The MACRA Landscape: Risk and Reward? Part II

You can access Part I of this article here.

Additional Alternative Payment Structures (Medicare Shared Savings Program [MSSP] Track 1+)

Right now the Advanced Alternate Payment Models (APMs) are CPC+, MSSP Tracks 2 and 3, Next Generation accountable care organizations (ACOs) and the 2-sided Comprehensive End-Stage Renal Disease care model.

The Medicare Access and CHIP Reauthorization Act (MACRA) final rule more than hints that a MSSP Track 1+ can be expected for 2017, as well as re-launched programs such as the Maryland All-Payer Model and the Comprehensive Care for Joint Replacement.

Into the weeds, the rule notes it is finalizing 2 types of Advanced APMs: advanced and “other payer.” Other payer models can be Medicaid or commercial payer ACO models, and medical homes. Expanding Advanced APMs through bundled payments is really the only clear way that specialists can get into this structure, along with some medical home models.

Again, the near-final rule notes this will all become clear by January 1, 2017. The rule also notes that providers at Federally Qualified Health Centers, Rural Health Centers, and Critical Access Hospitals who meet Qualified Professional (QP) thresholds could be eligible for Advanced APMs. That makes sense in line with anticipated Medicaid models coming into play next year and/or beyond. Based on language in the proposed rule, CMS is actually accelerating the growth of Advanced APMs beyond what was expected based on language in the proposed rule.

Reporting Strategies and Looking Ahead

Still in the weeds, and carried over from the proposed rule, is another designation called a partial QP. These providers can fall below the QP threshold, but are risk-bearing enough that they can decide to forego the Merit-based Incentive Program (MIPS) or elect to report to MIPS.

This means providers will need to examine September Quality and Resource Use Reports, or QRUR, scores past Value-Based Modifier results, and understand the MACRA’s APM benchmarking formula to make educated decisions about optimal reporting options and whether to report as an individual or group.

With 2017 being a relatively low bar overall, the time is arguably there for analysis. Keep in mind also that this rule notes the emergence, likely next year, of a “virtual group reporting” option for small practices, allowing eligible clinicians to be merged in with others.

Data Blocking and the Other Final Rule

In case you missed it another final rule was also issued October 14, 2016, this time by the Office of the National Coordinator for Health Information Technology (ONC), and this time more final. This rule expands ONC’s oversight of health information technology (IT) platforms and healthcare entities, including provisions to decertify health IT solutions and mandate “corrective action” if patient safety and security issues arise.

The crossover with the MACRA rule includes language about lingering perceptions of data blocking:

As the MACRA rule puts it, “We are finalizing the requirement that MIPS eligible clinicians, as well as EPs [in meaningful use], eligible hospitals and critical access hospitals (CAHs) under the existing Medicare and Medicaid EHR Incentive Programs demonstrate cooperation with certain provisions concerning blocking the sharing of information under section 106(b)(2) of the MACRA and, separately, to demonstrate engagement with activities that support health care providers with the performance of their CERHT such as cooperation with ONC direct review of certified health information technologies.”

Congress, Rulemaking to Come, and CPC+

Lingering congressional bills on health IT also include data blocking and decertification language, so expect stakeholders very much against the ONC rule—based on regulatory and statutory powers—to ask Congress to block ONC powers and establish oversight legislatively.

Finally, given that MACRA is such a long-term and seemingly all-encompassing payment model structure, it’s safe to expect annual rulemaking in line with a final-final rule upcoming for 2017. Right now though, and pending comments, it looks like the final-final rule will primarily deal with expanding APMs for 2017 and beyond, along with the means to apply for them.

And a final-final note, practices that applied to be Comprehensive Primary Care Plus participants should learn the results “by around Thanksgiving,” CMS representatives have said.