TMA Wins MACRA Improvements, Wants More

Medicine won some relief in the Centers for Medicare & Medicaid Services' (CMS') final rule implementing the Medicare Access and CHIP Reauthorization Act (MACRA). Responding to medicine's vehement concerns, CMS decided physicians who at least try to comply with the new rules next year will see no penalty in their payments in 2019, the first year the penalties were set to apply. That's because starting in 2017, physicians' performance on various quality, cost, technology use, and practice improvement measures determines cuts or bonuses in their payments two years later.

Check out the newly updated version of TMA's Five-Step Checklist for MACRA Readiness (login required) to ensure your practice is prepared for the Merit-Based Incentive Payment System (MIPS) and alternative payment models (APMs).

In addition to reduced reporting requirements under Medicare's new Quality Payment Program, TMA and organized medicine won other significant improvements that create a more palatable transition period, including a broader exemption for small practices with few Medicare patients or little revenue inform the program.

Of TMA's 50 recommendations to improve MACRA, CMS completely accepted 21, partially accepted 13, and rejected 16. Among the most significant improvements for 2017:  

  • A broader exemption that excludes physicians who see fewer than 100 Medicare patients or submit Medicare charges of less than $30,000. The draft rule originally set the low-volume threshold at $10,000. 
  • Reduced reporting requirements to avoid a penalty in 2019. Any physician who successfully reports one quality measure or one of the new improvement activities will earn enough credit to avoid a 4-percent payment cut in 2019. 
  • A simpler system that gives physicians and groups leeway to pick the most meaningful quality measures and reporting mechanisms for their practices and their patients. 
  • Eliminating the cost category in calculating physicians' overall performance scores.
  • A shortened performance period that allows physicians to report quality and technology use data for 90 days, instead of a full calendar year, to be eligible for a bonus. 

TMA will continue to work with CMS and the Texas congressional delegation to rewrite and reform ongoing problems identified in the draft regulations that stuck in the final rule. Here's a list of further improvements TMA would like to see: 

  • Keep and/or raise the low-volume threshold to exempt physicians from the Merit-Based Incentive Payment System (MIPS). Although CMS increased the initially proposed low-volume threshold, many physicians still will have no possibility of a positive return on the investment in the cost of reporting. 
  • Keep the MIPS performance threshold as low as possible for as long as possible. CMS set the MIPS performance threshold at 3 points, but only for 2017. To reduce the negative impact on small practices, CMS should continue to set the composite performance threshold as low as possible. CMS plans to increase the performance threshold in 2018, and beginning in 2019, will use the mean or median final score from a prior period. Setting the threshold higher results in a larger number of physicians who receive penalties and larger incentive payments to large practices that can absorb the necessary administrative costs to facilitate full compliance and reporting.
  • Create and apply a "hold harmless" policy. No payment penalty should be created for and applied to physicians when a technology vendor (electronic health record [EHR], registry, other) commits data collection and/or data submission errors that result in poor quality performance scores or failed reporting, especially when the issue is out of a physician's control. TMA strongly urges Congress and CMS to create physician protections for these instances.
  • No quality or cost measure should be used unless it can be properly attributed and risk-adjusted, and all measures must be developed and/or vetted in collaboration with the medical profession and relevant stakeholders, not just CMS. In the final rule, there is no improvement to risk adjustment. No financial incentives of any kind should be based on measures that are not properly attributed and risk-adjusted. Physicians should not be penalized for factors not in their control. Volume minimums on all measures should be set high enough to avoid the statistical volatility of small numbers. Additionally, all measures must be adequately vetted with input from the medical profession and relevant stakeholders, and must be developed and maintained by appropriate professional organizations that periodically review and update these measures with evidence-based information in a process open to the medical profession. 
  • Remove the requirement for all-payer data. Although the law is permissive on this subject, it does not require the use of all-payer data. CMS has finalized the requirement for all-payer data for three of six reporting methods. In 2017, physicians reporting through registries, qualified clinical data registries, and EHR systems must report all-payer data, whereas physicians who report via claims, web interface, or patient experience survey/CAHPS need report only on Medicare Part B patients. This would result in an inequitable assessment of quality performance among physicians and practices. Medicare bonus payments and payment penalties based on all-payer data are wrong. Physicians should not be rewarded or penalized based on variations in payer mix. 
  • Design a system that provides real-time feedback and meaningful data to physicians. CMS reports it can only provide feedback on performance as often as data are reported, which currently is on an annual basis. Timely access to feedback reports is vital for physicians to identify gaps in care and performance to make improvements where necessary within the performance period. CMS should allow submissions of data more frequently throughout the year to provide timely feedback for performance corrections or compliance issues, and avoid delays in performance improvement that result in payment penalties. CMS reports it plans to leverage the vendor community to disseminate data contained in performance feedback reports in the future. If and when such a process is created, physicians should not have to pay practice or technology vendors extra fees for such data and information that CMS currently offers annually at no cost. 

Action, Dec. 15, 2016