As the United States is shifting to a value-based care model, “MACRA” has become a popular buzzword among healthcare providers this last year. MACRA, which stands for the Medicare Access and CHIP Reauthorization Act, is a historic Medicare reform law that permanently repealed the sustainable growth rate (SGR) methodology for determining updates to the Medicare physician fee schedule.

The replacement payment program is known as the Quality Payment Program, which rewards the delivery of quality patient care through either the Merit-based Incentive Payment System, known as MIPS, or Alternative Payment Models, known as APMs.
With over 2,000+ pages of policy that make up this complex rule, it is no surprise that many clinicians are not quite sure the effect MACRA will have on their practices. However, despite the fact that many do not know of this rule, just like the mantra that “ignorance of the law is no excuse,” clinicians will need to adhere to the guidelines this next year whether they are ready or not.

MIPS ties payments to performance based on a compilation of quality measures:

  • Physician Quality Reporting System (PQRS),
  • Physician Value-based Payment Modifier (VM),
  • Medicare Electronic Health Record (EHR) Incentive Program

MIPS will focus on quality and practice-based improvement activities to award an overall score to clinicians, called the Composite Performance Score (CPS), which will determine what kind of payment adjustment, either penalty or bonus, that a clinician will get for the corresponding payment year. Top performers will have the potential for bonuses as high as 14 percent in 2019.

Those who do not perform will be financially penalized, with the lowest 25 percent seeing revenue cut by 9 percent by 2022. Initially, MIPS eligible clinicians will includes physicians, PAs, NPs, clinical nurse specialists, certified registered nurse anesthetists; however, this may be expanded to other groups starting in year three of program implementation. MIPS does not apply to hospitals or facilities at this time.

APMs move providers towards true value-based payments, which go beyond the MIPS quality scores by incorporating quality with shared risk to the providers. A qualified APM includes a Medicare Shared Savings Program Accountable Care Organization; a Center for Medicare & Medicaid Innovation Center model (CMMI); a Medicare Health Care quality Demonstration Program; or a demonstration program required by federal law.

Several requirements exist for successful provider participation in APMs. Providers who meet these requirements will receive a 5 percent annual lump sum bonus every year from 2019 to 2024 and will be exempt from the MIPS program.

Below are some aspects of the rule to consider as clinicians ramp-up for program implementation.


2017 is a transition year to allow providers time to ramp-up the program and performance thresholds. CMS has also envisioned that calendar year 2018 will be a transitional year as well.


For the transition year, clinicians may choose a variety of ways to participate in a way that is best for them, their practice, and their patients. This includes three options to submit data to MIPS and a fourth option to join Advanced APMs in order to become qualifying APM Participants.

  • To avoid a Medicare reimbursement reduction in 2019, eligible clinicians must submit data on at least one MIPS measure.
  • To qualify for value-based incentive payments, eligible clinicians must submit data on more than one MIPS measure on at least 90 days of 2017 to earn a neutral or small payment adjustment in 2019.
  • For those that submit all required MIPS data for 2017, eligible clinicians may receive a moderate value-based payment adjustment.
  • Qualifying clinicians participating in an Advanced APM that receive a sufficient portion of their Medicare payments or see a sufficient portion of their Medicare patients through the Advanced APM will be eligible for a 5 percent value-based incentive payment in 2019 and will not be required to report any MIPS data.


CMS is selecting contractors to implement technical assistant program for small practices, rural practices, and practices in medically underserved health professional shortage areas.


Many small practices will be excluded from the requirements in 2017 due to the low-volume threshold, which is less than or equal to $30,000 in Medicare Part B allowed charges or less than or equal to 100 Medicare patients. For providers at a CAH, only the portion of charges paid under the Medicare physician fee schedule counts toward the $30,000 threshold, not the facility payment to the CAH.


Solo and small practices may join virtual groups (consisting of no more than 10 clinicians) and combine their MIPS reporting; however, this will not be implemented in the 2017 transition year.


Some providers that are excluded from MIPS include clinicians that are newly enrolled in Medicare, Qualifying APM Participants (QPs), certain Partial Qualifying APM Participants, Rural Health Clinics and Federally Qualified Health Centers.

For those clinicians who have not yet taken steps to prepare for MACRA, there is a chance that a Trump presidency will dismantle the Affordable Care Act, significantly impacting MACRA, which may result in a windfall for those that did not want to participate and have held out.

However, “undoing” the existing regulations will take some time, so it is still up in the air how this will all play out. For those that take the risk of a “wait and see” approach and decide to do nothing, the final rule did confirm that if a MIPS eligible clinician chooses to not report even one measure or activity in 2017, they will receive the full negative 4 percent payment adjustment in 2019.

The question that will need to be asked is whether gambling the potential negative 4 percent adjustment is worth it. Although there might be some interest in avoiding the performance pressure under MACRA in taking the chance that a Trump presidency may do away with it altogether, not participating wipes out the chance to gain a bonus for high performance, which may be a considerable funding source for some clinicians.