MACRA: Everything We Need to Know (But Are Afraid to Ask)

The Centers for Medicare & Medicaid Services (CMS) has been keeping health policy wonks like me busy this month, digesting the legislation and its implementation rules (about 2400 pages in total) and analyzing its impact on healthcare IT. So I decided to shape my thoughts into a blog to share some important highlights with you.

By Boris Rachev, Global Health Economist


On April 27, the CMS published a proposed rule on implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The proposed rule provides details on the new Merit-Based Incentive Payment System (MIPS) for eligible clinicians by consolidating components of three existing programs: Physician Quality Reporting System (PQRS); Physician Value-Based Payment Modifier (VM); and the Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals or groups under the physician fee schedule. The proposed rule also establishes incentives for participation in certain alternative payment models (APM).

In the rule, the Department of Health and Human Services (HHS) and CMS identified three central priorities for MACRA, which we should keep in mind while developing our population health management strategy and solutions:

  • Improved interoperability and the ability of physicians and patients to easily move and receive information from other physicians’ systems
  • Increased flexibility in the Meaningful Use program
  • User-friendly technology designed around how a physician works and interacts with patients

CMS is proposing that the MIPS performance period would be the calendar year 2017 – two years prior to the year in which the MIPS adjustment is applied.

Doctor Listening to WomenWho will be affected by MACRA?

The focus of MACRA is on the Medicare clinician community: all physicians, physician assistants, nurse practitioners, clinical nurse specialists and nurse anesthetists. Starting in 2017, all affected providers will be required to report MIPS. CMS will expand the list of eligible providers in 2019. Let me also note that many changes in the MACRA proposed rule focus on Medicare payments for the clinician community, and do not directly impact hospitals and Medicaid providers.

Why does MACRA Matter?

Three words, “competitive healthcare market.” Finally, right? The fee-for-service system for physician payment that has been in place is being eliminated and replaced with a system that rewards quality – the Quality Payment Program (QPP) and its two pathways for satisfying reporting requirements – MIPS and APM.

By tying payments to outcomes and quality of care, MACRA becomes bigger than just reimbursements. As reimbursement becomes increasingly tied to outcomes under the QPP, physicians and clinicians must demonstrate strong quality scores based on the measures outlined below to ensure referrals. Thus, not measuring up to MIPS standards doesn’t just mean reduced reimbursement; it could mean doctors don’t get called to provide care, with competitors getting those referrals.

So what are the QPP criteria?

Quality measures for these core domains will be selected annually, but the first year performance categories are:

  • Quality: 50% of total score in year 1
  • Advancing Care Information: 25% of total score, formerly EHR Meaningful Use
  • Cost or Resource Use: 10% of total score in year 1, based on Medicare claims data – no reporting necessary
  • Clinical Practice Improvement Activities (CPIA): 15% of total score; this is essentially the “new” domain added to the previously existing three above

What does this mean for partnerships between providers and health IT vendors?

Within the MIPS program, quality measures reporting for clinicians (practices and ACOs) can be done by a third party, including “healthcare IT vendors.” Eligible providers need to “ensure that EHR technology consistently meets current standards, implementation specifications, and certification criteria,” meaning that someone needs to make sure provider technology is up-to-date.

The act establishes the use of “voluntary virtual groups” of MIPS-eligible providers for certain assessments,” however the Implementation Rules identify “significant barriers regarding the development of a technological infrastructure required for successful implementation and operationalization of such provisions” – meaning providers will need an IT partner to overcome this barrier.

Providers will also be graded on security risk measures, as part of their MIPS evaluation, like secure messaging, etc. – i.e., cybersecurity solutions and testing are up for bids.

One of the CPIA measures with a “high” weight is the “use of a registry or other certified health information technology functionality to support active care management and outreach to patients in treatment.” Therefore, the Implementation Rules update the list of MIPS-eligible primary care services with transitional care management and chronic care management.

And these are just a subset of the opportunities for partnership with physicians, clinicians and their organizations that this legislation presents for healthcare IT companies like CSC. All of the above highlights not only the opportunities but the necessity of a productive and far-reaching partnership between providers and healthcare IT companies to prepare for the MACRA landscape-changing requirements.

What happens next?

CMS is accepting comments on its proposed rule until June 27, 2016, after which it will use the public’s feedback to craft a final rule. The final rule, expected to be published in November 2016, will determine exactly how physicians will be paid and measured starting as soon as next year. We need to be ready to capitalize on these opportunities.


  1. From my own point of view i thing people should allowed access to information on health care to avoid been ignorant.


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