MACRA Insights for Clinics and ACOs

MACRA Gets harder in 2019

MACRA gets tougher in 2019.  Click for useful Infographic to share with colleagues.  

2018 and and 2017 were pretty easy for MACRA.  The only "big" financial impact was for providers who chose not to participate and received a negative adjustment on their Medicare claims.  The vast majority of MACRA participants received very high scores ... and very low positive adjustments.

But 2019 is different.  In four ways, this year hits harder.  Scores will be more difficult, positive and negative adjustments will be bigger, and MIPS scores will start to impact patient referrals. In some cases, providers who relied on ACO's will lose MIPS support as many ACO's decide to exit the MSSP Program. 

  1. PI Scores reduced to 50% across the board - the automatic 50 points in "base" PI is no longer available.  This means that if you scored 95 points in 2018, the very same performance would result in a PI score of 45.  Add in the fact that everyone must comply with Stage 3 measures - usually requiring a big EHR upgrade - and it is reasonable to expect PI to drop further yet. 
  2. Quality gets harder, and hits harder - Topped out measures in 2018 were able to earn up to 10 points per measure (not counting bonus values).  But the very same performance in 2019 on topped out measures will receive a maximum of 7 points, due to new rules.  For ACOs, the ACO-11 report (percentage of providers passing PI Base) becomes pay-for-performance, rather than pay-for-reporting which will effect overall ACO quality scores.  But the really big deal will be publication of quality scores for every physician in the country, in an easily understandable format.  To see how this will work, you really need to view a CMS video on their physician compare site.  Fast forward to minute 2.00 to see the impact of "performance", which is quality measures.  Also, see our related blog post on the topic.  
  3. MIPS Thresholds increase adds a bit to payout pools - In 2017, providers needed to score 3 points to avoid penalty.  In 2019 that threshold is 30 points.  There is a threshold for "exceptional" performance which requires 75 points for 2019.  Now ... while these values are higher than before, both the base / revenue neutral value and the "exceptional" values are below the Mean values CMS calculated for 2017 performance.  Go figure.  But the practical implication is that 2017 should have a bit more money in the "revenue neutral" pool as a result of these higher thresholds, together with lower expected scores.  
  4. ACO Closures - CMS just updated some rules that will require ACOs to accept a higher level of risk, or close.  CMS expects a large number of ACOs to choose the "close down" option.  Those ACOs deciding to close could create physician relationships problems under MACRA.  For example, any clinic covered under an ACO agreement has not needed to generate their own Clinical Quality Measures (CQMs), comply with CPIA requirements, nor been subject to independent CMS Cost requirements.  Absent some type of Safety Net, many of those provides will struggle.  

Bottom Line: 2019 deserves an expanded level of MACRA diligence, relative to prior years.  Our clients are stepping up to monthly MACRA measurement, optimization, and management reporting, starting as soon as April (rather than waiting until December to see "what happened".