Ready or Not, Here We Go: MACRA’s Quality Payment Provisions

CMS is making good on its promise to force physicians to reduce overall cost and improve quality (measures) or risk reduced payments. As many know, CMS’ value-based programs represent a handful of one-size-fits all approaches aimed at judging practices of all sizes, shapes, and specialties.

Recently, the National Association of Accountable Care Organizations conducted a survey of its membership and found that only three percent of its member ACOs are already accepting financial risk and over 50 percent do not expect to be ready to accept risk in the next four years. Think about this. ACOs are groups of providers who are making investments in building a value-based infrastructure. These groups are at the forefront, willing to make investment without promise of return. The vast majority of physicians across the country are not part of ACOs. Despite this, even the ACOs are not ready to accept downside payment risk.

The Medicare Access and CHIP Reauthorization Act (MACRA) mandates that all providers, whether already engaged in an ACO or some other kind of value-based transformation or not, will be taking downside risk based on performance in 2017. While the value-based modifier was headed in this direction already, MACRA accelerates the progress.

Despite the well-publicized announcement of the law and the proposed MACRA regulations first published in April, 2016, awareness of it and its implications among the provider community is surprisingly low. According to a June, 2016 Deloitte survey, 50 percent of all physicians had never even heard of MACRA and another 32 percent had heard of it, but were not familiar with its requirements. That means only a small minority of physicians were even thinking about MACRA with only five months to go before its implementation.

What are the requirements? What options do physician groups have?

    MACRA requires that all physicians who see more than 100 Medicare patients annually or bill more than $10,000 in Medicare allowables to take downside risk through one of two pathways: the Merit-Based Incentive Payment System (MIPS) or an Advanced Alternative Payment Models (Advanced APMs).


    MIPS, which CMS expects most providers to choose, involves reporting a set of measures including quality measures (PQRS measures), EHR measures (meaningful use measures), clinical practice improvements, and cost. All providers in MIPS will eventually have 9 percent of Medicare revenues put at risk based upon performance. Providers in “non-Advanced APMs”, which are APMs that do not take downside risk, will be in MIPS but gain scoring advantages such as automatic half credit on the clinical performance improvement measure.

    To avoid the MIPS pathway and qualify as an advanced APM, providers must hitch their wagons to Medicare risk-bearing program like an ACO, a bundled payment initiative, or certain types of primary care transformation programs such as PCMH and CPC+.

    Group Practice Summary

    MIPS replaces “meaningful use” and PQRS reporting with similar reporting requirements and adds additional reporting requirements. Administrative burden is likely to increase. Regardless of their current practice size, group practice physicians in MIPS who are not reporting as a non-advanced APM, will need to decide whether or not to report to CMS an individual or with their practice. Failure to report can produce a zero score in at least two of four MIPS categories and will minimize ability to earn a bonus or avoid a penalty.

MACRA’s Quality Payment Program: Key Facts and Figures

  • 50 percent of physicians had not heard of MACRA in June, 2016.
  • The MIPS pathway will begin measuring providers in 2017 and begin adjusting payments in 2019. 4 percent of Medicare payments can be lost / gained in 2019, rising to 9 percent in 2022.
  • Ultra-high performers can earn an additional bonus up to 8 percent in 2019 and 18 percent in 2022.
  • Providers or groups will be scored in four areas.
  • Quality reporting will comprise of 50 percent of the total MIPS score. There will be 250+ quality measures from which to select six.
  • mips-scoring

  • Qualifying providers or groups who are part of an advanced APM will receive an automatic 5 percent bonus (but remember, the program requires the APM to bear other financial risk).
  • Non-advanced APMs that do not take on risk, such as Track 1 MSSP ACOs, do not qualify as Advanced APMs.

If you haven’t planned for MACRA yet, what should you do?

    Determine your strategy before the first reporting period begins in 2017

    No single approach that will work for all practices. The right answer will be different for every practice and every specialty, small or big, independent or hospital-based. The key is set yourself on the right path now, then work to make steady improvements over time. Practices that delay preparations for MACRA may have fewer strategic options down the road. The next step beyond the on-line assessment tools is a clear strategic action plan.

    PDA’s MACRA Accelerator Consultation can help you evaluate options and quickly establish a MACRA that fits your practice. Let PDA do the legwork and help set you on the right path. PDA is an experienced, independent strategy consulting group without ties to any particular technology or methods. We specialize in creative solutions.

The PDA Accelerator Consultation Covers:

    First Things First: Learn the Proposed Rules.

    Proposed CMS MACRA quality payment program rules are out. Final rules are due in November. The rules will be a complex set of options and requirements, but it’s important to know what you face.

    Determine the impact on your practice.

    Your plan involves more than simply understanding the potential gain/loss on Medicare dollars. It considers: What investments have you already made? What stage of meaningful use have you reached? What are your current quality scores? What investments will it take to capture and report data? What investments will it take to gain a financial return?

    Decide your strategy.

    Which is best? Minimal investment to protect existing revenues? Go for gold and seek high returns? Drop Medicare business altogether? Become and Advanced APM? Avoid the headaches and join forces with others to minimize time away from your clinical practice? With so many options, understanding your own culture and risk tolerance as a practice is vital before charting a course.

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