Massachusetts Medical Society: MACRA: What Physicians Need to Know

MACRA: What Physicians Need to Know

The essence of MACRA is the new Quality Payment Program (QPP), which sets up two payment pathways for physicians and other health care providers. One pathway, the Merit-Based Incentive Payment System (MIPS), creates an enhanced fee-for-service model.

Under MIPS, physicians will receive a MIPS composite score, which is based on their work in four categories: quality, improvement, advancing care information, and cost. Several of the metrics are specialty- and subspecialty-specific. MIPS reimbursement is based on a physician’s fee for service, multiplied times the conversion factor, times the MIPS composite score. This determines whether the physician will be eligible for a bonus payment or penalty. In 2019, the bonus or penalty will be up to or down to 4 percent. The bonus funds are budget-neutral, meaning they must balance out. There is an additional fund for those who excel; these physicians can receive an additional 10 percent.

The other payment pathway is called advanced payment models (APMs). These groups manage risk of varying degrees. There are different kinds of APMs. Whether a group qualifies as an APM or an advanced APM depends on the amount of financial risk they take, as well as other criteria including EMR utilization and MIPS-type metrics. Those who are in advanced APMs automatically get a 5 percent bonus. Those who perform well above the benchmark are also eligible for an additional bonus.

Three categories of providers are exempted from the MIPS reporting program: 1) providers receiving $30,000 annually or less in allowable billed Medicare charges or if they treat 100 Medicare patients or less in one year, 2) physicians in their first year of the Part B program, and 3) providers who qualify for the advanced APM. Physicians in the first two exempted categories will be paid on a straight fee-for-service formula.

There are special provisions and protections for small practices, generally defined at 15 and fewer clinicians, and for “non-patient facing providers” (e.g., anesthesiologists, radiologists, pathologists), and for medical homes. CMS is also working on options for physician-led groups as well as “virtual practices.”

In the final rule, which defines a number of the details of implementation, CMS builds in more flexibility, time, and options for physicians to participate in the new programs. For some practices that have successfully reported metrics in the past or have managed risk and/or are part of the networks or systems with staff, the expectation is that the new law will be less of a challenge. For those practices that have never successfully reported or who do not use an EMR, the new law will be more difficult.

Those who want to find out more about the new law have two options: 1) The MMS has prepared a one-hour presentation that will give you and your staff a general overview of the law, timelines, and requirements, contact Lori DiChiara at, for information, and 2) for more personalized help, contact the Physician Practice Resource Center at

The MMS, as a member of the national team that helped develop and pass the new Medicare law, will continue to help you navigate the new program and choose the best course for you and your patients.

MACRA Timeline

While 2017 is a transition year, choices made then will affect your payments in 2019. During this time, CMS also needs to collect information on your practice to check attribution and allow time for changes. The “Pick your Pace” program is designed to enroll physicians in the program while minimizing penalties for those who were new to reporting quality and other metrics. All physicians in Medicare will receive an annual 0.5 percent update in 2016 through 2019.

Five choices as of January 1, 2017, include the following:

1) Perform a Test: You can submit as little as one quality measure, or one clinical improvement activity on one patient, for CMS to test their system. You will not be eligible for any bonus payments in 2019, but you will not be cut.

2) Partial Participation: You can choose to report on one or several of the MIPS metrics for at least 90 days. You will not be cut and might be eligible for a small bonus update.

3) Report for the Full Year: You can report on all the MIPS measurements that will be required. You will be eligible for up to a 4 percent bonus payment in 2019.

4) Qualify as an Advanced APM: You don’t need to worry about MIPS. You will receive 5 percent update in 2019. (If you don’t know what this is, you mostly likely aren’t one.)

5) Do nothing: You will be cut 4 percent in 2019. The amount of this penalty increases each year. Unless you are exempt you will be cut 4 percent in 2019.

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