• CMS on Tuesday released the anticipated proposed rule updating the Quality Payment Program — the program implementing MACRA — for 2018.
  • The proposal allows for the exemption of small providers participating in the program by increasing the low-volume threshold to $90,000 or less in Medicare Part B charges or 200 or less Medicare patients annually. The original threshold was $30,000 in Medicare Part B charges or 100 Medicare patients. The agency believes the move will exclude about 134,000 clinicians from MIPS.
  • The proposal follows more than 800,000 clinicians in May being informed they will not be evaluated under the MIPS program.

The much-anticipated rule continues the CMS’ trend of letting more and more physicians delay MACRA implementation. Small and rural providers have frequently said their lack of capital and resources make complying with the reporting requirements too taxing.

MACRA will eliminate the sustainable growth formula and replace it with a .5% annual rate increase through 2019, after which physicians are encouraged to shift to one of two Quality Payment Programs: 1) Merit-Based Incentive Payment System (MIPS) or 2): Alternative Payment Model (APM).

It is believed most physicians will enter into the MIPS program in the first year.

“We’ve heard the concerns that too many quality programs, technology requirements and measures get between the doctor and the patient,” said CMS Administrator Seema Verma in a prepared statement. “That’s why we’re taking a hard look at reducing burdens. By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork. CMS will continue to listen and take actionable steps toward alleviating burdens and improving health outcomes for all Americans that we serve.”

American Medical Association President David Barbe released a statement commending the CMS for hearing the concerns of practicing physicians. “Not all physicians and their practices were ready to make the leap, and many faced daunting challenges. This flexible approach will give physicians more options to participate in MACRA and takes into consideration the diversity of medical practices throughout the country,” he wrote.

Although many providers are happy with the proposal, champions of value-based care payment models say more exemptions just set back the movement. “If CMS wants to transition to value-based payment for care, the program needs to be fully implemented,” said Chester Speed, vice president of public policy at the American Medical Group Association. “We recommend that CMS revise its proposal to fully incentivize high performers in the Medicare program.”

One of MACRA’s selling points was that it was a bipartisan effort, and former CMS Administrator Andy Slavitt touted how the agency was engaging with and listening to clinicians’ concerns over the legislation.

The news may come as a relief for some clinicians. In March, Healthcare Informatics found 43% of more than 2,000 providers stated they needed help with MACRA preparation while 30% said that are not prepared at all.

However, after exclusions, CMS estimates 36% of clinicians will be eligible for participation in 2018.

CMS also outlined some proposals on how to participate in MIPS through virtual groups.

First, the proposed rule defines a virtual group as a combination of two or more taxpayer identification numbers (TINs) composed of a solo practitioner or a group with 10 or fewer eligible clinicians under the TIN that elects to form a virtual group with at least one other solo practitioner or group for a performance period of a year.

A representative for the group must submit written notice by December 1 of the calendar year prior to the start of the applicable performance period to submit an agreement amongst virtual group participants. The low-volume threshold will not be granted at the virtual group level. “[S]olo practitioners (individual MIPS eligible clinicians) or groups with 10 or fewer eligible clinicians that are determined not to exceed the low-volume threshold at the individual or group level would not be eligible to participate in MIPS as an individual, group or virtual group,” the rule stated.

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