Most small practices will see no change in their Medicare payments or perhaps even a bonus for participating in MACRA’s new Quality Payment Program (QPP) beginning in 2017.

Contrary to the initial proposed regulations from the Centers for Medicare & Medicaid Services, analysis of the final regulations shows that 90% of practices with one to nine clinicians should see no impact or even a pay increase in 2019 if they start participating in QPP next year, according to an agency analysis. The only way to fare worse would be to completely opt out of the program.

The projection is based on reporting rates for other quality programs in 2015. The increase stands in stark contrast to when the proposed regulation was issued in May, with actuaries predicting that 87% of solo practice and 70% of practices with two to nine clinicians would face a cut to their Medicare payments under the Medicare Access and CHIP Reauthorization Act of 2015 ( MACRA ). At the time, CMS based its estimates on 2014 quality program reporting trends.

The sea change is based on two modifications to the proposed rule, according to Walter Gorski, director of regulatory affairs at the American College of Physicians. The first is the new flexibility for QPP participation for 2017. In September, CMS announced that any level of participation in the Merit-Based Incentive Payment System ( MIPS ) – from reporting “some data” as a low-level test to full participation in an Advanced Alternative Payment Model – would result in no penalty or pay cut for physicians and other health care providers.

The second key is the higher threshold for exemption from reporting requirements. Under the proposed rule, providers who receive Medicare payments of more than $10,000 for 100 and see fewer Medicare patients had to participate; the final rule raises that to $30,000 or more or 100 or fewer Medicare patients. Mr. Gorski said this could result in 30% of physicians being exempt and therefore not having to face the penalties associated with the program.

In comparison, CMS expect 98.5% of practices with more than 100 clinicians to receive either a bonus payment or no bonus/penalty.