The Centers for Medicare & Medicaid Services (CMS) released the final Medicare Access and Chip Reauthorization Act rule in mid-October 2016–and at about 2,400 pages, it’s a bear.

The good news is that acting CMS Administrator Andy Slavitt seemed to hear what doctors and advocacy groups had to say about the initial rule, and took the input into account when crafting the final one.

In April 2015, Congress repealed the Sustainable Growth Rate formula by passing MACRA. In essence, MACRA aims to shift physician payment so that it rewards value and quality over volume via the creation of the Quality Payment Program (QPP). The QPP offers two pathways for reimbursement: The Merit-based Incentive System (MIPS) and Advanced Alternative Payment Models (APM). MIPS comprise the Physician-Value Based Payment Modifier, Physician Quality Reporting System, and the Medicare EHR Incentive Program. MIPS will be the most likely pathways for dermatologists who participate in MACRA.

There are numerous of details in the new document, but here we will try to distill it down to the most essential action items for dermatologists.

Important Dates

As with many other CMS programs, there will be a two-year lag period for MACRA. That means that you will be measured for the first year of MACRA (2019) beginning in January 2017. Data must be submitted by March 31, 2018. The first payment adjustments will take effect on January 1, 2019.

What this means: Participating physicians could see as much as four percent bonus payment in 2019. The only physicians who will experience a negative four percent penalty in 2019, the first year of the program, are those who choose to report no data.

New Pick Your Pace Format

The initial reporting period was slated to begin in January 2017 for all participating clinicians, but a new “pick your pace” format allows physicians to ease their way in. Options include submitting only some of their data in 2017 to avoid a penalty or going full throttle.

What this means: It’s not all or none. The four data submission options under the MIPS framework include:

No data

• Receive a negative four percent payment adjustment

Minimal data

• No negative payment adjustment

90 days of 2017 data

• Neutral or “small positive payment adjustment”

Full year’s worth of 2017 data

• “Moderate positive payment adjustment”

Increased Exemption Threshold for Small Practices

Small practices worried that MACRA could cripple them, but the final rule aims to allay these concerns. The CMS will exempt physician practices with less than $30,000 in Medicare charges or fewer than 100 unique Medicare patients per year, essentially tripling the “low-volume” threshold detailed in the initial iteration of MACRA. The American Academy of Dermatology Association advocated for this change.

What this means: (Very) small practices, and some pediatric dermatology practices, will get a stay of execution.

Shorter Reporting Period

There is a 90-day reporting period outlined in the final MACRA Rule. This is a significant change from the initial rule’s full calendar-year requirement.

What this means: If you report for at least 90 continuous days in 2017, you will be eligible for a positive payment adjustment. Individuals and group practices can report any one measure in the quality performance category; one activity in the improvement activities performance category; or report five measures of the advancing care information performance category for any 90-day period between January 1 and December 31, 2017.

Those who choose to report more measures during this time frame may see bonus payments up to four percent.

Reduced Reporting Thresholds

In 2017, you will only have to report successfully on a measure on 50 percent of patients, and 60 percent of patients in 2018. This threshold was set at 90 percent in the proposed rule.

What this means: No penalty for those meeting a lower bar for participation in the first year.

New Derm-Specific Measure

Measure 440: Biopsy: Reporting Time - Pathologist to Clinician requires that the pathologist communicate final pathology findings to the clinician for review within seven business days from receipt of the tissue specimen.

What this means: Fewer delays, reduced anxiety for patients, and improved care/outcomes. n

In next month’s issue of Practical Dermatology® magazine, Dr. Kaufmann gets real about what dermatologists can expect from MACRA.

Mark D. Kaufmann, MD is an associate Clinical Professor of dermatology Dept of Dermatology at the Icahn School of Medicine at Mount Sinai in New York City.