The final rule for the new Medicare payment system is expected by November, yet the draft rule issued in April has many physicians in small or rural practices concerned that proper considerations have not been taken to set them up for success.
When Congress enacted the Medicare Access and CHIP Reauthorization Act (MACRA), it recognized the unique challenges of small and rural practices and required that special consideration be given to these practice types. But, the proposed rule provides only limited flexibility for small and rural physicians, which may jeopardize their ability to successfully participate.
The infamous “table”
If you are in a small or rural practice, or a health professional shortage area, by now you’ve heard about the regulatory impact analysis table the Centers for Medicare and Medicaid Services (CMS) included in the MACRA proposed rule. Although many observers claimed that this table showed that the Merit-based Incentive Payment System (MIPS) would negatively impact most physicians in solo and small practices.
But, the table doesn’t actually present a clear picture of the likely impact under MIPS for five reasons:
- It doesn’t reflect the accommodations in the proposed rule that are intended to provide flexibility to small practices
- It only looks at 2014 quality and resource use data and omits performance in the Advancing Care Information and Clinical Practice Improvement Activities categories
- It includes many non-physician health professionals such as dentists and chiropractors, who were previously not eligible to participate in Medicare’s quality and resource use programs
- It includes specialties and practices that may be exempt from certain MIPS measures or categories
- It is based on 2014 data when physicians and other clinicians in many solo and small practices did not report their performance
Unfortunately, it is not possible to develop an accurate estimate of MIPS impacts, but it is clear that there are several changes CMS could make in the proposed MIPS policies that would improve the likelihood of success for physicians in solo, small, rural and health professional shortage area practices.
What needs to change before November
In a comment letter to CMS, the AMA outlined a number of recommendations to help these physicians succeed under MACRA:
- Increase the low volume threshold to exempt more physicians. The proposed rule would exempt from MIPS physicians and groups with less than $10,000 in Medicare allowed charges and fewer than 100 unique Medicare patients per year. It its comments, the AMA recommended that physicians with less than $30,000 in Medicare allowed charges per year or fewer than 100 unique Medicare patients. The key word above—other than the $20,000 increase to the threshold—is the word “or.” That provides two possibilities that create a safety net for physicians in solo and small practices.
- Compare practices to their peers rather than larger or more advanced entities. If peers are compared to peers, group size or specialty is no longer the determining factor to a practice’s success. The scoring methodology should not provide distinct advantages for practices simply because they are large or part of a hospital system, and should not penalize others for their size or unique patient population. Also, CMS should revise the rule using a consistent definition of small practices across performance categories so that physicians don’t qualify for one accommodation but not others.
- Lower reporting burdens for small, rural and similarly situated practices. CMS should include explicit exemptions and lower thresholds throughout the proposed rule for physicians in these practice types. Incorporating specific accommodations into each of the four MIPS categories as well as approving alternative payment models specifically designed for small and mid-sized practices will provide the flexibility these practices need for success.
- Provide education, training and technical assistance to small practices. Physicians in small or rural practices will need assistance to help them onboard the new programs—and this assistance should start as soon as possible. Help desks and staff ready to assist physicians when they have questions about the program should be provided by CMS as well as other educational information. The AMA is developing several resources that will soon be available. Check out the AMA’s MACRA resources for more information on the new Medicare payment system.
- Allow participation in virtual groups as soon as possible. The MACRA statute included the concept of virtual groups to help assist small practices. However, CMS proposes not to implement the groups until the 2018 performance period. CMS needs to form these groups as soon as possible. Smaller practices will need more time to learn about virtual groups to make them effective. CMS should provide a timeline for this implementation and offer significant flexibility in forming these groups including no initial, annual or other limits placed on the maximum number of groups approved each year—or required geographic proximity or specialty composition of the groups.
The MACRA rules are still in the draft phase. The AMA continues to work with CMS to make sure that all practice types and sizes are provided the flexibility to be successful in the new program.
For more information on how to prepare for the new Medicare payment systems, review the AMA’s MACRA checklist, or check out the AMA’s STEPS Forward™ collection of practice improvement strategies that can help your practice prepare for value-based care.
