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The MACRA Landscape: Risk and Reward? Part II
November 04, 2016
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The MACRA Landscape: Risk and Reward? Part I
November 02, 2016

The MACRA Landscape: Risk and Reward? Part I

Read on for a breakdown of what to expect from the near-final MACRA rule announced by CMS on October 14, 2016.
If the intent of the Medicare Access and CHIP Reauthorization Act (MACRA) is to move providers into a risk structure, via a so-called value-based care model or ongoing carrot-stick quality reporting on more singular levels, then the almost-final rule is merely a preview in the short term.
For 2017 and 2018, marginal risk and the minimum loss rate have been dropped from the nominal risk equation for providers participating in Advanced Alternative Payment Models (APMs). As buried about halfway through the rule—page 1624 to be exact—nominal risk will only address a revenue standard of 8% of average estimated total Medicare Parts A/B revenue. And also like much else in the rule, this level is expected to grow. The rule states that CMS will propose the revenue risk to rise to 10 to 15% beginning in 2019, and include as part of the equation…“or 3% of expected expenditures” as a benchmark standard.
Keep in mind also that this rule comes with a comment period toward a final-final rule prior to January 1, 2017.
For medical homes, which carry a lot of flexibility as an Advanced APM, as an automatic scoring element in the Merit-based Incentive Payment System (MIPS) and so forth, CMS has been clearer on long-term Advanced APM risk. Based on a total amount a provider could “owe for forego,” risk here is set at 2.5% of the APM entity’s total Medicare Parts A/B revenue, increasing to 3% in 2018, 4% in 2019, and 5% for 2020 and beyond.
What does it all mean? Coupled with Advanced APM Qualified Professional thresholds unchanged from the proposed rule and an expanded overall low-volume threshold for MIPS exclusion, the launch of MACRA decreases the risk and offers reward if providers are motivated to seek it.
For MIPS, the composite performance score has been set at a score of 3. Those scoring at 70 or more can receive a bonus of up to 10% of Part B charges from the $500 million pool set aside for this.
What’s also encouraging about the rule is the accelerated language around introducing expanded APMs and/or Advanced APMs such as bundled payments, which is really the only way specialists can get into the Advanced APM game.
Taken together, if MACRA comes out of the gate with a risk/reward whimper, that’s fine, because it’s not wrong to consider it a forever program.
The New Normal
Overall, deeming 2017 a “transition year,” the October 14 rule is option-heavy, lowers the bar for first-year measure reporting within the MIPS scoring track, lowers the bar for MIPS exemption, and sets a year-one reporting deadline of March 31, 2018.
For the Advanced APM scoring track, the rule maintains 5 models for now, and expands the criteria for “MIPS APMs,” meaning risk-bearing models bringing automatic MIPS scoring credit for eligible clinicians (ECs) who may not qualify as an Advanced APM: Advanced APM participants can receive a 5% bonus and be exempt from MIPS.
MIPS APM providers may well be participating in the same models, but may not reach certain patient count or payment levels to received Advanced APM benefits. These so-called Qualified Professional thresholds are unchanged from the percentages of the proposed rule. As the rule clarifies, existing and new model types that will bring automatic MIPS scoring credit also clarifies another APM set called “other payer” models and accompanying benefit options, all detailed below.
This means that the overall list of APMs is expected to grow, this year and next. And yes, this means this rule is not completely final; a 60-day comment period ensues and one or more new APMs are expected in a final-final rule by January 1, 2016.
CMS has provided a dedicated Web page on the rule, which includes links to various fact sheets and the entire 2300-page document. The Web pages include the entire list of 271 quality category measures and 93 (clinical practice) improvement activities ECs can select from for MIPS. Webinars will no doubt also be announced.

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