Proposed rules released by CMS concerning the Medicare Access and CHIP Reauthorization Act contain some notable changes for the 2018 reporting year (the 2020 payment year). The overall feel of the changes is a slowdown of MACRA progression, which should come as no surprise considering that CMS has already made 2017 a “transition” year for providers and delayed many of the requirements involving financial risk. The newest round of changes would further delay serious financial ramifications, adding bonus points, higher thresholds, and caveats to rules that will help providers avoid penalties.

Many of the changes will mainly affect the Merit-based Incentive Payment System, which is one of two possible reporting tracks providers can chose under the Quality Payment Program (Advanced Alternate Payment Models is the second option). Key changes in the proposed MIPS rules include the following:

  • Boost the low-volume threshold that would allow physicians with fewer than 200 patients or $90,000 in Part B charges to be excluded from MIPS.
  • Allow small and rural doctors to form “virtual groups” for participation in MIPS.
  • Allow 2014 Certified Electronic Health Record Technology to be used for the 2018 reporting year.
  • Give bonus points for exclusive use of 2015 CEHRT.
  • Add possible bonus points for small practices, reducing the likelihood of penalties.
  • Possibly reduce cost-scoring weight from 10 percent in 2018 to zero.
  • Introduce an optional voluntary facility-based scoring system based on the Hospital Value-Based Purchasing Program, which converts a hospital’s Total Performance Score into a MIPS score. This would only be available for facility-based clinicians who provide 75 percent of services in an inpatient setting or ER.

During the first comment period, many providers and health systems expressed concern about the timeline for implementing MACRA, fearing CMS was pushing too far, too fast. The proposed rule released this week suggests their voices are being heard, as many of the 2018 rules would significantly cut down on penalties for eligible clinicians who do not meet MACRA requirements.

While this is good news for those who were in danger of paying a fine, providers who were expected to excel under MIPS could be out of luck. MIPS uses a balanced-budget system, which means bonuses are paid out of fines. With fewer potential penalties paid under the newly proposed rules, there will subsequently be less money in the bonus pool to pay the high achievers. This could cause some providers to opt for the Advanced Alternative Payment Model, which exposes them to risk but would allow for greater financial gain.

The proposed rules also stand to impact technology, effectively pushing back development by an entire year. For years, CMS has been advancing technology through initiatives that tie reimbursement to quality and outcomes recorded by EHRs, forcing providers and health systems to invest in such systems. By pushing back the requirement to invest in new EHRs, the tech timeline is also pushed back a year, hindering progress in this area.

Because MACRA has an open-comment policy, the law will continue to evolve and change, with comments on the 2018 proposed rules remaining open until August 18 and a final rule expected later in the fall. While the law itself will continue to move forward, it does so at a much more leisurely pace under the proposed rules. Year 2 is almost turning into Transition Year 2.0, slowing progress and development.

While this was clearly not the envisioned plan when MACRA was created, a slower pace could allow for more providers to achieve success under the law, as they will have more time to adjust and prepare for the new rules. Despite the delay, MACRA will continue to roll ahead, pushing new reimbursement models that are tied to results rather than service volume. Providers and health systems should stay on top of changes to the law as it progresses, as shifts will most likely affect future strategy and investments.


Evan Camden is an associate analyst at DRG and an expert on electronic health records. Follow him on Twitter at @EvanCamdenDRG


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