Understanding MACRA

By | Reimbursements

By Dr. Jerry Reeves and Aaron Hubbard | HealthInsight Nevada

How clinicians perform compared to their peers will determine whether they receive bonuses
or penalties for services they provide Medicare beneficiaries under the Medicare Access and
CHIP Reauthorization Act of 2015 (MACRA). Required performance reporting for these
incentives begins in 2017.
The Centers for Medicare & Medicaid Services (CMS) recently announced how they plan to
implement MACRA, which replaced the embattled Sustainable Growth Rate formula. The new
Quality Payment Program (QPP) means most clinicians in outpatient practices will participate in
the Merit-Based Incentive Payment System (MIPS), which requires reporting the following to
CMS to determine the performance score that drives payment adjustments:

  • Quality (50 percent weighting at first; decreasing to 30 percent)
  • Resource use (10 percent weighting initially; ramping up to 30 percent)
  • Clinical practice improvement activities (15 percent weighting)
  • Advancing care information (formerly meaningful use; 25 percent weighting)

A few clinicians in CMS-approved advanced alternative payment models (APMs) that share
more than nominal upside and downside payment risk, accept bundled payment arrangements
or participate in patient-centered medical homes may qualify for global bonus payments with
less intensive performance reporting requirements. Those in their first year of Medicare Part B
participation, billing Medicare less than $10,000 and seeing less than 100 Medicare patients
need not participate in MIPS.
With this new system, quality and value are more heavily rewarded than the volume of services
delivered, and burdensome duplicative reporting systems, such as the physician quality
reporting system (PQRS), the value modifier (VM) payment system and the Medicare electronic
health record (EHR) meaningful use incentive program, are combined. The number of quality
measures to report is reduced, and quality measures relevant to more specialties are made
available. A 15-minute video with greater detail can be found here: http://goo.gl/szdR5w
As with prior experiences rolling out Medicare, DRGs, Part D Medicare Drug Programs and
other huge federal payment programs, there may be bumps in the road initially. HealthInsight
has been aggressively preparing for the changes and is offering assistance and answers to help
Nevada clinicians survive and thrive during the challenging transition. We hope you will reach
out and join us as we raise the bar for health quality and safety to improve the health and wellbeing
of the Nevadans we serve.