« Donald or Hillary? H... | Main | You Can Drive Change... »

Tuesday Oct 25, 2016

MACRA 101: What You Need to Know

We are now 14 days from Election Day (assuming you did not participate in early voting). After more than 18 months of campaigning, the end is in sight. Soon, the nation will elect its 45th president, and our favorite television stations will return to a mix of auto insurance and pharmaceutical advertisements in place of the plethora of political ads that have aired for the past six months.  

In my previous post, I outlined the two major party candidates' positions on health care issues. I urge each of you to vote on Nov. 8. Our democracy benefits from participation.

Fall also means rule-making, and the folks at CMS have been busy. On Oct. 14, CMS released the final rule implementing the Medicare Access and CHIP Reauthorization Act (MACRA). AAFP News has a good story on the rule and the AAFP's response. CMS finalized all provisions of the law, including eligibility, participation and evaluation requirements for the MACRA Quality Payment Programs (QPP). These criteria become effective Jan. 1.  

The following is a high-level summary of the law. I will dig deeper into each of these sections during the next few months, but this post is designed to give you basic information.  

First, I must state three things up front:

  • This final regulation includes numerous policies that are the direct result of AAFP advocacy. Since submitting our comment letter on the proposed regulation, we have continued to advocate on your behalf to improve the regulation. I am especially proud of the Pick Your Pace program. This is a concept the AAFP provided CMS, and we are pleased that it was incorporated.
  • All physicians participating in the Medicare program will receive a 0.5 percent update in payments for services provided in 2017.
  • If you participate in the Merit-Based Incentive Payment System (MIPS) program, no matter for how long, you will not be penalized in 2019.

CMS has provided an excellent online resource(qpp.cms.gov) on the QPP program.  Let’s jump into the details.

Eligibility Criteria
The MACRA QPP creates two pathways for Medicare participating physicians:

  • MIPS
  • Advanced Alternative Payment Models (Advanced APM)

If you are one of the following, you are eligible to participate in either of the QPP pathways:

  • physicians;
  • physician assistant;
  • nurse practitioner;
  • clinical nurse specialist; and
  • certified registered nurse anesthetist.

You are not required, as a condition of participating in the Medicare program, to participate in either of the QPP pathways. You may elect to provide care to Medicare patients and not participate in the QPP. However, if this is your decision, you will face maximum negative payment updates as outlined below.  

Exemptions -- If your Medicare allowable charges are less than $30,000 a year or you do not provide care to more than 100 Medicare fee-for-service patients in a year, you are exempt from participation in the QPP. However, if your Medicare allowable charges exceed $30,000 a year and you provide care to more than 100 Medicare fee-for-service patients a year, you are part of MIPS. Additionally, if 2017 is your first year as a Medicare participating physician, then you are exempt from participation in the MIPS program. You may participate in an Advanced APM.

Performance period -- The performance period starts Jan. 1 and concludes on Dec. 31, 2017. Due to the flexibility provided by the Pick Your Pace provisions, physicians may initiate their 2017 performance period at any point between Jan. 1 and Oct. 2.

Data Submission -- Physicians participating in the MIPS pathway must submit quality, advancing care and clinical practice improvement activity data to CMS by March 31, 2018. Physicians participating in an Advanced APM also must submit data by March 31, 2018. If you do not submit 2017 data by the March 31, 2018 deadline, you will receive a negative 4 percent payment adjustment in 2019.

Report as an individual -- If you submit MIPS data as an individual, your payment adjustment will be based on your performance. An individual is defined as a single national provider identifier (NPI) tied to a single Tax Identification Number (TIN).

Report as a group -- If you submit MIPS data as a group, the group will get one payment adjustment based on the group's performance. A group is defined as a set of physicians and other clinicians, identified by their NPIs, sharing a common TIN.

Feedback -- Medicare will provide feedback to individual physicians and physician groups and notify you of your performance score and subsequent payment rate for 2019.

Payment -- Based on your performance in 2017, you will receive a neutral or positive payment update, up to 4 percent, in 2019. If you successfully participate in an Advanced APM, you will receive a 5 percent incentive payment in 2019.

MIPS Payment Adjustments

  • 2019 = +/- 4 percent
  • 2020 = +/- 5 percent
  • 2021 = +/- 7 percent
  • 2022 and beyond = +/- 9percent

Advanced Alternative Payment Model

  • 2019 to 2024 = +5 percent

Performance Criteria & Weighting -- MIPS

Quality -- 60 percent of total score.
Report up to six quality measures, including an outcome measure, for a minimum of 90 days.

Clinical Practice Improvement Activities -- 15 percent of total score.
Attest that you completed up to four improvement activities for a minimum of 90 days.  For solo and small group physicians, or if you practice in a rural or health professions shortage area, attest that you completed up to two activities for a minimum of 90 days. If you are a certified patient-centered medical home or an APM designated as a medical home model, you automatically receive full credit for this category.

Advancing Care Information -- 25 percent of total score.
Fulfill the five required functions which are: security risk analysis, e-prescribing, patient access, summary of care, request/accept summary of care. You may earn additional credit if you submit up to nine measures for a minimum of 90 days. Additionally, you can earn bonus credit for reporting public health and using clinical data registry reporting measures and/or use a certified EHR to complete clinical improvement activities in the performance category.

Cost -- 0 percent of total score.
This category is delayed until 2018 and will not impact payments in 2019. Compliance with the measure does not require data submission on the part of the physician. It is measured using claims data submissions. 

Performance Criteria -Advanced APM

APM Model -- You must participate in a selected APM, which includes the following:

  • Comprehensive Primary Care Plus (CPC+)
  • Next Generation ACO
  • Shared Savings Program Track 2 and Track 3.

Risk -- The APM must take on more than nominal risk or be a recognized medical home model as determined by the Center for Medicare and Medicaid Innovation (CMMI) a recognized Medicaid Medical Home Model.

Beneficiary Threshold -- Twenty-five percent of your Medicare Part B payments must be received through the Advanced APM or 20 percent of your Medicare patients are assigned to your Advanced APM.

Data Submission -- Advanced APMs are required to submit data on identified quality measures using a certified EHR.

Pick Your Pace Program

Test -- If you submit a minimum amount of 2017 data to Medicare, you can avoid a downward payment adjustment in 2019. Minimum amount of data can be as de minimis as one quality measure, one improvement activity, or only four advancing care information measures.

Partial Participation -- If you submit 90 days of 2017 data for all three categories (quality, advancing care information and clinical practice improvement activity) to Medicare, you may earn a neutral or small positive payment adjustment in 2019.

Full Participation -- If you submit a full year of 2017 data, in all categories, to Medicare, you may earn moderate positive payment updates in 2019.

Advanced APM -- If you receive 20 percent of Medicare payments or see 20 percent of your Medicare patients through an Advanced APM in 2017, then you earn a 5 percent incentive payment in 2019.

For additional information, check out the following resources:

« Donald or Hillary? H... | Main | You Can Drive Change... »


Stephanie Quinn, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

Read author bio »



The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.