MACRA final rule offers greater flexibility; AOA still has concerns

Medicare's novel physician payment framework officially takes effect Jan. 1, 2017, stoking concerns over all-new disruptive or burdensome policies, yet stated flexibilities in its final rule could work to doctors' advantage.

Released by the Centers for Medicare & Medicaid Services (CMS) on Oct. 14, the much-anticipated Medicare Access and CHIP Reauthorization Act (MACRA) final rule intends to "align and modernize" Medicare payments under a new Quality Payment Program (QPP) following Congress' ouster of the sustainable growth rate formula in 2015.  

This new incentivized reimbursement system offers two payment paths: the default track that the majority of doctors of optometry will participate in, the Merit-Based Incentive Payment System (MIPS) that combines elements of the Physician Quality Reporting System, the Value-Based Modifier and meaningful use programs; and the Advanced Alternative Payment Models (Advanced APMs) track. However, AOA and CMS expect few doctors of optometry to participate in Advanced APMs. Additionally, most other physicians will not be in Advanced APMs, as well.  

Under MIPS, doctors will receive small increases or reductions in their fee schedule reimbursement based on their ability to meet performance measures across four categories, including quality improvement, resource use, clinical practice improvement activities, and advancing care information (ACI, formerly known as meaningful use).  

Based on 2017 MIPS performance, doctors could see up to a 4% increase or penalty assessed on 2019 Medicare payments. This percentage maxes out at 9% in 2022 (based on doctors' 2020 MIPS performance). Advanced APM participants are excluded from penalties and instead may earn a 5% bonus.  

AOA petitions CMS for common-sense changes

Throughout the rulemaking process, AOA advocated for commonsense modifications to the QPP that would ensure the program worked as-advertised for optometry.  

Following publication of the proposed rule, the AOA submitted formal comments to CMS Acting Administrator Andy Slavitt on June 27 that communicated the need for more simplification and flexibility so that the MIPS program becomes a tool for quality improvement, rather than just another regulatory hurdle for doctors. These comments expressed concern for potentially disruptive, burdensome or unwieldy policies, supported greater flexibility and reinforced optometry's access to patients.  

After AOA's extensive review of the newly released final rule, it's clear that CMS took many of AOA's concerns—as well as that of other health care associations—under consideration and implemented policies tailored to the provider, as opposed to a one-size-fits-all approach.  

MACRA final rule highlights

Significantly, the final rule allows for sweeping exemptions from the program. Congress mandated that CMS create a low-volume exclusion so that doctors who treat low numbers of Medicare beneficiaries are not required to participate in the program.  

In the final rule, CMS indicated that doctors who have Medicare Part B allowed charges less than $30,000, or treat fewer than 100 Medicare patients, will qualify for the low-volume exclusion. If a doctor is part of a group of doctors (two or more) that reassigns benefits to one Tax Identification Number (TIN), and the group chooses to report on the group level, the low-volume threshold will be measured by combining the Medicare allowables of the group. CMS intends to develop a National Provider Identifier (NPI) search function so doctors can easily assess whether they qualify for the low-volume threshold exclusion. This search function will be made available by CMS closer to the reporting period.  

For those doctors who are required to participate in the program, CMS announced doctors can "pick their pace" of participation for the first performance period. Doctors ready to participate can start Jan. 1, 2017, while others can defer up to Oct. 2, 2017. Outlined in four gradient options that would ensure physicians do not receive a penalty in 2019, these options range from submitting some data to fully implementing.

These four options include:

• Test MIPS. Doctors can submit "some data," including data anytime between Jan. 1, 2017 and Oct. 2, 2017 to avoid a penalty. CMS says this option is to ensure doctors' systems are working and prepared for broader participation in 2018 and 2019. In defining "some data," CMS uses the example of submitting on quality measure or one improvement activity to avoid a penalty.
• Participate in part. Doctors can submit 2017 data for 90 days. CMS says this means doctors' first performance period could begin later than Jan. 1, 2017, and doctors would still qualify for a payment increase. Doctors would be required to report for a full 90-day period at a minimum and report more than one quality measure, more than one improvement activity, or more than the base measures in the advancing care information performance category.
• Participate in full. If doctors are fully prepared for the transition, they must meet all program requirements for a full 90-day period or more. Doctors choosing this path could receive up to a moderate payment increase. Physicians with exceptional quality performance are eligible for an additional positive adjustment for each year of the first 6 years of the program.
• Participate in an APM. Alternatively, doctors not participating in MIPS can join an APM, such as Medicare Shared Savings Track 2 or 3 in 2017, CMS says. Doctors receiving 25% of Medicare covered professional services or seeing 20% of Medicare patients through an Advanced APM in 2017 can earn a 5% Medicare incentive payment in 2019.  The number of APMs will be rather limited in 2017 and few doctors of optometry, an estimated 0.1%, will likely participate in APMs in the initial program year.
  

For those doctors required to participate in MIPS, the AOA's qualified clinical data registry (QCDR), AOA MORE (Measures and Outcomes Registry for Eyecare), will be an important tool for meeting MIPS program requirements.