Essential Considerations With MACRA Participation In 2017
Several drop-dead deadlines for ICD-10 implementation came and went, giving us all more time to get ready. If you think the same thing will happen with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), guess again.
The Centers for Medicare and Medicaid Services (CMS) announced on Sept. 8 that there will not be a delay in implementation. However, the CMS will allow physicians to pick their pace of participation for the first performance period that begins Jan. 1, 2017.
The CMS Acting Administrator Andy Slavitt wrote that in 2017, “eligible physicians and other clinicians will have multiple options for participation. Choosing one of these options would ensure you do not receive a negative payment adjustment in 2019.”1 However, we have to wait for the release of these options and other supporting details, which will be described fully in the final rule. The final rule should be published around Nov. 1.
There are four options provided by CMS for physicians to consider.
First option: Test the Quality Payment Program. With this option, as long as you submit some data to the Quality Payment Program, including data from after January 1, 2017, you will avoid a negative payment adjustment. This first option is to help you evaluate whether your system is working and that you are prepared for greater participation in 2018 and 2019 as your learning curve increases.
Second option: Participate for Part of the Calendar Year. You may choose to submit Quality Payment Program information for a reduced number of days. This means your first performance period could begin later than Jan. 1, 2017 and your practice could still qualify for a small positive payment adjustment. As Slavitt writes in his blog, “For example, if you submit information for part of the calendar year for quality measures, how your practice uses technology, and what improvement activities your practice is undertaking, you could qualify for a small positive payment adjustment. You could select from the list of quality measures and improvement activities available under the Quality Payment Program.”1
Third option: Participate for the Full Calendar Year. Practices that are ready to go on Jan. 1 may choose to submit Quality Payment Program information for a full calendar year. This means your first performance period would begin on Jan. 1, 2017 and if you submit information for the entire year on quality measures, how your practice uses technology, and what improvement activities your practice is undertaking, you could qualify for a modest positive payment adjustment. CMS reportedly has seen “physician practices of all sizes successfully submit a full year’s quality data, and expect many will be ready to do so.”1 I remain somewhat skeptical on this point for small or solo practictioners.
Fourth option: Participate in an Advanced Alternative Payment Model in 2017. Instead of reporting quality data and other information, an advanced alternative payment model allows you to participate in the Quality Payment Program by joining an Advanced Alternative Payment Model, such as Medicare Shared Savings Track 2 or 3 in 2017. If you receive enough of your Medicare payments or see enough of your Medicare patients through the Advanced Alternative Payment Model in 2017, then you would qualify for a 5 percent incentive payment in 2019. Just know, however, that an alternative payment model that qualifies under MACRA will bring with it a greater amount of financial risk. It is also known that a majority of current entities that are participating in an Advanced Alternative Payment Model will not likely meet the guidelines set forth in the new rules. Accordingly, it is likely that smaller practice/practitioners will not be able to choose the fourth option for participation.
Earlier in September, congressional leaders wrote a letter to the U.S. Department of Health and Human Services, asking for flexibilities within the MACRA law. Two areas of concern for eligible physicians were the effect MACRA would have on small practices and the short window that participants will have from the release of the final rule to the scheduled Jan. 1 start for collecting the data required for reporting and implementation of technologies and improvement activities required under the program. The CMS believes it will address these concerns when it releases the final rules Nov. 1. We will have to wait and see on this point.
Should You Skip Participation Altogether?
After hearing about MACRA at every turn, perhaps you are considering not participating. There are several things to consider before making this decision. It is not just whether you want to avoid a penalty to your Medicare reimbursement, or to take a hit of 4 percent in 2019 and up to 9 percent in subsequent years. You have to consider that private payers may also take this approach to reimbursement once they determine how Medicare has controlled costs and “improved quality.” Could you afford to not participate with private payers that follow the CMS lead with MACRA and reimbursement?
There are other questions I have considered with the impending MACRA changes. What is the actual cost to my small solo practice if I chose to participate? Is my current electronic medical records (EMR) vendor able to collect all the data I need for reporting, or will I have to change my EMR vendor? There may be a greater fee associated with my current or new EMR vendor to be able to collect the data seamlessly. How much time will my staff and I have to spend on implementing the specific improvement goals, or patient engagement items required under the program? This clearly translates into increased financial resources I will have to allocate for this activity.
The decision will not be easy. Do a return on investment calculation before you either leap forward to participate or not participate.
I feel that most physicians will fall into three categories regarding the decision for participation.
1. You are just starting practice and as such, you have no option but to participate from the start. You have a long career ahead of you. If you do not participate now, your ratings and or scores may affect your ability to contract with private insurance panels or affect your visible quality ranking that CMS will be publishing.
2. You are perhaps in the middle of your career. You also may feel that you have no option but to participate in this program. However, consider the costs of participating versus not participating before making your decision. Your considerations are about the same as the young practitioner as your composite score that CMS will calculate may be low and you may find yourself left off insurance panels or hospital groups.
3. You may be one to five years from retiring. In this case, you may chose not to participate as it would have little long-term effect on your ability to practice albeit with some short-term impact financially. If you don’t have a large Medicare population, this financial impact may be a lot less than the costs involved to participate.
Clearly, it is not just a simple short-term 4 percent or even the 9 percent loss in reimbursement. The decision to participate may impact your career in a way you have not thought about. Even referring patterns may change as primary care providers may look at scores of specialists and refer their patients to those who are showing higher ranking scores, “better outcomes,” and participation with quality improvement programs.
Reference
1. Slavitt A. Plans for the Quality Payment Program in 2017: Pick YourPace. CMS Blog. https://blog.cms.gov/2016/09/08/qualitypaymentprogram-pickyourpace/ . Published September 8, 2016.
