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What Healthcare Providers Should Know About MACRA

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With the election of Donald Trump and the announced appointment of Tom Price as secretary of Health and Human Services, uncertainty and apprehension loom concerning the future of the ACA and how MACRA will actually be implemented. The repeal of the sustainable growth rate methodology for establishing payment for physician and eligible clinician services and its replacement with the Quality Payment Program and its two tracks for payment and implementing regulations are scheduled to become final, and thus operational, on January 1, 2017, approximately three weeks before President-elect Trump’s inauguration. How much of the system becomes and stays effective is unclear due to the generous rolling time period physicians and eligible clinicians have to comply before payment penalties set in. By the time the program is scheduled to be fully implemented in 2019, Trump’s HHS team and Congress will have had the opportunity to review and change the program. Despite this uncertainty, physicians and eligible clinicians should immediately begin efforts to participate in these programs, keeping in mind that it is difficult to repeal and change a program implemented through regulations and requires rescission through the administrative regulatory process. Thus the best course is to work through the process with the understanding that things may slowly change.

Creating a new payment system that integrates quality measures into payment for services has been a long and difficult task that has resulted in a complicated system with two payment models—Advanced Alternative Payment Models (Advanced APMs) and Merit-based Incentive Payment Systems (MIPS), two new acronyms that are destined to become everyday terms. While replacement of the sustainable growth rate formula was required by statute, the operational details are in the Final Rule, published as a final regulation with a comment period that expires sixty days after publication. In the final rule, the Obama administration has focused on laying the groundwork for a system that is outcome-focused, patient-centered, and resource-effective using a staged approach. The goals are (1) supporting improved care by focusing on better outcomes for patients, decreasing provider burden, and preserving independent clinical practice; (2) promoting alternative payment models by paying incentives; and (3) working to reform system delivery with a new system promoting high-quality, efficient care. Recognizing the challenges in understanding the requirements and being prepared to participate in the Quality Payment Program, the Final Rule focuses on encouraging participation and educating clinicians for the first year. Given the wide diversity of clinical practices, clinicians are given three options to submit data to MIPS and a fourth option to join Advanced APMs to become a Qualified Participant to assure that they do not receive a negative payment adjustment in 2019.

So, what’s an eligible clinician to do in 2017?

1. Don’t panic.

Several options for participation and collection of data exist. Reductions in Medicare payments will not be implemented until January 1, 2019, which means that you have until March 31, 2018 to start the submission process for 2017 data.

2. Participate.

Physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists who bill Medicare more than $30,000 a year or provide care for 100 Medicare patients must participate. For providers new to Medicare in 2017, participation is not required until the next year.

3. Pick one of two.

Two tracks for participation as a Qualified Participant exist: (1) Advanced Alternative Payment Model (APM); or (2) Merit-based Incentive Payment Systems (MIPS). While both tracks offer enhanced payment based upon quality and reporting factors, the APM program provides that physicians who participate with at least 25 percent of their Medicare payments or 20 percent of their Medicare patients through an advanced payment system will be paid a five percent incentive fee starting in 2019. This system is designed for providers who are participating in specific value-based care models. Participation in the MIPS program is designed for providers in traditional, fee-for-service Medicare. Regardless of path selected, start collecting and managing your practice performance data and statistics. Incorporate data collection into your everyday practice through your electronic health records system.

4. Easing requirements for other programs.

MIPS rolls together three legacy programs – Meaningful Use, Physician Quality Reporting, and Value-Based Payment Modifier. Providers will earn payment adjustments based on performance in four categories linked to quality and value similar to previous programs. CMS has a gradual path of participation to allow physicians/eligible providers to pick their pace. This should streamline the process and eliminate some of the burdens of compliance with the legacy programs.

5. Adjustments don’t start until 2019.

While non-participation in 2017 results in an automatic four percent negative quality payment adjustment in 2019, submission of a minimum amount of data – one quality measure – results in no payment adjustment. Submission of 90 days of data has the potential for a small positive payment adjustment, and submission of a full year of data has the potential to earn a moderate payment adjustment.

6. Advanced APM participation means more money.

If physicians are able to participate in the APM program, a five percent lump sum incentive payment each year from 2019 through 2024 can be earned along with avoiding the MIPS adjustments. These programs include Medicare Shared Savings, Comprehensive ESRD Care Model, Next Generation ACO Model and Comprehensive Primary Care Plus Model.

Participation may not be mandatory for your practice as CMS has estimated that those who fall below the requirements of at least $30,000 in Medicare Part B charges or 100 Medicare patients are exempt from participation in 2017. CMS estimates that this represents 32.5 percent of clinicians, but accounts for only five percent of Medicare spending. CMS is also offering an option for small practices and solo physicians to join together in virtual groups and submit combined MIPS data. The details

In conclusion, the only certainty that providers have is slow uncertainty with Trump’s new HHS administration and the call for repeal of two regulations for every new one proposed. Because the long-needed change is finally here, providers should not miss out on the opportunity for enhanced payment. The complexities of providing health care only grow!

Lisa English Hinkle is a Member of McBrayer, McGinnis, Leslie & Kirkland, PLLC. Ms. Hinkle concentrates her practice area in health care law and is located in the firm’s Lexington office. She can be reached at or at (859) 231-8780. This article is intended as a summary of newly enacted federal law and does not constitute legal advice.