ASNC Begins Deep Dive into MACRA Proposed Rule

On April 27, the Centers for Medicare & Medicaid Services (CMS) released the much-anticipated proposed regulations  that will govern implementation of the new Medicare physician payment system that replaces the sustainable growth rate formula repealed by Congress one year ago under the Medicare Access and CHIP Reauthorization Act (MACRA).

The new system offers physicians two pathways for Medicare payment beginning in 2019: the Merit-Based Incentive Payment System (MIPS) or participation in an alternative payment model (APM). As with past CMS reporting programs, MIPS scores will be based on the care that a physician or other eligible clinician delivers in 2017. 
New Performance Categories for Calculating Medicare Payment
MACRA sunsets CMS's current separate quality incentive programs, including the Physician Quality Reporting System, the physician value-modifier and electronic health record (EHR) meaningful use. Under the new MIPS, Medicare payment will be determined based on an eligible clinician's performance in the following categories: (1) quality, (2) resource use, (3) clinical practice improvement activities (CPIAs) and (4) Advancing Care Information (previously referred to as EHR meaningful use). 

With limited opportunity from the outset for nuclear cardiologists to participate in APMs other than through accountable care organizations, it will be important that the rules governing participation in MIPS not disadvantage specialty physicians.  

Alternative Requirements for Non-Patient-Facing Eligible Clinicians
CMS has proposed alternative requirements for non-patient-facing, MIPS-eligible clinicians across the proposed rule. In its analysis, CMS identified the majority of non-patient-facing Medicare clinicians to include anesthesiology, nuclear medicine and pathology. CMS proposes to define a non-patient-facing, MIPS-eligible clinician as an individual eligible clinician or group that bills 25 or fewer patient-facing encounters—such as general office visits, outpatient visits and surgical procedure codes—during a performance period.  

CMS Lays Out New Rules for EHR Use
Most notable among proposed regulations is CMS's scaled back approach to the current EHR meaningful use program. Although CMS proposes the Stage 3 EHR meaningful use objectives and measures as the basis for the new Advancing Care Information performance category, CMS notably moves away from the concept of requiring a single threshold for a measure and instead incentivizes continuous improvement and recognizes onboarding efforts among late adopters and MIPS-eligible clinicians facing continued challenges in full implementation of certified EHR technology in their practices. Still, requirements could prove challenging for some specialties and small practices, putting them at risk for a zero Advancing Care Information performance score. Read ASNC's summary of the Advancing Care Information performance category.  

Activities Aimed at Improving Care Would Be Recognized Under MIPS
For the first time, MIPS will recognize activities for calculating an eligible clinician's overall performance score, identified as improving clinical practice or care delivery that, when effectively executed, are likely to result in improved outcomes. The CPIA performance category would comprise 15 percent of an eligible professional's performance score, and while the proposed rule appears to heavily weighted in favor of primary care (for example, giving MIPS-eligible clinicians or groups certified as a patient-centered medical home or comparable specialty practice the highest potential CPIA score), CMS has proposed a broad array of qualified activities

Earlier this year, ASNC spoke with CMS officials about the types of CPIAs that would be applicable to nuclear cardiologists. In the proposed rule, CMS notes its consultation with “organizations that represent cardiologists involved in nuclear medicine.” CMS notes that Nuclear Cardiology and other organizations suggested consideration for appropriate use criteria (AUC) as a CPIA. As a result, CMS has incorporated AUC into some of the activities but is encouraging MIPS-eligible clinicians or groups who are already required to use AUC (such as through CMS's AUC program for advanced imaging) to report a CPIA other than one related to appropriate use. 

ASNC has created a MACRA Resource Center  where it will post updates to its analysis of the proposed rule. ASNC will submit comments to CMS by the deadline of June 27, 2016