The Centers for Medicare & Medicaid Services (CMS) has released a proposed rule regarding the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. This article will summarize some of the details of the proposed rule, including an outline of the Merit-Based Incentive Payment System (MIPS), one of the key components of MACRA.

It is important to remember the MACRA legislation was focused solely on Medicare and replacing the sustainable growth rate. In short, MACRA is not up for repeal, nor is this a piece of legislation tied to the Affordable Care Act directly; therefore, it is not expected to change even if there is a change following the presidential election.

The proposed rule, released on April 27, 2016, is in fact the first step in introducing the rules for MIPS. As with any proposed rule from the Medicare system, there is a 90-day comment period allowing any interested party to criticize the rule, point out any inconsistencies, suggest changes, and propose modifications. The AUA, American Medical Association, American College of Surgeons, and other specialty organizations will be submitting comments by the deadline of June 27, 2016. As a participating provider, you have the opportunity to provide comments directly to CMS or to any one of the organizations that you feel may represent you.

CMS expects a number of comments will be received and that modifications to this initial proposal will follow. CMS also indicated that it expects this program will be modified as it is implemented over a period of several years.

MIPS: The four-legged stool

One of the key provisions of MACRA was the replacement of the current Physician Quality Reimbursement System, meaningful use, and value-based payment modifier—the three-legged “quality” stool—with MIPS, a four-legged stool comprising Quality, Resource Use, Clinical Practice Improvement Activities, and Advancing Care Information.

For reporting under MIPS, CMS has indicated that it will continue to accept virtually all MIPS-required reporting via multiple formats. Similar to the reporting for the value-based payment modifier (VBM) today, some reporting will be considered automatic or administrative, meaning CMS will use information submitted to CMS via claims to calculate a portion of the composite program score (CPS). The CPS is a single scoring system that will be used for eligible clinicians.

One of the stated goals of the new system is to eliminate overlap and decrease the workload of providers. (The jury is definitely still out on this projection.) Bonuses and penalties have been consolidated in the new system with a stair step approach to an eventual potential 9% bonus or a 9% penalty for all Medicare payments. Bonuses/penalties will be awarded based on a sliding scale and are budget neutral, which means you will be in competition with your colleagues.

Tables 1 and 2 demonstrate the group and individual reporting methods proposed for MIPS.

The four elements of the CPS

The proposed rule outlines the components of the MIPS CPS (table 3). Initially, the CPS will consist of the following elements:

Quality Performance. CMS has touted that MIPS lowers the administrative burden. The Quality Performance area does provide a small amount of relief because although measures are still required (similar to and including existing PQRS measures), there will “only” be six measures required, down from nine under the current PQRS.

Additionally, the Quality Performance component allows for more flexibility as the restriction of three cross-cutting measures has been removed. Now, the six measures must include only one cross-cutting measure and one outcome measure, if available. If an outcome measure is not available, the eligible clinician may select a “high-priority” measure.

As you can see from the tables, practices will be allowed to report in multiple ways. However, Medicare proposes to provide bonus points in the CPS for quality if you report through a qualified clinical data registry (QCDR), certified EHR, qualified registry, or web interface.

Resource Use. This component as proposed currently continues to employ similar formulas and methods currently in use in the VBM. CMS has acknowledged the system is flawed and is vowing to make some changes, but in the form of additional measures for episodes of care. This component is measured on the claims submitted to Medicare for each beneficiary and includes not only those services submitted by urologists but also services submitted by others. No additional reporting is required.

Clinical Practice Improvement Activities (CPIA). CPIA is a new measure under MACRA. The proposed rule allows for points for participating in any CPIA selected from a list to add points to increase your score in this component. Individuals and groups will be essentially graded on a curve compared to others. Medical home participants and those in alternative payment models will be required/encouraged to participate by including CPIAs in the requirement for those programs.

CPIAs include tasks like using telehealth for treatment, developing patient surveys and improvement protocols based on results, participation in population health review and study, improved coordination of care, active engagement of Medicare beneficiaries, patient safety protocols and practice assessment, and participation in a QCDR. In all, there are 90 proposed CPIAs with varying values that can be implemented for a period of 90 days. Medicare has encouraged more input in this area, and more clarification and education undoubtedly will be required once the final rule is published.

Advancing Care Information (ACI). Primarily, this portion of the CPS is to continue to encourage (insist/implore/require) the use of electronic health records based on the objectives of the HITECH Act, which provided incentives to adopt an EHR. As such, the proposed rule modifies the existing requirements for meaningful use. The reporting period under MIPS is for a full calendar year. Clinical quality measures, computerized physician order entry, and clinical decision support have been removed as specific reporting measures.

The CPS for this element is a combination of requirements including patient access and interoperability. Bonus points will be awarded to reporting to multiple sources and increasing patient access.

Summary

Stay tuned for the final rule, and be prepared to participate in or consider an alternative to participating in Medicare. There is a lot of money at stake.

A few issues that were identified by the AMA as problematic include limited measures for some specialties, including urology; retention of current flawed methods for VBM; costs to providers for certified EHR technology; lack of ability of providers to perform true security risk assessments; reliance on hospital-based programs for clinical services; continuation of policies that physicians already fail; and a complexity that makes MIPS difficult to understand and implement, among other issues.

MIPS, as noted by many, is going to impact the smaller practice more harshly than the larger group. Clearly, CMS has much work to do. Equally as obvious, physician groups have their work cut out for them.

This rule is not final, but history tells us that a proposed rule is the foundation for any final rule set. MACRA requires change, and the changes outlined in the proposed rule comply. We encourage you to watch for your AMA, AUA, and state publications, read the summaries, and react to them or in concert with them as you see fit. This change is not going to be easy, but change never is.

For our part, we will continue to watch for updates and attempt to develop recommendations and actions to meet the requirements of the “new Medicare” regardless of their final form.