Last month, Centers for Medicare and Medicaid Services Acting Administrator Andy Slavitt announced some flexibility as providers prepare to transition to payment reform under the Medicare Access and CHIP Reauthorization Act (MACRA).

Still set to start Jan. 1, 2017, CMS has now given eligible physicians and other clinicians four options to comply with new requirements as the reimbursement system continues to move toward a value-based model that emphasizes quality care. Under the proposed rule, which was released in April, CMS set up two tracks within MACRA - Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

Ingrid Lund, practice manager in Research for Advisory Board, said the announcement from Slavitt really offers three options for reporting under MIPS, with the fourth option being participation in an APM as previously outlined.

While there are two MACRA tracks, Lund noted, "One of the most common misperceptions I've heard is there is a choice ... 92 percent of clinicians will fall into MIPS because the criteria for risk is very stringent for the APM track."

The vast majority of providers, therefore, will have three options to consider next year. The first option is the most flexible, and Lund said it offers a "nice reprieve" for those who didn't feel ready to go with their reporting. "The idea is that you can essentially test the program," she explained, adding submitting "some data" would allow providers to avoid a negative payment adjustment. Lund added that she hoped the final rule would offer more clarity as to how much data qualifies as "some" for reporting purposes.

Under the second option, Lund said you could submit data for a partial year. "You won't get penalized, and you may even get rewarded," she said of the announcement that practices could still qualify for a small positive payment adjustment with this choice.

"The third option is MIPS as usual for the full calendar year," Lund noted. She added that while CMS heard from providers who were concerned over the complexity and short timeframe for implementation, officials also heard from those who were well prepared and not pleased at the prospect of a delay. Those who opt to have their first performance period begin Jan. 1 might qualify for a "modest positive payment adjustment," according to Slavitt.

No matter what option is chosen Lund said, "2017 is still the year you will be evaluated on for 2019 payments. We're not expecting a full-on delay in the final rule."

The final rule, which is anticipated to come out by Nov. 1 at the latest, should fill in details to allow providers to more fully evaluate the three MIPS options. "I think the big looming question is how will these flexible options work to make this budget neutral?" Lund asked.

She noted the law sets MIPS up as revenue neutral. Eligible clinicians who don't report in 2017 were to receive a 4 percent payment penalty in 2019. Those who reported and scored in the top decile, were to receive a 4 percent or higher bonus. With the new reporting flexibility, she said it remains to be seen how bonuses will play out when payment changes go into effect.

While Lund said most of the practices with which she works are prepared and "absolutely engaging on the topic of MACRA," she also recognized the level of readiness varies widely across the country. "Certainly there are a lot of legitimate concerns about what MACRA will do for solo or small practices," she said. Lund added there is a $100 million fund to help support small practices as they prepare to meet the new reporting requirements. "It's an open question about whether that (amount) is adequate," she noted.

For those struggling to get up to speed, Lund said, "Quality is absolutely where you start your efforts." She added that MIPS has four scoring sections, and the quality performance category, which replaces the Physician Quality Reporting System, accounts for 50 percent of the composite score. "It's where you probably have the most work to do ... and where you have the most opportunity," she added.

The balance of the score comes from Advancing Care Information (25 percent), Clinical Practice Improvement Activities (15 percent), and Resource Use (10 percent). The Advancing Care Information category is what was formerly known as Meaningful Use. Clinical Practice Improvement offers more than 90 activities from which to choose. Lund suggested looking for areas where you are already collecting data that align with the new requirements.

The score for Resource Use is based on claims and volume sufficiency. In addition to being the smallest percentage of the composite score, Lund said it also might be the hardest area to actually control. "I would only recommend tackling it once you feel you have the other categories well in hand," she advised. "It's the category I expect to be the most ignored because of its low weighting and because it's hard to control. That said, I think it's got a lot of opportunity. It could separate the cream of the crop."

While providers and industry associations have expressed relief over the "pick your pace" options from CMS, Lund said the partial reprieve is only temporary. The expectation is 2018 will roll out with full reporting requirements for all.

"The flexible options are not a reason to sit on the sidelines," Lund cautioned. "The one option, which has sort of been left unsaid, is that if you don't report at all, you can be penalized." Ready or not, MACRA is almost here.