MACRA: What You Need To Know

Value Based Services

MACRA (The Medicare Access & Chip Reauthorization Act of 2015) is coming…

What’s The Big Idea?
In April, The Centers for Medicare & Medicaid Services (CMS) released the Notice of Proposed Rulemaking that will alter regulations on how Medicare reimburses Eligible Clinicians and their practices beginning in 2017. With a stronger emphasis on quality, value, and bigger financial risk, there are three key areas MACRA seeks to address:

  1. Repealing the Sustainable Growth Rate (SGR)
  2. Extending the Children’s Health Insurance Program (CHIP)
  3. Shifting from fee-for-service to pay-for-performance

MACRA’s Quality Payment Program will allow practitioners to select between two quality payment program options:

  • Merit Based Payment System (MIPS) MIPS combines MU, PQRS, and VM to measure Eligible Clinicians in four different categories: quality, resource use/cost, use of certified EHR, and clinical practice improvement. The financial implications of this option are that practices can receive negative or positive payment adjustments based on their MIPS score.
  • Advanced Alternative Payment Models (APMs) Advanced APMs require certified EHR use, payment based on quality measures, and states that practices must bear some financial risk in their APM.

Less than 10% of ACOs currently qualify as Advanced APMs and therefore most practices will participate in MIPS. Since most Eligible Clinicians will be participating in MIPS, we will delve deeper into this Quality Payment Program option.

When Will MIPS Begin?
MIPS is scheduled to begin in 2017 as its first performance year so there will be no change to MU, PQRS, and VM in 2016. The final ruling is expected by November. While the first reporting year for MIPS is scheduled for 2017, payment adjustments will be based on a two-year look back period: starting in 2019, payment adjustments will be applied based on 2017 performance.

Example: A MIPS Eligible Clinician that has a better than average MIPS score for the 2017 reporting year may be eligible for a positive payment adjustment in 2019.

Click here to learn more about the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Who Does MIPS Affect?
Eligible Clinicians in 2017 and 2018 include:

  • Physicians (MD,DO,OD,DPM,DMD&DDS)
  • Physician Assistants
  • Nurse Practitioners
  • Clinical Nurse Specialists
  • Certified Registered Nurse Anesthetists

Then, Eligible Clinicians in 2019 include:

  • All Previous Eligible Clinicians
  • Physical or Occupational Therapists
  • Speech-Language Pathologists
  • Audiologists
  • Nurse Midwives
  • Clinical Social Workers
  • Clinical Psychologists
  • Dietitians and Nutritional Professionals

Furthermore, non-patient facing Eligible Clinicians must also participate in MIPS. A non-patient facing Eligible Clinician includes clinicians or groups that have fewer than 25 patient-facing encounters during a particular reporting period, including telehealth services. If an Eligible Clinician has more than 25 patient-facing encounters, they are considered a traditional MIPS eligible clinician.

The following exclusions are available:

  • New Medicare Providers
  • Low Threshold Providers
  • Advanced APM Participants

Major Changes From Existing Categories

What Is MIPS All About?
Previously, there were three stand-alone programs: MU, PQRS, and VM. MIPS will combine these programs and be comprised of four program categories: quality, resource use/cost, advancing care information, and clinical practice improvement.

  • Quality:
    • Reduction of 9 measurements to only 6 with no domain requirements
    • Emphasis on reporting outcome measures
    • 2017 percentage of MIPS Composite Score is 50%
  • Advancing Care Information:
    • Directly mirrors MU Stage 3 concepts with minor changes
    • Scoring focused heavily on patient engagement and information exchange (interoperability) measures
    • In an effort to achieve better coordination and better patient outcomes, MIPS will introduce flexible scoring – performance measures will no longer be “all or nothing”
    • 2017 percentage of MIPS Composite Score is 25%
  • Clinical Practice Improvement Activity (CPIA): Brand new program
    • Eligible Clinicians must select a combination of CPIA activities from 90+ options
      • Additional credit for more activities
      • Varying weight for harder activities
    • Full credit for patient-centered medical homes
    • Minimum of half credit for Alternate Payment Model (APM) participation
    • 2017 percentage of MIPS Composite Score is 15%
  • Resource Use/Cost:
    • Addition of more than 40 episode specific measures. This will address more specialties with more applicability.
    • Automatic value modifier calculations based on claims submitted, which means there will be no additional reporting requirements from practices
    • Clinician’s key focus will be reducing unnecessary spending, such a hospitalizations and tests
    • 2017 percentage of MIPS Composite Score is 10%

How Will MIPS Be Scored?
MACRA will allow MIPS measures and activities to be converted into points that calculate the MIPS Composite Performance Score.

  • Example: in middle school, your book report was graded on a scale of 0-100 and counted towards 50% of your overall class grade. In the same way, your MIPS Composite Score is similar to your “overall class grade” and made up of various “weighted” activities. The distributions are noted below, but please note these are just proposals and may be subject to change.

Composite Performance Score
Composite Performace Score for MIPS

More Exciting Changes
MACRA proposes more exciting reporting options, including individual or group reporting options. According to CMS, an individual is identified by the Eligible Clinician’s tax ID and NPI combination. A group will be defined by taxpayer identification number. It is important to note that Eligible Clinicians can report as a group across all four MIPS performance categories or as an individual across all four MIPS performance categories. Practices cannot report as an individual for some categories and as a group for others.

There are also several new data submission options, but MIPS Eligible Clinicians and groups may only use one submission mechanism per category. MACRA grants practices more flexibility by allowing practices several ways of submitting their data and eliminating the previous “all or nothing” performance evaluations.

What’s Next?
TSI Healthcare recommends the following in preparation:

  • Continue to run your MU reports with special focus on patient engagement and interoperability
  • Continue to run your PQRS & CQM reports
    • It is important to remember that MU, PQRS, and VM are still in effect for 2016!
  • Restructure your team and meet often
    • Meet at least every other week to review MU and PQRS reports
    • Identify areas of improvement
    •  Share feedback with your entire team

TSI Healthcare understands how challenging it can be to navigate various government regulations. We are committed to partnering with our clients to keep you up to date as CMS’s Quality Payment Program evolves. To learn more about MACRA, view our infographic below or visit

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