A New Article Series Looking at MACRA’s Impact

MACRA aggressively seeks to reform Medicare by rewarding the quality of patient care over volume, and reducing wasteful healthcare spending. As the period for public comments comes to a close and the deadline for MACRAs Final Rule draws near, it is a critical time for healthcare clinicians and their provider organizations to understand and prepare for the new requirements they face in 2017.

Since the law itself is complex, multi-faceted, and entirely too much information to digest all at once, we will be producing a series of new articles that highlight various key provisions we feel providers should know about.

In this article series, we will break down topics such as:

  • MACRA’s timeline for change
  • Providers subject to MACRA’s Quality Payment Program (QPP)
  • MACRA’s new expectations placed on physicians and other providers
  • Key challenges for clinicians facing the MIPS payment model
  • New and emerging opportunities for telehealth in the Medicare population
  • Alternative Payment Models such as CPC+ and more

Given the short timeline, it’s more important than ever to ensure your organization is prepared to manage the many new requirements. Stay up to date on the latest MACRA related analysis by signing up for our newsletter and never miss a post!

MACRA Overview

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was created to further health care delivery and payment reform and signed into law on April 16, 2015. MACRA is a transformative law that will ultimately lead the American health care system away from a fee-for-service model and towards a new risk-bearing, value-based, coordinated care models. MACRA will drive payment and delivery reform across the payer mix for the foreseeable future in an attempt to lessen the overall burden of ever-climbing healthcare costs in the US.

Pushing for Value Over Volume in Medicare

MACRA will leverage payment incentive programs in combination with new patient-centered care models to assist Medicare in its transition to a payment model that rewards value over volume. By refocusing healthcare more directly to address patient-centered care and quality, the law tackles the priorities set forth by the US Secretary of Health and Human Services Sylvia Burwell, as she seeks to tie 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018.

MACRA Impact on Healthcare Stakeholders

MACRA will have a broad impact on healthcare stakeholders as it impacts clinicians, health systems, Medicare, government and commercial payers, albeit each in different ways. While there are different payment model paths and requirements for each of these respective organizations including hospitals, health plans and other organizations that employ clinicians that are paid through Medicare’s Physician Fee Schedule; MACRA puts significant revenue at stake for all of them. If your healthcare organization will be providing Medicare services, or expect to in 2017 and beyond, it is imperative that you understand what impacts MACRA will have on both care delivery and business priorities.

In this multi-part article series on how MACRA is expected to reshape the healthcare landscape through new programs and provider requirements, it is only fitting that we begin at the most practical point of departure – MACRA’s payment reforms.

MACRA’s Medicare Payment Reforms

From a high-level, MACRA introduces a new Merit-Based Incentive Payment System (MIPS), a new Technical Advisory Committee for assessing Physician Focused Payment Model (PFPM) proposals, and incentive payments for participation in Alternative Payment Models (APMs) along with scheduled Physician Fee Schedule (PFS) updates.

But rather than present the overwhelming amount of details associated with each of the topics, let’s first start by looking at how The Medicare Access and CHIP Reauthorization Act changes how Medicare plans to pay those who provide care to Medicare beneficiaries.

In this respect, MACRA involves 3 significant changes.

  • MACRA ends the Sustainable Growth Rate (SGR) formula for determining Medicare payments for health care providers’ services. MACRA replaces the SGR with a more predictable payment method that incentivizes value.
  • MACRA establishes a new framework for rewarding quality over quantity (i.e., value over volume) for health care providers.
  • MACRA combines several existing quality reporting programs into one new streamlined system.

Subsequently, these changes have coalesced to form the new Quality Payment Program (QPP).

MACRA’s Quality Payment Program and New Value-based Reimbursements

MACRA’s Quality Payment Program was designed to support the Centers for Medicare and Medicaid Service’s (CMS) goal of paying for value and better care. Accordingly, the new Quality Payment Program (QPP) replaces the Sustainable Growth Reimbursement (SGR) formula by establishing a new value-based reimbursement systems comprised of two paths.

The  Quality Payment Program has 2 paths:

  1. Merit-Based Incentive Payment System (MIPS)
  2. Alternative Payment Models (APMs)

Providers Subject to MACRA’s QPP

Each Medicare Part B clinician is in MIPS, an Advanced APM, both, or neither (regular fee-for-service). CMS officials predict that most Part B clinicians will be subject to MIPS, anticipating that as many as four-fifths of Medicare-participating physicians will begin in the MIPS program rather than selecting the APM risk sharing counterpart. It is worth noting that MIPS only applies to office-based physicians or other clinicians who are reimbursed by Medicare. It does not apply to hospitals, facilities, or Medicaid.


  • April 27, 2016 – CMS released proposed MACRA rule containing MIPS regulations
  • May 9, 2016 –CMS
  • By November 1, 2016 – MACRA final rule published (mandated by the MACRA legislation)
  • January 1, 2017 – Program launch and MIPS performance year begins

Both MIPS and APMs will go into effect over a timeline from 2015 through 2021 and beyond. MIPS payment adjustments and APM incentive payments will begin in 2019, based on performance or APM participation, respectively, in a prior performance period.

Continue on to Part II of our series on MACRA where you will learn about which providers are subject to the MIPS payment model and how CMS scores the four MIPS categories.