Top 10 Takeaways from the MACRA Final Rule

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By Tony Schueth

The Centers for Medicare and Medicaid Services rolled out the final rule on October 14 for implementing the Medicare Access and CHIP Reauthorization Act (MACRA). It details the new ways physicians and other clinicians will be reimbursed now that the old payment system, based on the reviled sustainable growth rate formula, has been abolished. It also contains several provisions that directly relate to the required use of certified electronic health record technology (CEHRT) and health information technology (health IT).

The MACRA law and the new, nearly 2,200-page final regulation are very complex. In short, the final rule sets in stone two payment paths for Medicare providers that were proposed last spring: the Merit-Based Incentive Payment System (MIPS) and incentive payments for Advanced Alternative Payment Models (Advanced APMs). MIPS is designed for providers in traditional, fee-for-service Medicare. The advanced APM track is designed for providers who are participating in specific value-based care models. Both require the use of CEHRTs.  The final rule addresses issues raised during a months-long listening tour with nearly 100,000 attendees and the nearly 4,000 public comments submitted in response to the proposed rule last spring.

We believe that our readers will be focused primarily on the MIPS requirements related to CEHRT and health IT. These are mostly found in the advancing care information component (ACI) of the MIPS payment formula.  We are focusing on those, as well as highlighting provisions in the new regulation that we think have specific requirements of interest.  With that in mind, here are our top 10 takeaways:

1. CEHRT is required.  The new regulation reinforces the government’s desire to improve diagnosis, treatment, record-keeping and data exchange through the use of CEHRTs. The objectives and measures for the ACI are based on the 2015 Meaningful Use (MU) program requirements. In 2017, a clinician can use the 2014 edition of CEHRT, 2015 CEHRT, or a combination. All clinicians must be on the 2015 edition of CEHRT beginning with the 2018 performance period. New to the final rule is the concept of earning bonus points for using a certified EHR (CEHRT) to meet a clinical practice improvement activity (another MIPS payment component). A clinician can earn a maximum of 10 percentage points in this category by completing an improvement activity using CEHRT.

This is a further signal to providers, vendors and others that EHRs—and only certified EHRs–are here to stay.  EHR Certification will continue on a parallel track, which currently is overseen by the Office of the National Coordinator for Health IT (ONC). See our blog on the latest certification rule.

2.  Say goodbye to Meaningful Use (MU) – sort of.  For the last several years, stakeholders wondered what would happen to the MU EHR incentive program.  It was set by statute to end on December 31, 2018.  and there was speculation about what would happen beyond MU stage 3. Now there’s no doubt about it:  MU as we know and love it is over.  MACRA sunsets MU as well as two other programs: the Physician Quality Reporting System (PQRS) and the Physician Value-based Payment Modifier. The three are rolled up into MIPS in an effort to create a more streamlined, quality- and value-based reimbursement system.  However, MU attestation will be required for the rest of 2016.

3.  Many MU elements are retained for MIPS.  MU is gone as a program, but many of its elements live on in the advancing care information (ACI) component of MIPS. The objectives and measures are based on the 2015 MU stage 3 requirements.  In response to comments, CMS reduced the number of required measures to five. That is down from the 11 spelled out in the proposed rule and the 18 in MU stage 3, which MIPS replaces. 

It gets a little tricky because the requirements vary according to which CEHRT edition is used (2014 versus 2015) and because CMS slightly changed the name of the individual measures from the proposed rule last spring (details are summarized in Tables 9 and 10 of the rule).  There are five required measures for the advancing care information component of MIPS that must be reported on for a minimum of 90 days. Failure to meet these measures will immediately earn a clinician a big, fat goose egg in the entire ACI category, which accounts for a quarter of the total MIPS score.

There are five required measures for 2017 for those using technology certified to the 2015 edition.  The measures are:  performing a security risk analysis, electronic prescribing (ePrescribing), providing patients electronic access to their clinical data, sending a summary of care and requesting/accepting a summary of care.  

The remaining ACI measures can be used to raise the MIPS score for eligibility for the exceptional performance adjustment.  For those using technology certified to the 2015 edition, these measures are: view download and transmit; patient-specific education; secure messaging; patient-generated health data; patient record exchange; clinical information reconciliation; immunization registry reporting; syndromic surveillance reporting; public health registry reporting; and clinical data registry reporting. A bonus will be given to those who report use of—or attest to use of–CEHRTs to public health and clinical data registries in 2017.

4. Application program interfaces (APIs) are still required.  APIs are still front-and-center, as they were in the proposed rule.  APIs are a critical component of the health data exchange portion of the required measure of giving patients access to their data. This underscores the government’s emphasis on APIs as ways to spur innovation and further patient engagement. The rule says:

For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient authorized representative) is provided timely access to view online, download and transmit his or her health information; and (2) The MIPS eligible clinician ensure the patient’s health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programing [sic] Interface (API) in the MIPs eligible clinician’s certified EHR technology.

