations were issued to allow sufficient preparation time for EPs (see CMS gives physicians options for easing into MACRA Quality Payment Program, September 9, 2016). The agency also announced its plans to expand opportunities for physicians to join Advanced APMs and to approve additional models for inclusion in the program for future calendar years (see New alternative payment models announced by CMS, October 26, 2016). Overall, 2017 will be a "transition" year for the QPP, allowing clinicians and CMS to build reporting capabilities and gain experience in the program.
1. Final regulations for the QPP were published
Finally, after receiving almost 4,000 comments on the proposed regulations, CMS published the QPP Final rule in November 2016 (see MACRA final regulations reflect input from ‘months-long listening tour’, October 14, 2016). The rule tripled the low-volume threshold for small practices from $10,000 to $30,000 billed Part B charges per year. It also simplified EHR technology-use requirements and, as CMS announced earlier in the year, made participation in the QPP voluntary and flexible for 2017. Since releasing the regulations, the agency has continued its planning for the future of MACRA implementation, making additional strides toward easing the reporting burdens for EPs and streamlining quality measures. CMS released an online tool known as the Application Program Interface to make it easier for organizations to customize their quality tracking and reporting (see Tool designed to ease clinician participation in the Quality Payment Program, CMS says, November 18, 2016).
MACRA in 2017
MACRA’s status under the incoming Donald Trump (R) Administration is not entirely clear. Although the president-elect has repeatedly shared his intent to repeal and replace the ACA, it is likely that MACRA will mostly continue. A number of MACRA provisions build on programs or ideas created by the ACA; the future of those items remain in flux as the incoming Congress and Administration make plans for the future of health reform. However, MACRA was passed by large bipartisan majorities in both the House of Representatives and the Senate, with Trump’s pick for HHS Secretary, Rep. Tom Price, M.D. (R-Ga) among the yea votes. Price, who is part of the House Congressional Doctors Caucus, called MACRA "one of the biggest changes in Medicare policy" since the program began. In a letter to CMS, Price and other members of the Doctors Caucus called aspects of the proposed MACRA regulations "too complex" and "unrealistic." After the MACRA Proposed rule was released, Price spoke favorably about regulatory changes to the electronic health record (EHR) reporting period, which changed from a full calendar year to 90 days; however, he also questioned whether EPs would have enough time to prepare for the new reporting requirements under the law.
Price later raised concerns about the Final rule, particularly with "how this rule could affect the patient-doctor relationship" and shared his plans to carefully review the regulations; however, the results of his review have not yet been made public. The MACRA regulations are effective on January 1, 2017, and EPs should be prepared to participate to the level they choose (see Save time and money with careful MIPS preparation, July 7, 2016). The overall trend toward value-based reimbursement is likely to continue apace (see Value-based reimbursement: the new normal, April 18, 2016).
Other issues on the table for 2017 include an ongoing discussion in Congress about the role of traditional prohibitions against physician self-referrals in the face of value-based payment changes. In July 2016, the Senate Finance Committee held a hearing on whether the Stark law (42 U.S.C. §1395nn) remains relevant now that Medicare is moving away from the fee-for-service model (see Stark law needs a check-up, says Senate Finance Committee, July 13, 2016). These questions will continue to be deliberated during the next year, with a smaller compliance burden being the goal of change. In addition, many of MACRA’s changes will not go into effect until 2018, so Proposed and Final rules for those provisions of the law will be released during 2017.
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