This October, after listening to thousands of public comments, the Centers for Medicare & Medicaid Services (CMS) released its final rule for the Medicare Access and CHIP Reauthorization Act (MACRA), the new physician payment program designed to reward all Medicare Part B clinicians who put a premium on quality—rather than quantity—of care.

After reflecting on it in the weeks since, the following are my picks for the rule’s most notable developments:

  1. One of CMS’s strategic objectives is to increase the availability and adoption of robust Advanced Alternative Payment Models (APMs). In order to increase participation, CMS has set ambitious yet achievable goals.
  1. The types of eligible clinicians will likely expand over the first few years. In years one and two, just MDs, PAs, NPs, CNSs (clinical nurse specialists), and CRNAs will be eligible for MACRA, but by 2019, PTs, OTs, audiologists, and others will likely become eligible, too. 
  1. The criteria for clinicians who are exempt from the Merit-based Incentive Payment System (MIPS) has been updated for 2017. Many small practices will be excluded from the new requirements due to the low-volume threshold, which has been set at less than or equal to $30,000 in Medicare Part B-allowed charges, or less than or equal to 100 Medicare patients. Also exempt are those clinicians who are newly enrolled in Medicare, have billed $10,000 or less in Medicare charges and have 100 or fewer Medicare patients, or are significantly participating in an APM. 
  1. MIPS renamed a new performance category, Clinical Practice Improvement Activities (CPIA), to simply “Improvement Activities.” This category gives a clinician a choice of 94 activities across eight sub-categories, including care coordination, extended practice access, and population management. Most participants will attest to completing four improvement activities for a minimum of 90 days. Groups with fewer participants, or in rural areas, can attest to up to two activities in 2017.
  1. 2017 will be a pick-your-pace year for MACRA. While the Quality Payment Program kicks off on January 1, 2017, CMS wants clinicians to get acclimated to the new rules gently. So while ideally a clinician will begin collecting data on January 1, they’ll actually have until October 2 to begin collecting data. Regardless of when they start collecting, they’ll have to submit all of their data by March 31, 2018. That submittal will determine whether their 2019 Medicare payments will be adjusted up, down, or not at all.
  1. Participation in APMs. MIPS-eligible clinicians can participate in APMs, and if they receive a sufficient portion of their Medicare payments or see a sufficient portion of their patients through APMs in 2017, they can earn a five-percent incentive payment in 2019. For the transition year, clinicians who achieve a final score of 70 or higher will be eligible for an exceptional-performance adjustment funded from a pool of $500 million.
  1. CMS is exploring development of the Medicare ACO Track 1+ model to begin in 2018. Stay tuned: the model would be voluntary for ACOs currently participating in Track 1 of the Shared Savings Program or ACOs seeking to participate in the Shared Savings Program for the first time.
  1. The number of providers to be penalized in 2017 has been reduced. That’s because CMS lowered the performance threshold to 3, which is a neutral payment (i.e., no penalty or bonus). But even if a clinician reports just a single quality measure, they can get three points, which means the most likely way to get penalized in 2017 is to report nothing at all.
  1. The 10 percent weight cut from the Cost category has been added to the Quality category. Participants can choose just one measure to report in order to avoid a negative adjustment. Many may report up to six quality measures, including one outcome measure, for a minimum of 90 days. However, more measures are required for groups using the CMS web interface.
  1. Clinicians must engage in just four medium-weighted or two high-weighted Improvement Activities to receive full credit in this performance category in CY 2017, rather than the proposed six activities.

This final rule reflects how CMS genuinely wants to encourage clinicians to utilize this period of transition and get their houses in order, because participation is really going to pick up in the next few years. CMS anticipates that the iterative learning and development period will last longer than the first year of the program, CY 2017, as we move toward a steady state. Therefore, they envision CY 2018 to also be transitional in nature and serve as a ramp-up of the program and of the performance thresholds.

The bottom line: the time to get a jump start is now.

(This blog post has been revised to add further clarity.)

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