5.  Not all measures are counted equally, including electronic prescribing. It should be noted that not all measures are weighted equally for computing the 2017 base score for Advancing Care Information. Security risk analysis and ePrescribing have no performance score weighting, compared to the other measures, which account for at least 10%. To meet the 2017 ePrescribing objective in the ACI, participants must query a drug formulary for and transmit electronically using CEHRT for no less than “one permissible prescription.”  That’s a low bar indeed, especially given the widespread adoption of ePrescribing in ambulatory care.

Also, clinicians cannot report the ePrescribing measure as one of their performance-based measures (another component used to compute the total MIPS score).  This is due to the fact that many clinicians already receive high scores in this measure today.

6.  Concern continues regarding information blocking.  The government still considers information blocking as an issue, which is being dealt with through the attestation process. The new rule requires hospitals and clinicians to attest they are not engaging in the practice.  There is an exception, of sorts.  The rule clarified that providers “should not be held responsible for adherence to health IT certification standards” beyond their control.  We have a different take on whether and why this could be a problem.  

7.  There are many reporting paths to bonus payments—or penalties. In response to comments, changes were made to required reporting periods. This allows providers to “pick their pace” of implementation. It looks as though the government bent over backward to make it easy for MIPS-eligible clinicians to get with the program. However, there are consequences for not doing so. 

Four options are available in 2017:

  • Report to MIPS for a full 90-day period or, ideally, the full year. More data reported over a longer period of time is likely to maximize the chances for an eligible provider to qualify for a positive adjustment (bonus payment). In addition, exceptional performers, as shown by the information that they submit, are eligible for an additional positive adjustment for each year of the first 6 years of the program.
  • Report to MIPS for less than all of 2017 but for a full 90-day period at a minimum. In addition, they must report more than one quality measure, more than one improvement activity, or more than the five required measures in the advancing care information performance category.  This would prevent a negative MIPS payment adjustment and possibly qualify for a positive MIPS payment adjustment.
  • Report one measure in the quality performance category; one activity in the improvement activities performance category; or report the required measures of the advancing care information performance category. Alternatively, if MIPS-eligible clinicians choose to not report even one measure or activity, they will receive the full negative 4 percent adjustment.
  • MIPS-eligible clinicians can participate in Advanced APMs. If they receive a sufficient portion of their Medicare payments or see a sufficient portion of their Medicare patients through the Advanced APM, they will qualify for a 5 percent bonus incentive payment in 2019. 

8.  A low performance bar is set for transition. Calendar year 2017 is a transition year, with performance on various measures used to determine MIPS payments in 2019. For 2017, the performance threshold will be lowered to an astonishing 3 points on the MIPS scale, out of 70. That should be achievable by just about everyone, and prevent payment penalties.   In addition, CMS will not score participating clinicians on the cost and resource performance categories in MIPS in 2017 due to concerns about the readiness of the measures.  However, all requirements ramp up in subsequent years (details are yet to be forthcoming).  And there are rewards for high performers in 2017. Clinicians who achieve a final score of 70 or higher will be eligible for the exceptional performance adjustment, funded from a pool of $500 million.

9.  Fewer clinicians will participate in 2017. The protection of small, independent practices is an important objective, according to CMS. For that reason, many small practices will be excluded from new requirements due to the low-volume threshold. They are defined as those with equal to or less than $30,000 in Medicare Part B allowed charges or 100 Medicare patients or less. CMS estimates that this policy and others in the rule will exempt some 380,000 clinicians in 2017. However, 90% of physicians are expected to participate by 2019.

10.  It’s not necessarily final till it’s final.  In an unusual move, CMS made the MACRA final rule, err, final but with a 60-day comment period. Presumably that will allow stakeholders to weigh in on certain portions that are viewed as still being exceptionally unworkable and for the government to make some kind of last-minute adjustment before the curtain falls in December. This could happen, but we’re betting that what we see is pretty much what we will get.

What do we think? We commend CMS for their efforts in getting this final rule put together and out the door to meet the statutory deadline. We understand their setting low thresholds for clinicians in the 2017 transition year to ease fears and confusion among providers. It will be interesting to see how these requirements will be ratcheted up in coming years and whether the new Administration and/or Congress will want changes. As experts on EHRs and health IT, we are pleased to see their prominence in the final rule.  We also were pleased to see the government’s recognition that health care will continue to rely on health IT and need continued investments to meet the more stringent MIPS requirements that are inevitable. Let us know if we can help your organization understand MIPS and plan for the future.

Tony Schueth

Tony Schueth

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