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Date: Aug. 17, 2016

Contact: Tamiya Williams, CMPE and LaDonna Kessler, CMUP, Senior Manager | |

MACRA – What Is It and What You Can Do Now to Prepare

On April 16, 2015, the Medicare Access and CHIP Re-Authorization Act (MACRA) of 2015 was signed into law, permanently repealing the Sustainable Growth Rate (SGR) formula and imposing a new payment methodology for Medicare Part B payments starting in 2019 (reflected from performance year 2017). Transitioning from Fee for Service (FFS) to a Quality Payment Program creates two new payment tracks:


  • The Merit-Based Incentive Payments System (MIPS)
  • Advanced Alternative Payment Models (APMS)
  • Initial Performance Period will be January 2017 – December 2017


On April 2017, 2016, CMS released the proposed rule outlining how it plans to implement the Medicare payment changes stipulated in the law. CMS is soliciting public comment on this proposal until June 27, 2016 and Eligible Clinicians (EC) are encouraged to do so.


The Merit-Based Incentive Payment System (MIPS)

 Medicare currently measures the value and quality of care provided by physicians and other clinicians through a conglomerate of programs, including the Physician Quality Reporting System (PQRS), the Value-Based Modifier Program, and Meaningful Use. Congress streamlined these programs into one new Merit-Based Incentive Payment System (MIPS).  MIPS reduces the number of measures clinicians are required to report on in some categories and allows clinicians the flexibility to select from a set of measure to report on based on the relevancy to their practice.


Eligible Clinicians Under MIPS

  • Years 1 and 2 (2017 and 2018)
    • Physicians – MD/DO and DMD/DDS
    • Physicians Assistants
    • Nurse Practitioners
    • Clinical Nurse Specialists
    • Certified Registered Nurse Anesthetists


  • Years 3+ Secretary may broaden Eligible Clinicians to include others


  • Although most clinicians will participate in MIPS, there are some that will not qualify. They are:
    • Clinicians who are in their first year of Medicare Part B participation
    • Medicare eligible clinicians who have billed charges less than or equal to $10,000 and wo provide care for 100 or fewer Medicare patients in one year
    • Certain participants in ADVANCED Alternative Payment Models
    • MIPS does not apply to hospitals or other facilities


MIPS allows Medicare clinicians to be paid for providing high quality, efficient care through success in four performance categories:


  • Resource Use (Cost):  10
  • Clinical Practice Improvement Activities (CPIA):  15
  • Advancing Care Information (ACI) (formerly Meaningful Use):  25
  • Quality (PQRS/VBM):  50



The Quality category counts as 50% of the total score in 2017. This category also replaces the current PQRS and Value Based Modifier programs. Clinicians will need to report on six measures versus the nine measures that they are required to report on under the current PQRS guidelines. This category will also give clinicians reporting options to choose from to accommodate differences in specialties and practices. Clinicians will still be required to report on at least one cross-cutting measure and one outcome measure. If an outcome measure is not available, then the clinician would report on one other high priority measure in lieu of an outcomes measure.

Advancing Care

The Advancing Care Information (ACI) category counts as 25% of the total score in 2017. This category replaces the Medicare EHR Incentive Program (Meaningful Use). Clinicians will be required to report on customizable measures that reflect how they use EHR Technology in day-to-day practices, with a particular emphasis on interoperability and information exchange.  ACI requires clinicians to report on fewer objectives than the original Meaningful Use requirements. Keep in mind that the Medicaid Meaningful Use and Hospital Meaningful Use programs are unaffected. The six proposed ACI Objectives are as follows:


  • Protect Patient Health Information
  • Electronic Prescribing
  • Patient Electronic Access
  • Coordination of Care through Patient Engagement
  • Health Information Exchange
  • Public Health and Clinical Data Registry Reporting  


Clinical Practice Improvement Activities (CPIA)

The Clinical Practice Improvement Activities (CPIA) category counts as 15% of the total score in 2017.

Clinicians can select activities that match their practice goals from a list of more than 90 options. At minimum, clinicians must select one activity to implement. Bonus credit will be earned for additional activities. If a practice has earned a designation of Patient-Centered Medical Home (PCMH), full credit in the CPIA category will be earned.   Clinicians who are participating in an Advanced Payment Model (APM) will earn half credit for the CPIA category.


Resource Use/Cost

The Resource Use/Cost category counts as 10% of the total score in 2017. Resource Use, also known as Cost, replaces the Value-Based Modifier Program. CMS will calculate this score based on Medicare claims and availability of sufficient volume, meaning no reporting requirements for clinicians. This category will use more than 40 episode-specific measures to account for differences among specialties. 

Quality  +  Resource Use  +  Clinical Practice Improvement Activities  +  Advancing Care Information  =  CPS

The Cost Performance Score (CPS) will be used to determine whether a MIPS Eligible Clinician receives an upward payment adjustment, no payment adjustment, or a downward payment adjustment. All payment adjustments will be scaled for budget neutrality as required by the statute. The CPS will also be used to determine whether a MIPS eligible clinician qualifies for an additional positive adjustment factor for exceptional performance.

Advanced Alternative Payment Models (APMs) “Pre-Approved” by CMS

CMS is continuously taking the steps needed to attain care transformation with the development and approval of the following Advanced Alternative Payment Models:

  • Medicare Shared Savings Program – Track 2 or Track 3
  • Next Generation ACO Model
  • Comprehensive ESRD Care Model (large dialysis organization arrangement)
  • Comprehensive Primary Care Plus (CPC+1)
  • Oncology Care Model Two-Sided Risk Arrangement (2018)


APM track participants will be exempt from MIPS payment adjustments and would qualify for a 5% Medicare Part B incentive payment in 2019-2024.


What Can Be Done Now to Prepare

It is very important that preparation for MACRA starts now. The final rule is expected to be released by CMS in November 2016.  Some of the key components to success are as follows:

  • Educate your organization on MACRA
  • If your practice does not have an EHR, it is important to implement one
  • Make sure you are successfully participating in PQRS
  • Make sure you are successfully participating in Meaningful Use
  • You must complete a Security Risk Analysis
  • Monitor Quality Reporting Dashboards on a regular basis to identify deficiencies


Remember, Meaningful Use and PQRS as we know it will end on December 31, 2016, and MACRA will take effect January 1, 2017. Be on the lookout for the final rule coming later this year.


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