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MACRA Final Rule Brings Optimism, Lingering Concern : Page 2 of 2

MACRA Final Rule Brings Optimism, Lingering Concern : Page 2 of 2


The changes from the proposed rule to the final rule on the Advanced APM pathway was another major talking point from experts in wake of the final rule being released. APMs are a desirable path, says Lloyd, because physicians can receive a 5 percent incentive payment for participation and avoid MIPS altogether. However, in the proposed rule, few risk-based payment models qualified as Advanced APMs, meaning a very small percentage of physicians would be eligible for that pathway. Moreover, the APMs that were eligible required physicians to take on a decent amount of risk.

In the final rule, CMS made adjustments to make it so more physicians can qualify for Advanced APMs by adding more eligible risk-based models. It also created a new track (Track 1+) that would lower the risk practices would be taking in these models. Because of the creation of this track, CMS’ acting administrator, Andrew Slavitt said in a blog, CMS estimates "25 percent of eligible Medicare clinicians could be in an Advanced APM by the second year of the program."

Many, like Lloyd at Premier, are happy with these changes, but say the needle needs to be pushed even further. "We're hoping moving forward, CMS will develop even more [lowered risk-based models] … Medicare Shared Savings Program (MSSP) Track 1+ will certainly help, because right Tracks 2 and 3 of the MSSP program require a lot of risk. For Track 2, in the third year, you have 10 percent risk for your population. That's way more than nominal risk. That's significant risk. That has been a deal breaker for many of the organizations," she says.

The MGMA’s Gilberg agrees and says the "bar of nominal risk" in APMs is still too high for small practice physicians to join. He says CMS isn't taking into account the inherent risk physicians are taking by moving from a fee-for-service to a value-based payment model. "CMS kept the nominal risk standards quite high and it remains to be seen, truly in the end, how many physicians are going to move into alternative payment models."

Going Forward

One area of optimism — and somewhat annoyance — for Gilberg is that he doesn't see this as a "one shot deal." In other words, the MACRA rules will continue to evolve and there will be additional rulemaking in 2018 and beyond. In one sense, he says it gives him faith that CMS will adjust the rule accordingly to reduce the burden on practices. However, he says these adjustments make things unstable for practices on a year-to-year basis.  

"We've seen this before with Meaningful Use and Accountable Care Organizations, these rules [from CMS] come out, we learn and then CMS adjusts accordingly. That doesn't provide stability for practices and that's a problem," says Gilberg. "This is the kind of thing CMS has to stop. Instead of this yo-yo effect, the rules have to be manageable going forward so CMS doesn't have to keep pulling back. For three years they've pulled back on Meaningful Use because they've overshot on its initial complexity."


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