MACRA: Five Things You Should Know

Here are five potentially pivotal MACRA issues that you should know about.

When the Medicare Access and CHIP Reauthorization Act (MACRA) passed and was signed into law in 2015 it marked a sea change in how Medicare reimburses physicians — from volume of services to value.

MACRA replaced the Medicare Part B Sustainable Growth Rate (SGR) reimbursement formula; the Quality Payment Program (QPP) will take its place, with 2 main facets: Alternative Payment Models (APMs) and the Merit-Based Incentive Payment System (MIPS).

What does this mean for you and your patients? While I cannot (and would not even want to try to) distill this law’s 962 pages into this brief post, here are 5 potentially pivotal questions:

1. How does MACRA affect patient care?

The hope and goal is to provide better care. There is an emphasis on quality related to patient outcomes, care coordination, as well as greater patient engagement in their care — including patient access to their electronic health record (EHR), offering the ability to send and receive secure messages within the EHR, and enhanced patient education and activation. Will these changes promote improved care?

2. What’s the impact on physician reimbursement?

Most physicians will participate in MIPS, since there are only 3 categories of exempt providers:

  • physicians who care for 100 or fewer Medicare Part B patients or have <$30,000 in Medicare Part B-allowed charges
  • physicians in their first year of participating in Medicare Part B
  • physicians who are eligible to participate in AAPMs or who qualify for the APM bonus

Small practices may absorb a larger, negative impact. The Centers for Medicare & Medicaid Services (CMS) estimates that about 90% of solo practices will face negative adjustments, and 70% of practices with 2 to 9 clinicians.

There’s also much more reporting of data, such as the metrics included above.

The author of the National Center for Policy Analysis’ (NCPA) report on MACRA, Senior Fellow John Graham, noted, “Future regulatory and legislative reforms must do both more and less than the currently proposed rule does. They must reduce the role of the federal government in setting fees for physicians and determining what quality is, while continuing to move the locus of control to patients and doctors, [and] by continuing to move away from paying for individual procedures toward paying for episodes of care.”1

3. How might MACRA change health care payments?

For example, in MIPS, payment adjustments are determined by a Composite Performance Score made up of these 4 components: clinical practice improvement activities (15% of the score), Advancing Care Information program (25%), resource use (10%), and quality achievement (50%). MIPS payments can be adjusted upward or downward based on performance from 2 years ago — these can range from ±4% in the first year of payments in 2019 to ±9% in 2021.

4. What about MIPS and APMs?

This is a bit complicated. APM’s quality measures are similar to those of MIPS, along with requiring the use of EHRs. APMs provide 5% bonus payments, and to earn this incentive in 2019 and 2020 at least 25% of Medicare revenues must be through an APM. This increases to a minimum of 50% by 2021 and 2022.

MIPS also provides a bonus of up to an additional 10% for physicians in the top 25th percentile of an annual performance standard.

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5. What can you and your practice do to prepare?

Start thinking about APM or MIPS.

“Certified PCMHs automatically qualify for the highest possible score for the practice improvement component of the MIPS program (15% of their total score), and as noted above, PCMHs also can qualify as an APM without having to take direct financial risk.”2

To further complicate matters, there are Advanced Alternative Payment Models. Participating physicians are exempt from MIPS. They must meet quality metrics similar to MIPS, use EHR, and bear financial risk “in excess of a nominal amount.”

Keep your eyes and open for updates.

Delve deeper.

If you’re like me, there’s much to learn, and to continue learning. Keep reading up on these changes; ask questions and speak with others and stay tuned.


  1. Belliveau J. Is MACRA a true doc fix for value-based reimbursement? RevCycle Intelligence. Updated July 21, 2016. Available at: Accessed August 12, 2017.
  2. Walker T. Four crucial tips to consider when picking MIPS or APM. Medical Economics. Updated September 22, 2015. Available at: Accessed August 12, 2017.

This article originally appeared on Medical Bag