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Yesterday, CMS released its proposed 2018 regulatory updates for MACRA’s Quality Payment Program. Officially titled, "CY 2018 Updates to the Quality Payment Program," the rule includes several key policy updates that would impact providers’ participation in MACRA starting in 2018. And at 1,058 pages in length, for those who have other items atop their summer reading list, here are 10 Things to Know about CMS’ New 2018 MACRA Proposed Rule:

  1. Use of a 2015 certified EHR is now optional for MIPS participants in 2018.
    In response to the industry's calls for relief, CMS will allow MIPS-eligible clinicians to use either 2014 or 2015 Edition certified EHRs (CEHRT) for MIPS' Advancing Care Information (ACI) category in 2018. As an incentive to still make the change next year, providers who do use the 2015 Edition would receive a 10 percent ACI bonus. Meanwhile, CMS also proposed a 90-day reporting period for ACI for both 2018 and 2019, which would allow providers to delay moving to the 2015 Edition until October 2019 to comply with the final 90-day reporting period that year.
  2. Use of a 2015 certified EHR is still required for certain APM participants in 2018.
    While CMS delayed the requirement for MIPS participants to use a 2015 certified EHR in 2018, no similar relief was provided for certain APM participants. This includes those in the CPC+ program that are required to use 2015 CEHRT in 2018 for a full year, starting 1/1/2018. This rule itself does not change the requirement for participants in the Medicaid MU program to use the 2015 Edition in 2018. However, we can expect CMS to make changes through future rulemaking to align the MIPS ACI and Meaningful Use (MU) program requirements to offer similar relief to Medicaid MU participants.
  3. CMS has increased the low-volume threshold exclusion and as a result, 63% of all Medicare clinicians will be exempt from MIPS in 2018.
    In a nod to small practices, individuals or groups with fewer than $90,000 in Part B charges or 200 Part B patients (up from $30,000 and 100 patients this year) will be excluded from MIPS in 2018. CMS projects 585,560 clinicians will fall under this exclusion, while other exclusions will exempt another 390,000 clinicians, leaving just 37% of all Medicare Part B clinicians in MIPS in 2018.
  4. "Pick your pace" will continue in 2018.
    CMS' 2017 "pick your pace" policy for MIPS, which allows clinicians to report a minimum amount of data to avoid MIPS penalties and ease into the program, will continue in 2018 with some important revisions. Notably, scoring for the quality category retains the three-point floor imposed in 2017 (out of 10 possible points), while the overall MIPS performance threshold, or benchmark, will increase from three to 15 (out of a possible 100 points.)
  5. Cost will remain 0% of the overall MIPS score in 2018.
    As in 2017, the MIPS cost category will remain 0% of the overall MIPS score in 2018 while the quality category will account for 60% of the overall score. However, MIPS clinicians should continue to gather knowledge and develop a strategy for future success in the cost category. CMS also noted that as required by the MACRA legislation, the cost category will account for 30% of the overall MIPS score in 2020.
  6. CMS will allow multiple submission mechanisms within the ACI, quality, and improvement activities categories.
    For the 2017 performance period, MIPS-eligible clinicians are required to use only one submission mechanism (EHR, claims, registry, etc.) per performance category. In an effort to provide clinicians with more flexibility, in 2018 CMS will allow individual MIPS-eligible clinicians and groups to submit measures and activities through multiple submission mechanisms (as available) within a performance category to meet the requirements of the quality, improvement activities, or ACI performance categories.
  7. Providers can now participate in MIPS as individuals, groups, or virtual groups.
    As a new reporting option in 2018, CMS will allow solo practitioners and groups with 10 or fewer eligible clinicians to join together "virtually" to participate in MIPS as a Virtual Group. CMS declined to implement virtual groups in 2017 due to the complexities of the program. However, in 2018 the new reporting option may be an attractive choice for smaller practices. Notably, the proposed regulations would require providers to elect to participate in a virtual group prior to the start of the 2018 performance period, but would not restrict the formation of virtual groups by size or geography.
  8. CMS will offer small practices a "significant hardship" exception to opt out of MIPS ACI starting in 2018.
    Under new authority granted by last December's 21st Century Cures Act, CMS will offer practices with 15 or fewer clinicians a new category of hardship exception to reweight the ACI performance category to zero and shift the ACI scoring weight of 25% to the quality category. Although the final details are still pending, starting in 2018 a clinician could apply for the exception, if "there are overwhelming barriers that prevent the MIPS-eligible clinician from complying with the requirements" for ACI.
  9. CMS made only minor tweaks to the Advanced APM regulations.
    Regulations governing Advanced APM Incentives would largely remain unchanged in 2018. However, current CPC+ participants with more than 50 clinicians in their parent organization did receive the welcome news that CMS would be offering them an exemption to allow them to remain as an Advanced APM in 2018 and beyond. Also, CMS for the first time outlined critical details regarding the 2019 implementation of the All-Payer Combination Option.
  10. This rule includes several wins for small practices as the Trump Administration clearly made an effort to reduce the regulatory burdens MACRA places on physicians.
    The changes proposed in this rule clearly reflect the new administration's desire to reduce the regulatory burden on physicians while continuing the transition to value-based reimbursement. As a result, the impact of MACRA will be mitigated for many smaller practices, despite the increased complexity of the program that will accompany the changes in many areas. On the flip side, because MIPS is a zero-sum game, there will be a smaller pool of penalty dollars to fund the incentives for high performers, which could discourage participation across the market by practices of all sizes.

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Chris Emper
Government Affairs Advisor, NextGen Healthcare
Chris Emper, JD, MBA, is government affairs advisor at NextGen Healthcare and president of Emper Healthcare Advisors—a health IT industry advisory and consulting services firm in Washington, D.C. that specializes in helping healthcare providers and technology companies successfully navigate and comply with complex regulations and value-based reimbursement models. Prior to forming Emper Healthcare...