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MACRA Spells Big Change

Written by Tammie Lunceford on August 24, 2016

The application deadline for 2015 Meaningful Use hardship has passed.  It’s quite ironic we are analyzing the Meaningful Use replacement program.  Many physicians stopped participating in Meaningful Use prior to 2015 due to the administrative burdens, time constraints and the mere complexity of the program.  Managers who have listened to a CMS National call or viewed a webinar related to the Merit-Based Incentive Payment System are concerned with the transition.  It is important for providers and managers to understand that 2016 Meaningful Use participation is crucial in avoiding a 2018 adjustment to Medicare payments, since the Merit-Based Incentive Payment System will not be implemented until January of 2017.  Andy Slavitt, the CMS Administrator was quoted in Modern Healthcare on July 14th stating “it is likely that MIPS is delayed,” and he indicated several options for transition into the new program will be discussed.  The Medical Group Management Association and the American Medical Association have pressed CMS and the Senate to reconsider the January 2017 implementation.  CMS is also discussing a 90 day reporting period for 2016 Meaningful Use and reduced complexity to Stage 3 objectives.

While the onset of the Medicare Access and Chip Reauthorization Act (MACRA) may be undecided, in April, lawmakers passed MACRA, issued by the Centers for Medicare and Medicaid Services. This Act implements key provisions to replace the Sustainable Growth Rate Formula. The new approach to paying clinicians for value and quality includes two paths: The Merit-Based Incentive Payment System (MIPS) or Advanced Alternative Payment Model (APM).  CMS accepted public comments until June 27, 2016. Small practices will be allowed flexibility in the MIPS program if the size of the group consists 15 or fewer clinicians, if the practice is located in a rural area or is located in a health professional shortage area.

The Advancing Care Information portion of MIPS replaces Meaningful Use beginning January 2017. The proposed rules will not impact EPs in Medicaid program or hospitals. The proposed program will:

  • Allow physician flexibility in choosing measures that reflect how EPs use EHR technology;
  • No longer require an all or nothing measurement for quality by CMS;
  • Reduce measures from 18 to 11;
  • No longer require reporting of clinical decision support and Computer Order Entry;
  • Only require EPs to report to a single public registry;
  • Exempt some physicians when EHR technology is less applicable.

The new MIPS program replaces the single track programs known as Meaningful Use, PQRS and the quality and cost components of the Value Based Modifier. MIPS further transitions the payment system from fee for service to quality and value in four categories:

  • Cost                                                           10 %    Based on Medicare claims, no reporting (formerly VBM)
  • Quality                                                        50%    Six measures vs nine (formerly PQRS and VBM)
  • Clinical Practice Improvement                    15%     Focus on care coordination- 90 options
  • Advancing Care Information                       25%     Use of EHR technology (formerly MU)

Practice leaders have stated their lack of participation in previous programs were due to low Medicare or Medicaid patient volume.  However, most commercial carriers adopt the same initiatives on cost, quality and care coordination.  I am concerned for those practices that are continuing to practice using paper charts and outdated practice management systems that limit patient focus.  Payment adjustments for lack of participation and positive adjustments for successful performance will be awarded based on the table below:

2019 -4% 4% up to 12%
2020 -5% 5% up to 15%
2021 -7% 7% up to 21%
2022 -9% 9% up to 27%


According to the law, during the first five payment years of the program there is 500 million dollars provided for an additional performance bonus that is exempt from budget neutrality for exceptional performance.  The gradual increase for exceptional performance would not be higher than an additional 10 percent based on the MIPS score.

Incentive payments can also be earned through participation in Advanced Alternative Payment Models known as:

  • Comprehensive End Stage Renal Disease Care Model
  • Comprehensive Primary Care Plus
  • Medicare Shared Savings – Track 2
  • Medicare Shared Savings – Track 3
  • Next Generation ACO Model
  • Oncology Care Model Two-Sided Risk Arrangement (2018)

Incentive payments for significant participation in Advanced Alternative Payment Models begin in 2019 for practices who earn 25 percent of their payments through Advanced APM or 20 percent of their patient base is through an Advanced APM.  These parameters increase to 50 percent and 35 percent in 2021 and to 75 percent and 50 percent in 2024 respectively.

Starting in performance year 2019, a clinician could qualify for incentive payments for participation in Advanced APMs developed by non-Medicare payers such as private insurers or state Medicaid programs.  It is important for practice leaders to stay informed as the proposed programs are implemented.  We need to understand MACRA and its implications to prepare for MIPS implementation. This valuable time should be utilized to assess your practice management systems, electronic health record systems and interfaced products available to you.  Meet with your vendors to assure you have the correct resources to align your practice for participation in the upcoming programs.  Assure you are communicating with your academy or board of certification for updates and joining registries to assist you with successful participation in quality metrics.

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