Final MACRA rule too strict for some, too loose for others: ‘Do we need MIPS at all?’

While the proposed rule for the second year of the Medicare Access and CHIP Reauthorization Act (MACRA)’s Quality Payment Program (QPP) earned mostly praise from the healthcare industry, the finalized rule earned a mixed reaction from groups alternating saying it’ll burden providers and it’s allowing too many physicians to avoid the program altogether.

Among the biggest changes the final rule makes for 2018:

  • Raises low-volume exemption level for the Merit-based Incentive Payment System (MIPS) from $30,000 in Medicare Part B charges and treating 100 Medicare beneficiaries to $90,000 and 200 beneficiaries.
  • Allows clinicians—as long as they exceed the low-volume thresholds individually—to form virtual groups to report for MIPS.
  • Makes the MIPS cost category account for 10 percent of the total MIPS score.
  • Directs CMS to develop a demonstration project to test how risk-based Medicare Advantage contracts can be included in the beneficiary count test for the Advanced Alternative Payment Models (AAPMs) track.
  • Allows use of 2014 certified electronic health record technology (CEHRT) rather than requiring providers to use 2015 CEHRT products.

The American Hospital Association praised the rule for its “flexible approach” on exempting clinicians and on EHR requirements, with the caveat that the agency should aim to “provide similar relief” to hospitals. The American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) similarly praised measures which either exempted smaller practices entirely or from specific requirements, like the hardship exception for the Advancing Care Information category.

Despite the additional flexibility, AAFP and ACP complained MIPS scoring is still too complex, that it’s too early to incorporate cost into the overall score and practices aren’t ready for a full year of quality reporting, a concern echoed by the Medical Group Management Association (MGMA).

“This fourfold increase to the quality reporting requirements is in stark contrast the agency’s statements that the final rule reduces regulatory burdens,” MGMA’s senior vice president of government affairs, Anders Gilberg, told HealthExec in an email. “CMS is in effect prioritizing quantity over quality and giving physicians less than 60 days to prepare for the 2018 MIPS requirements.”

CMS was also criticized not allowing clinicians the ability to opt into MIPS if they fall below the low-volume thresholds, which it had asked to be included in its comments on the proposed rule. The National Committee for Quality Assurance (NCQA) said it was unfortunate that the new virtual groups option leaves out small practices which were ineligible for MIPS on their own.

Some of the harshest critiques came from the American Medical Group Association (AMGA). While the group was pleased about the promise to test including MA contracts with a risk component in AAPMs, it said the increased number of clinicians which will be exempted from MIPS turns the program into a “regulatory compliance exercise” which doesn’t provide sufficient return on investment for the larger providers AMGA represents and that are required to participate.

“They’ve gone out of their way to protect and hold harmless the small practices,” AMGA’s director of regulatory affairs, Darryl Drevna, told HealthExec.

Adding to the uncertainty among providers which aren’t exempt from MIPS is the recommendation from Medicare Payment Advisory Commission (MedPAC) that the program be scrapped. Considering the limited upside “with virtually no impact on cost or quality” and the greater number of exemption of small practices, AMGA vice president of public policy Chet Speed, LLM, guessed its members may accelerate their moves towards Advanced APMs or at least MIPS APMs, like Track 1 of the Medicare Shared Savings Program.

“I wouldn’t be surprised if many of our members are having similar discussions about: do we need MIPS at all?” Speed told HealthExec. “Do we basically take the money that’s in MIPS, which is about $618 million for 2018 and just shift that to APMs?”