What the Final Rule Means for Small Practices – MACRA Monday

This guest blog post by John Squire, President and COO of Amazing Charts, is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program.

With the long-awaited issuance of the MACRA Final Rule earlier this month, the Centers for Medicare and Medicaid Services (CMS) tried to soften the blow for small practices in the first year of the program. Depending on the 2017 data you submit by March 31, 2018, your 2019 Medicare payments will be adjusted up, down, or not at all. This flexible timeline casts a wide net and should get everyone to participate.

Here’s a breakdown of all the options for 2017, from opt-out to maximum bonus, open to a small practice using a 2014 Certified EHR Technology (CEHRT). As you’ll see the sections get longer as we progress since each stage becomes more complex.

Be excluded from Medicare’s Quality Payment Program
In the Final Rule, CMS increased the exclusion threshold from $10,000 or less in Medicare Part B allowed charges, to $30,000 or less in billings, or seeing fewer than 100 Medicare Part B patients during the 2017 calendar year.

CMS estimates that this change will exempt approximately 30 percent of eligible clinicians from the Quality Payment Program. If you fall below the threshold, CMS will automatically exclude you. If you don’t meet the exclusion criteria, keep reading.

Do nothing… and take a penalty
Unlike previous programs such as Meaningful Use, there is no opt out for MACRA. If you don’t meet the exclusion requirement above, you are subject to downward adjustments. The Merit-based Incentive Payment System (MIPS) is the most likely option for small practices.

MIPS has a scale of 100 points. If you don’t report on any 2017 data by March 31, 2018, you’ll earn zero points and receive a four percent downward adjustment on your Medicare payments in 2019. This penalty rises over time, becoming five percent in 2020, seven percent in 2021, and nine percent in 2022!

A small minority of providers might be willing to make this financial sacrifice, but the vast majority of small practices using CEHRT are more likely to take a few simple steps to avoid the penalty.

Test out for a neutral outcome
You can avoid a downward adjustment by reporting just one quality measure, attesting to one improvement activity, or attesting to the four required Advancing Care Information (ACI) measures (formerly Meaningful Use) – for any length of time period in the calendar year of 2017. You’ll earn three points and there will be no downward adjustment to your 2019 payments.

This is a no-brainer for most small practices. If you use a 2014 Certified EHR, you’re already doing many of these activities, such as e-Prescribing, today. Belong to a Health Information Exchange? You’ve just earned your three points.

Participate for a bonus
You can earn four to 100 points for the chance of a small, moderate, or high positive adjustment to your payments in 2019. Submit at least 90 days of data on more than the minimum (i.e. on two or more quality measures, two or more improvement activities or more than the required four advancing care information measures) to earn more than three points.

Basically, the more information you submit over the longer length of time translates to more points and the more points you earn, the larger a positive adjustment on your payments will be, up to the maximum of four percent.

To earn the most possible points, (1) report for a full year on at least six quality measures (or a measure set); (2) attest to improvement activities worth 20 or 40 points (depending on the geography, size and make up of your practice); and (3) attest to all four of the required ACI measures as well as the five optional ACI measures, plus the one bonus ACI measure. Every 2014 Certified EHR technology has the functionality to support all ten ACI measures.

It could be easier than you think
CMS allows you to get a bonus for ACI when you use 2014 CEHRT to complete one of 94 eligible activities from the eight improvement activities categories. These include telehealth services, care coordination, or any kind of population health management. It could be something as simple as setting a flag for regular check-ups for your Medicare/Medicaid dual-eligible patients. A complete list can be found at this excellent CMS resource: https://qpp.cms.gov/measures/ia.

Even better news: providers participating in a patient-centered certified medical home (PCMH) will automatically receive full credit for the practice improvement category of MIPS. Similarly, providers participating in an Advanced Alternative Payment Model (APM) like an accountable care organization (ACO) will receive 50 percent of the full score for the practice improvement category.

Don’t get complacent – start today
While the agency’s idea of implementing a transition period was necessary, providers in small practices can’t get complacent. The formula for success is going to change very quickly. January 1, 2018 brings the full-year reporting requirement on the expanded measures.  The quality measures will still be required and the cost measures (previously called “resource use”) are going to dial up.  The year 2022 is only six years away, so unless the provider prepares next year, they could start facing some rather significant penalties.

About John Squire
John Squire, President and COO of Amazing Charts, has more than 27 years of high tech industry experience, 15 of them in Health IT. Before joining Amazing Charts, John was Senior Director of Alliances and Cloud Strategy for Microsoft’s U.S. Health and Life Sciences Business Unit.

Be sure to check out all of our MACRA Monday blog posts where we dive into the details of the MACRA Quality Payment Program.