MACRA Final Rule Offers Options for Value-Based Reporting

Psychiatrists can ease into the new Merit-Based Incentive Payment System (MIPS) by choosing among three relaxed “Pick Your Pace” options for 2017, the first year under the new system.

Analysis by APA staff of the final rule governing the Medicare Access and CHIP Reauthorization Act (MACRA)—which established the MIPS to replace current quality programs and repealed the sustainable growth rate formula for Medicare payment—reveals that under “Pick Your Pace,” psychiatrists and other clinicians can avoid penalties in 2019 by reporting just one measure in 2017 for “Quality,” one “Improvement Activity,” or all measures for “Advancing Care Information,” which measures electronic health record (EHR) use. (For a summary of the MIPS reporting categories and how the Centers for Medicare and Medicaid Services [CMS] will score clinicians on the categories, see box on page 5 at left).

Reporting complete MIPS data for part or all of 2017 can earn modest or slightly higher bonuses in 2019. The basic MIPS annual bonuses and penalties will be up to 4 percent in 2019, 5 percent in 2020, 7 percent in 2021, and 9 percent starting in 2022. These are calculated for each eligible clinician (or group) and occur as an addition or reduction to their Medicare Part B payments. “Exceptional performers” can earn an additional bonus of up to 10 percent.

Depending on a number of individual practice variables, however, some psychiatrists may want to decline to report and accept the 4 percent penalty for 2017, assessed in 2019. APA staff have developed the Payment Reform Toolkit, webinars, and other tools to help members navigate the transition to the new payment system (see sidebar.)

Additionally, psychiatrists who report for 2017 will not be penalized for seeing sicker, lower income patients, and resource utilization on the part of their sicker, lower income patients will not be counted in clinicians’ MIPS score that year. Additionally, psychiatrists will have to report only four medium-weight or two high-weight Improvement Activities and only five Advancing Care Information Measures (for EHR use) to get credit in those categories.

Aside from the options for a relatively “soft landing” in the first stages of the new era of value-based reimbursement, it also appears that a great many psychiatrists will actually be exempt from reporting altogether.

As reported in Psychiatric News (November 18), MACRA exempts clinicians from MIPS reporting requirements and payment adjustments if they fall below a “low-volume threshold.” CMS has defined this threshold as having Medicare Part B allowed charges less than or equal to $30,000, or providing care for 100 or fewer Part B-enrolled Medicare beneficiaries. The threshold was set fairly low to reduce “the risk of clinicians withdrawing as Medicare suppliers” and “mitigate an undue burden on small practices,” according to CMS.

For 2017 reporting, CMS estimates the low-volume threshold will exclude 49 percent (16,521) of the 33,632 psychiatrists who see Medicare Part B beneficiaries. Additionally, psychiatrists for whom 2017 is their first year of Medicare participation will be exempt.

CMS is planning to create an “NPI [National Provider Identifier] level lookup feature” that will allow psychiatrists to determine if they are below the threshold and therefore excluded from MIPS. The feature should be ready in January 2017 or shortly thereafter.

For each MIPS reporting year, psychiatrists will have two 12-month time periods in which to qualify, and clinicians will be exempt if they are below the threshold in either or both of these. For the 2017 reporting year, these two qualifying periods are from September 2015 through August 2016 and September 2016 through August 2017. The low-volume analysis will be calculated separately at the individual NPI level, and then also at the group TIN (Tax Identification Number) level, depending on how each psychiatrist is paid.

There is still yet another option for clinicians to be exempted from MIPS—participation in an Advanced Alternative Payment Model (APM). APMs include certain accountable care organizations, bundled payment arrangements for renal disease or cancer, medical homes, and the Comprehensive Primary Care Plus program.

To be considered an Advanced APM, a model must be approved by CMS and meet four criteria:

• It must be approved by the CMS Innovation Center, part of Medicare Shared Savings Program, a federal demonstration, or required by federal law.

• It must require at least 50 percent of its participants to use Certified EHR Technology. Any hospital within the APM must also use Certified EHR Technology.

• It must tie at least some payments to performance on one or more quality measures comparable to those under the MIPS program, including one outcome measure.

• It must accept financial risk—that is, it must assume financial consequences for failing to meet cost and/or quality metrics. These could be lower payments, deductions, or repayments. ■