Compared with an earlier proposed rule, an estimated 155,000 additional clinicians will be excluded from upcoming quality-reporting requirements.


Oct. 17—The much-anticipated final rule implementing the Medicare physician payment overhaul features several changes from a previously proposed version, including plans for new alternative payment models (APMs).

The final rule implementing the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) outlined physician payments under the Quality Payment Program (QPP), which replaces the sustainable growth rate formula and will apply to Medicare payments for more than 600,000 clinicians, according to the Centers for Medicare & Medicaid Services (CMS). Most physicians under QPP initially are expected to fall under the Merit-based Incentive Payment System (MIPS), while a smaller number will qualify for payment through participation in advanced APMs.

A new CMS QPP website explains the new program and aims to help clinicians identify the measures and activities most meaningful to their practice or specialty.

Clinicians who start participating in Medicare in 2017 are not required to participate in the QPP in that year.

Under QPP, clinicians will have until Oct. 2, 2017, to begin collecting quality data or face a 4 percent cut to their Medicare payments in 2019. The 2017 data is due by March 31, 2018. Providers can avoid a payment adjustment by submitting a small amount of data, while sending the full required amount could land them a “moderate” pay increase, according to a CMS fact sheet. The timeline and reporting gradations were significant changes from the proposed rule, which required full data reporting to begin Jan. 1, 2017.

Like other provider advocates, the Medical Group Management Association (MGMA) said in a statement that it supported the change but had hoped for similar flexibility beyond 2017.

“It’s disappointing that flexibility provided for quality reporting in 2017 largely disappears in 2018 and beyond,” Halee Fischer-Wright, MD, president and CEO of MGMA, said in a written statement. “The Centers for Medicare & Medicaid Services missed an opportunity to close the two-year gap between the measurement and payment periods, which would facilitate improved patient care by providing actionable feedback to physicians and more timely incentives.”

CMS estimates for 2017 that about 500,000 clinicians will begin on the MIPS track. Individual clinicians with a single national provider identifier tied to a single tax identification number must send in individual data for each of the MIPS categories through a certified electronic health record, a registry, a qualified clinical data registry, or the routine Medicare claims process. Groups of clinicians sharing a common tax identification number can send in MIPS data as a group and get a single payment adjustment based on the group’s performance.

The final rule noted that CMS plans to allow data submission by “virtual groups” consisting of individual clinicians and groups of up to 10 clinicians. The specific rules for virtual groups will come through future rulemaking.

Small-Practice Changes

The final rule emphasized flexibility, simplicity, and support for small practices. Part of that approach included a small increase in the threshold that will require physicians to participate in the new quality-reporting requirements. The final rule will exclude physicians from MIPS requirements if they treat fewer than 100 Medicare patients or are paid less than $30,000 through Medicare Part B—an increase from the previous low-volume threshold of $10,000. The change was expected to exempt about 380,000 clinicians from the MIPS program, up from about 225,000 under the proposed rule.

The change will “help provide a better safety net for small practices,” the American College of Physicians said in a written statement.

CMS also emphasized the $20 million in annual assistance that MACRA authorized for clinicians in practices of 15 members or fewer and for those working in underserved areas. Beginning December 2016, “local, experienced organizations” will use that funding to help small practices select appropriate quality measures and health IT to support their unique needs, train clinicians on the new quality improvement activities that are part of MACRA, and help practices evaluate their options for joining an advanced APM.

New APM Provisions

Clinicians who receive 25 percent of their Medicare-covered professional services or see 20 percent of their Medicare patients through an advanced APM in 2017 will earn a 5 percent Medicare payment bonus in 2019. Up to 120,000 clinicians were expected to qualify through participation in an advanced APM in 2017, with that total increasing to “more than” 125,000 in 2018, according to CMS.

Additionally, CMS said it is considering testing a new Track 1+ accountable care organization (ACO) for 2018. The proposed ACO would include lower risk levels than are currently available to Medicare ACOs that qualify as advanced APMs, according to CMS. The planned addition followed concerns raised by ACO advocates that the MACRA rules exclude Medicare Shared Savings Program (MSSP) Track 1 participants, which comprise 95 percent of the 434 MSSP ACOs.

“While we are disappointed that CMS continues to narrowly define advanced APMs, which means that less than 10 percent of clinicians will be rewarded for their care transformation efforts, we are encouraged that CMS is exploring a new option that would expand the available advanced APMs that qualify for incentives,” Tom Nickels, executive vice president for the American Hospital Association, said in a written statement. “We urge CMS to ensure that this option be available in 2017 and look forward to working with them so this new model achieves an appropriate balance between risk and reward.”

The final rule also eased the risk criteria for advanced APMs, which would allow for a broader range of models under MACRA, such as those tailored to small practices or specialties. New APMs expected to be available by 2018 included a new voluntary bundled payment model and the Advancing Cardiac Care Coordination Through Episode Payment Models program.

The final rule identified the APMs that in 2017 will qualify participating physicians for bonus payments and exemption from MIPS reporting:

  • Comprehensive Primary Care Plus (CPC+)
  • Next Generation ACO
  • MSSP Tracks 2 and 3
  • Oncology Care Model with two-sided risk
  • Comprehensive ESRD Care (for large dialysis organizations)

Other Resources

Additional clinician assistance is available through several CMS programs. The Transforming Clinical Practice Initiative (TCPI) aims to help more than 140,000 clinician practices over the next four years in sharing, adapting, and further developing their comprehensive quality improvement strategies. Clinicians participating in TCPI can learn about MIPS and how to move toward participating in advanced APMs.

The Quality Innovation Network’s 14 Quality Improvement Organizations aim to bring Medicare beneficiaries, providers, and communities together in data-driven initiatives that increase patient safety, make communities healthier, better coordinate post-hospital care, and improve clinical quality.

The CMS Innovation Center will provide clinicians in an APM with specialized information on what they need to succeed in the advanced APM track. Clinicians in an APM that not does not qualify as an advanced APM under MACRA can learn about how their APM participation can help them succeed in MIPS.

Because CMS expects the QPP to evolve over multiple years, it included an additional 60-day comment period to continue to solicit input from stakeholders. Comments may be submitted electronically through the e-Regulation website.


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Monday, October 17, 2016