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Nine things healthcare executives should know about MACRA


Although CMS released the final rule for MACRA in October, there is still quite a bit of confusion.

Although CMS released the final rule for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) in October, there is still quite a bit of confusion. In fact, nearly half of U.S. physicians are not even familiar with MACRA, per Deloitte’s recent survey of 600 doctors. What’s more, nearly eight in 10 physicians said they prefer fee-for-service over the types of risk-bearing, value-based arrangements under MACRA.

Yet, MACRA is here to stay. The final rule proposes changes that will have a major impact on providers and propel the healthcare industry toward a better future with value-based payment models.

Here are nine things to know about the final rule:

1. Participants can choose one of two program tracks. CMS created the Advanced Alternative Payment Models (APM) and Merit-Based Incentive Payment System (MIPS), which are the two tracks with related requirements within the Quality Payment Program (QPP), intended to increase focus on patient-centered care. The payment system’s patient engagement strategies will not only drive providers to attain the high scores needed to receive incentives, but also create a more predictable Medicare payment schedule.

2. MIPS combines three established payment programs. To reduce the burden of participation, three programs have been merged under MIPS. This ensures single submission for all providers and requires providers to report separately for each program. The incentive programs presently under Medicare Part B are:

  • Physician Quality Reporting System (PQRS)

  • Physician Value-based Payment Modifier (VM)

  • Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals (EPs)

3. The APMs track provides additional incentives to participations. The APMs payment track enables providers to earn added incentive payments by providing high-quality, cost-efficient care for specific clinical conditions, care episodes or populations. A qualified APM is any one of the following:

  • A Medicare Shared Savings Program Accountable Care Organization

  • A model expanded under the Center for Medicare & Medicaid Innovation (CMMI), which is not a Health Care Innovation Award recipient

  • Medicare Health Care Quality Demonstration Program or Medicare Acute Care Episode Demonstration Program

  • A demonstration program required by federal law

4. MACRA affects all providers beginning in 2017, including those with small and solo practices. It also affects healthcare IT vendors, such as data submission vendors, registries, EHRs, etc. The program will take effect over several years, beginning in 2017.

The QPP phased timeline:

Next: Five more things to know



5. CMS has made 2017 a transition year. The reporting period was reduced from one year to a minimum of 90 days to submit reports.

6. CMS has adjusted the weighting for the performance-based scoring categories for 2017:

  • Quality performance category score is now 60%

  • Advancing Care Information (ACI) performance category score is now 25%

  • Clinical Practice Improvement Category (CPIA) has been renamed Improvement Activities and the score is now 15%

  • Resource Use performance category has been renamed Cost and is now 0%, which eases the burden on Composite Performance Score (CPS) calculation

For 2017, the performance feedback was reduced from 40 episode-based measures to 10. The performance threshold has been set to three points with one point for each performance category, such as Quality, ACI, Improvement Activities, etc. A 10% bonus score will be awarded to clinicians who complete Improvement Activities through their EHRs and provide reporting to Public Health and clinical data registries.

7. Providers need to take steps to avoid negative payment adjustments. To avoid negative payment adjustments, participants should report at least one Quality measure and one Improvement Activity or a minimum of five required ACI measures.

8. Providers have good incentives to start preparing right away. They can either begin collecting performance data on January 1, 2017, or select any continuous 90-day period ending no later than October 2, 2017. Some things to keep in mind regarding MACRA’s effect on payments:

  • Negative payment adjustment for non-participants: If 2017 data is not submitted by March 2018, non-participants receive a negative 4% payment adjustment.

  • Avoid negative adjustment by submitting minimum data: Participants can avoid a negative payment adjustment by submitting minimum data, for example one Quality measure and one Improvement Activity from CPIA.

  • Benefits of submitting partial-year data: Participants who submit at least 90 days of data can earn a neutral or positive payment adjustment.

  • Earn positive adjustment by submitting full-year data: Participants who submit a full-year of data for 2017 can earn a moderate positive adjustment.

Steps to participate

Clinicians who are eager to participate in QPP should start preparing early to make the most of the special transition-year policies:

9. Technology plays a key role. It’s clear that CMS’s goal is to support a strong focus on quality and move the healthcare industry toward technology adoption that improves patient outcomes. Both the APM and MIPS payment tracks have been designed for greater technology inclusion and those requirements will continue to evolve.

In preparation, organizations are wise to create their own integrated framework-people, processes, data and underlying technology-that is efficient and able to evolve for future business requirements. For many providers, this means partnering with a healthcare IT organization that offers expertise in both managing technology and managing ongoing regulatory changes.

Success with APMs especially requires the ability to integrate health information technology, while creating strong collaboration across providers and health systems. Teaming with a right IT partner who offers the right mix of capabilities in interoperability, regulatory requirements, and data and process optimization will ensure a smoother transition to the QPP program. 

Pranjali Joshi is product manager, CitiusTech.


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