CMS releases new MACRA proposed rule

At the agencies

The Centers for Medicare and Medicaid Services (CMS) issued the 2018 Quality Payment Program (QPP) proposed rule, which addresses the two channels for physician payment established by the Medicare Access and CHIP Reauthorization Act (MACRA). Through MACRA, physician payments are possible using the Merit-Based Incentive Payment System (MIPS) or Alternative Payment Models (APMs).

The QPP proposed rule signals a shift in priorities, reflective of the Trump administration’s interest in easing the regulatory burden on providers while maintaining incentives for quality care. Notably, the proposed rule changes the threshold requirements for MIPS reporting by raising the number of patients a provider must see before triggering MIPS reporting requirements (thereby limiting the number of providers subject to the rule requirements). For those subject to the regulations, there are new options that allow providers to aggregate their data on how they care for patients. Other changes include not requiring doctors to use 2015 certified electronic health records (EHRs) next year, a delay in evaluating providers per patient expenditures and making it easier for physicians to qualify for APM designation (and earning the associated 5 percent bonus payment).

The CMS Office of Inspector General (OIG) issued a report evaluating payments made to eligible providers (EPs) and hospitals to encourage “meaningful use” of EHRs finding that $729.4 million in payments (12 percent of all payments made) have been paid in situations that did not meet the federal requirements. EPs and hospital systems attest to their meaningful use of EHRs in order to qualify for these payments. The CMS OIG has recommended increased training in documentation and compliance with these rules, and has encouraged CMS to attempt recovery of the $729.4 million paid in inappropriate payments. If CMS chooses to take the OIG’s recommendation it could lead to recovery actions against recipients of these incentive payments.

On the Hill

The Senate GOP released the Better Care Reconciliation Act (BCRA), the Senate bill aimed at repealing and replacing the Affordable Care Act (ACA). This bill eliminates the individual mandate that requires individuals to have health insurance, winds down cost-sharing reduction (CSR) payments (that are paid to insurers to subsidize the cost of certain plans offered through health insurance exchanges) over a period of two years and defunds Planned Parenthood for one year. Additionally, the bill fundamentally alters traditional Medicaid funding for states (allocating a set amount of funds for each enrollee), rolls back Medicaid expansion over a period of three years (starting in 2021), reduces the number of people eligible for subsidy payments from 400 percent to 350 percent (starting in 2020) and retains the requirement that insurers cover those with preexisting conditions but allows states greater flexibility to waive protections.

A vote on the BCRA is expected next week, and the Senate Parliamentarian is expected to rule on the provisions within BCRA before the vote. The Senate Parliamentarian’s determination about what elements of the bill may be passed through reconciliation (requiring 50 instead of 60 votes) will have a significant impact on the final version of the bill.

Further complicating the passage of BCRA is the continued fallout at the state level in the health insurance marketplaces. Citing increasing difficulties with the market, Anthem announced that it will no longer participate in the Indiana or Wisconsin health insurance exchanges for the 2018 plan year. It appears that other states could face a similar situation.

MedPAC has released its June 2017 Report to Congress that covers 10 issue areas critical to Medicare policy, including:

  1. implementing a unified payment system for post-acute care,
  2. Medicare Part B drug payment policy issues,
  3. using premium support in Medicare,
  4. the relationship between physician and other health professional services and other Medicare services,
  5. redesigning the Merit-based Incentive Payment System and strengthening advanced alternative payment models,
  6. payments from drug and device manufacturers to physicians and teaching hospitals in 2015,
  7. the medical device industry,
  8. stand-alone emergency departments,
  9. hospital and skilled nursing facility (SNF) use by Medicare beneficiaries who reside in nursing facilities, and
  10. provider consolidation and the role of Medicare policy.