Rulemaking in the spring of 2019: What to watch for

David Heller, Corporate Counsel, Regulatory Affairs

David Heller, Corporate Counsel, Regulatory Affairs

It is spring, which means we now enter CMS’s rulemaking season.

Between now and the summer, physician organizations can expect a host of proposed regulations that will impact their participation in various programs in 2019. This article explores what providers can expect with respect to MACRA and the Quality Payment Program (QPP).

The Bipartisan Budget Act of 2018

To begin, the Bipartisan Budget Act of 2018 will impact the proposed QPP rule in two notable ways. Originally, MACRA’s statute required CMS to set the performance threshold as the mean or median of prior years’ MIPS scores in 2019, and set Cost at 30%. The American Medical Association, joined by a host of other physician associations, urged Congress to extend MACRA’s transitional provisions.

Congress responded. In the Bipartisan Budget Act of 2018, it extended the transitional period through 2021. Until 2022, CMS will set the MIPS performance threshold higher than the prior performance period, but it will not be required to use mean or median scoring. Also, CMS has the discretion to set Cost anywhere between 10% and 30% of the MIPS composite score. The year 2022 will bring about full MIPS implementation. In 2022, payment adjustments will represent 9% of physicians’ Medicare Part B revenue. The performance threshold will be the mean or median prior years’ MIPS scores, and Cost will be 30% of the MIPS composite score.

Despite these recent adjustments, providers should not expect a repeat of the Sustainable Growth Rate (SGR), or further delays. Congress replaced the SGR with MACRA with overwhelming bipartisan support. In the House, it passed with 392 votes, and in the Senate, with 92.

In response to MedPAC’s recommendation that Congress repeal and replace MIPS, Rep. Frank Pallone (D-NJ), stated, “We just provided some significant flexibility,” POLITICO’s David Pittman reported.

“Like other members of Congress who clearly can’t contemplate another major payment reform effort, Pallone appeared puzzled by MedPAC’s position,” Pittman wrote.

What’s coming in the proposed rule

So what should providers expect in 2019’s proposed rule?

We will see a MIPS performance threshold that is higher than 15, 2018’s performance threshold. Given that Cost will have new episode-based measures introduced this year, it is likely CMS will weigh it closer to 10% than 30%. We also expect adjustments to Advancing Care Information (ACI), and clinical quality measurement.

CMS Administrator Verma recently announced a “complete overhaul” of meaningful use. The federal agency further elaborated that it wanted redesign measures to focus on interoperability and clinical outcomes. Right now, the details are still murky. This is somewhat in tension with another initiative, Patients Over Paperwork, which focuses on reducing clinician burden. How CMS balances burden reduction with recording clinical document exchange will be something to look for — and comment on — when the rule is proposed. Within meaningful use and ACI, we can also expect measures that relate to e-prescribing or prescription drug monitoring programs given the administration’s focus on the opioid epidemic.

With respect to reducing clinician burden, two elements stand out. The first is updating Evaluation and Management codes. Administrator Verma explained that “the billing requirements are outdated, so we will be updating and streamlining them so that doctors can spend less time using their EHRs, and more time with their patients.” This is in addition to the Meaningful Measures project, where CMS aims to reduce the administrative burden associated with quality measures and to bring a focus on measures that are outcomes-based and clinically relevant.

Concluding thoughts

In short, the proposed regulations this spring will offer plenty of meat for everybody’s consideration. From burden reduction to opioids and technology, the administration is considering significant adjustments to MACRA and QPP. Because of the short timeframes between when a rule is finalized and when it is implemented, we generally recommend that practices try to understand what is proposed so they have sufficient time to prepare their physicians and staff. That’s even more true this year, with the volume of initiatives and activities in play.

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