MACRA Mania – Breaking Down the Rule & Answering “What Now?”

The MACRA Proposed Rule was a daunting piece of legislation when it first arrived. Many took issue with some of its components and others questioned whether it would stick, most expecting to find clarity from assumptions by turning to the document itself. When all 2398 pages of the Final Rule were released in October of 2016, it became evident that gaining the coveted clarity would require more than an afternoon read. We are now into the third month of MACRA’s first reporting year, and understanding of the legislation is more critical than ever to the success of thousands of organizations.

The voluminous nature of the Final Rule is not for show. MACRA’s size is directly correlative to the amount of existing and novel regulation it takes on. At its most basic level, MACRA repeals the Sustainable Growth Rate formula (SGR) while bundling and sunsetting the Medicare Electronic Health Record Incentive Program (Meaningful Use), the Physician Quality Reporting System (PQRS), and the Physician Value-based Payment Modifier (VM). Those responsible for reporting through multiple of the above programs will breathe a sigh of relief when realizing that previously redundant reporting elements will now be consolidated and streamlined by MACRA.

A note of caution to organizations, however, is needed. Though these programs will be sunset by MACRA, they will be sunset by the onset of payment adjustments, not the onset of reporting requirements. For many clinicians, this means reporting will be required for several of the programs during the full transition to MACRA.

The first thing an organization should do in approaching MACRA readiness is to determine exactly what is required for reporting on behalf of its clinicians, not just through MACRA, but through the existing regulation MACRA will eventually fully replace. Once you understand the pre-existing program reporting requirements and timelines for sunset, you can focus in on MACRA.

The second thing an organization should do is ask how their clinicians will be categorized by MACRA’s Quality Payment Program and what that means for reporting requirements. CMS states on its website that “the Quality Payment Program has two tracks you can choose: Advanced Alternative Payment Models (APMs) or the Merit-based Incentive Payment System (MIPS).”1 While this is generally accurate, it doesn’t acknowledge the existence of what can be viewed as an additional participation track: the MIPS APM.

When determining, which path a clinician falls into, it’s easiest to work backward from the Advanced APM. Does the clinician participate in one of the below programs?

  • Comprehensive ESRD Care (CEC) – Two-Sided Risk
  • Comprehensive Primary Care Plus (CPC+)
  • Next Generation ACO Model
  • Shared Savings Program – Track 2
  • Shared Savings Program – Track 3
  • Oncology Care Model (OCM) – Two-Sided Risk
  • Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1- CEHRT)
  • Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)2

If so, does that clinician receive 25% or more of his or her Medicare payments or see 20% or more of his or her Medicare patients through the Advanced APM?

If the answer is yes to both questions, the clinician is a Qualified Participant (QP) in the Advanced APM track and is exempt from MIPS scoring and payment adjustments. If the answer is no to either of the above questions, the clinician is not eligible for the QPP’s Advanced APM track and is subject to the reporting requirements of MIPS. There is, however, an opportunity to have those reporting requirements reduced if the clinician qualifies as a participant in a MIPS APM.

So, naturally, the next question to ask is: is the clinician participating in a MIPS APM (one of the below models)?

  • Comprehensive ESRD Care (CEC) – Two-Sided Risk
  • Comprehensive Primary Care Plus (CPC+)
  • Next Generation ACO Model
  • Medicare Shared Savings Program—Track 1 (MSSP)
  • Shared Savings Program – Track 2
  • Shared Savings Program – Track 3
  • Oncology Care Model (OCM) (one-sided risk arrangement)
  • Oncology Care Model (OCM) – Two-Sided Risk
  • Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1- CEHRT)
  • Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)

If the answer is yes, then the clinician will be scored using the APM scoring standard rather than the generally applicable MIPS scoring standard, reducing reporting burdens.

You may notice many redundancies between the MIPS APM list and the Advanced APM list. This is so that if a clinician is determined ineligible for Advanced APM track participation by the 20/25 rule stated above, he or she can still qualify for the reduced MIPS reporting requirements associated with the APM scoring standard.

If all questions to this point have been answered with no, the clinicians will be subject to the scoring standards for MIPS and the MIPS payment adjustment.

The logic above provides a simple framework for determining the type of MACRA participation that will be expected of clinicians. Though simplified above, participation determination becomes much more difficult when it is being conducted for hundreds if not thousands of clinicians. The step, however, should not be avoided as it is critical to the next stage of MACRA preparation: determining reporting strategy.

If a clinician is a Qualifying Participant in QPP’s Advanced APM track, reporting requirements are simply the submission of quality data already required by the clinician’s Advanced APM.

If a clinician is participating in a MIPS APM or is participating in MIPS, he or she is expected to report on several categories: Quality, Improvement Activities, and Advancing Care Information. It is critical that MIPS participating organizations understand, what Quality measures they are capable of reporting on, which Improvement Activities are most attainable and beneficial to the organization, and which Advancing Care Information activities can be readily demonstrated. Each category has a number of items for reporting and it is up to the organization to select those which best represent it and promote the highest possible MIPS score, ensuring the highest possible payment adjustments.

Divurgent offer tools and resources to help organization strategize around MACRA readiness, select reporting measures, and drive higher scores, including MIPS Score Simulations, MACRA Workflow Optimizations, and robust MACRA Adoption Programs. With a transition as significant as MACRA, having a guiding partner with deep subject matter expertise can make or break an organization’s success. With a 4% positive or negative adjustment to 2019 Medicare Physician Fee Schedule payments based on 2017 performance, organizations needs to prepare themselves for MACRA’s impact now.

I’ve read this rule, studied each aspect, and researched the implications – if you still have questions or want to talk through any of the things covered in this blog, I’d be happy to set up a conference call with you.

Ralph Whalen | Senior Manager, Divurgent

Ralph.whalen@divurgent.com

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