MACRA 101: Noteworthy Changes in the Final Rule

Alanna Kroeker
Executive Editor
Loyola University Chicago School of Law, JD 2017


As our MACRA 101 series comes to an end, this article is intended to point out key differences between the proposed rule released earlier this year and the final rule which was released October 14th.  The lengthy final rule, reaching almost 2,400 pages, reflects many significant changes in response to stakeholder comments.  The idea of flexibility was a common thread amongst many of the commenters; flexibility for small providers, flexibility in reporting methods, flexibility in participation, and more.  The following are some of the more significant changes in the final rule:

  1. Big win for small practices

The final rule reflects changes that are meant to help smaller practices usher in this new system without being overburdened by its requirements.  One of the most noteworthy changes is the exclusionary threshold for MIPS.  If a clinician sees fewer than 100 Medicare patients or submits less than $30,000 Medicare Part B charges for the year, they will be exempt from reporting requirements under MACRA.  According to the AMA, this change in threshold is expected to exempt about 30% of physicians, compared to the 10% that were expected to be exempt under the proposed rule.  In addition, MACRA will provide for $20 million per year for the next 5 years to train and educate clinicians in small practices (15 clinicians or fewer) and those working in underserved areas.  This assistance will begin in December 2016 with local and experienced organizations providing guidance to small practices on how to select the most meaningful measures and health IT to support their practice.  The final rule also allows for “virtual groups” which is a reporting option for up to ten clinicians, however, this option will not be available in the initial transition year.

  1. Expanded access to Advanced APMs

The final rule eased the risk criteria for advanced APMs by reducing the percentage of expected expenditures for which the provider is responsible for under the APM from 4% in the proposed rule down to 3% in the final rule.  CMS will continue to explore additional models for qualification under the Advanced APM framework.  CMS also announced a new pathway to APM participation for 2018, the ACO Track 1+.  This new track requires a lower level of risk for providers to participate than the currently approved models.  CMS also announced that they anticipate adding new categories of APMs to the list of qualified arrangements and expect to include a new voluntary bundled payment model and the Advancing Cardiac Care Coordination Through Episode Payment Models program.

  1. Reduction in reporting burden under MIPS categories

Many commenters believed the proposed reporting requirements were too burdensome as written and CMS responded by reducing the burden under some categories.  The number of required measures have been reduced for the quality, advancing care information, and clinical practice improvement performance categories.  For performance year 2017, CMS altogether eliminated the Resource Use category from the composite score, but it will be back in the mix for performance year 2018.  In addition to reduced reporting requirements under each category, CMS confirmed the Pick Your Pace options available for the transition year.

Final Thoughts:

Initial reactions to the final rule seem to be fairly mixed, however, it appears that many providers are happy to see that CMS has taken their comments seriously and tried to implement changes in response.  In addition to listening to many grievances submitted through public comment, CMS has rolled out their Quality Payment Program website which is intended to help providers select the most meaningful measures under each category for their practice, again easing the transition to MACRA. Currently, the final rule is still open for public comment until December 19, 2016 and hopefully CMS will continue to respond favorably to clinician’s concerns.

As the first performance year draws near, providers must begin preparing for what is sure to be a significant change in healthcare reimbursement. One thing to note is that many of these flexible allowances for this initial transition year disappear for 2018 and providers will be expected to have fully transitioned over to MACRA reporting at that time.  The implementation of MACRA has effects across an entire organization: physicians and other providers have to understand how they can adapt their behavior to maximize reimbursement, operations must educate themselves and support the necessary changes under this new rule, IT must have a big role in advising what technology components are feasible and safe for the organization, and compliance should be involved every step of the way guiding each department on how they can optimize performance and ultimately reimbursement under MACRA.