Dr Kate Goodrich Discusses How CMS Changed MACRA After Reactions to Proposal

After CMS released its proposed rule for the Medicare Access and CHIP Reauthorization Act (MACRA), it received overwhelming feedback from clinicians that spurred the agency to make a number of changes for the final rule, according to Kate Goodrich, MD, director of the Quality Measurement and Value-Based Incentives Group in CMS. Some of these changes include designating 2017 as a transition year, removing cost measures from the calculation of a practice’s score, and raising the billing baseline so that more small practices will be exempt from the Measure-based Incentive Payment System (MIPS).

Transcript (slightly modified)

What changes were made for the MACRA final rule after taking into account comments on the proposed rule?

We made a number of changes in the final rule compared to the proposed rule based upon the comments that came in. We overwhelmingly heard from the clinician community that 2017 felt too soon for a lot of practices, particularly small practices. That some of the requirements were overly burdensome, in particular for small practices. And so we really tried hard to listen to everything we were hearing.

So a couple of key things that we changed. First of all, we designed the first year of the program to be a transition year. We know that practices that have been participating in the legacy programs—PQRS [Physician Quality Reporting Sysmte], Meaningful Use—are going to be fine. They have their systems in place, they understand their quality measures, they will not have a problem in 2017. But there are a lot of practices out there that have never participated, or have participated and maybe haven’t been as successful, and really feel like they need more time to understand the program, and are very worried about the burden of, the actual burden of reporting, and need to get a new EHR [electronic health record] system or partner with a registry or something like that.

So what we did was we said, okay, for the first year, for 2017, if you just try to participate, you have a new system you need to test out. You aren’t really sure which quality measures are going to work for you so you want to try out a few of them. You want to try out some improvement activities and understanding how to use your EHR to help your practice. Then we want you to do that. Because we want you to be in the program, so that you can be successful, but you may not be ready for full participation.

So even if you send in just a single quality measure or tell us you’re doing a single improvement activity, we are grateful for that and we’re not going to penalize you for it. And that should help you get ready for the future years of the program, where there probably is going to be more financial risk at stake. And certainly by the third year or fourth year of the program, we anticipate having it more fully implemented. But the first year or 2 is really a ramp-up period, to give people more time.

We also heard from folks that they were not really prepared to be measured on cost. We had proposed to weight the resource use, or the cost category, at 10%. While we are measuring cost in our legacy programs, for a small practice or a practice that is fewer than 10 physicians or a solo practice, you may not have had any exposure to cost measures before, even if you were participating in PQRS. Because of the way the program worked previously, the cost measures really were only applying to the large practices. So people said, look, we need more time to understand these cost measures. So, we’re still going to calculate cost measures for physicians, and we’re going to give them feedback on those cost measures, it’s just not going to count towards their score.

And the final thing I’ll mention is the low-volume threshold. So we proposed that you would be exempt from MIPS if you saw fewer than 100 Medicare beneficiaries a year or billed less than $10,000. And what we heard from people was that number of $10,000 was too low. Where we ended up finalizing was, if you see fewer than 100 Medicare beneficiaries or you bill less than $30,000 in charges through Medicare Part B, and we anticipate that that will exclude about 380,000 clinicians.