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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 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:


I am strictly nursing home practice . I have retired from office practice. do I still need to participate?

Posted by WILLIAM BOWERS on October 25, 2016 at 12:23 PM CDT #

Here's what you need to know: Don't do it. Just walk away. Ignore it or opt out of medicare or go to direct primary care. The government has over stepped their boundary and is telling us how to practice medicine. I am a physician trained to care for patients. I am not a statistician trained to click on codes to feed the system. I waste too much time on these programs and it takes away from patient care. The insanity has to stop.

Posted by Jennifer Hollywood on October 25, 2016 at 12:27 PM CDT #

I too am a family physician
42 years practicing what I consider high quality medicine. I spend time with my patients, answer their questions and keep myself educated on the latest practice standards thru the board recertification process. What the powers that be at CMS are now requiring is nothing short of tyrannical control of and the interference in the timely delivery of medicine by dedicated practitioners in this country. And by the way, when I deliver a service I do not think it un American to expect a fair fee for that service. Does not the rest of our economy function in this manner?
I'm with you Jennifer. The insanity must be stopped!

Posted by Stephen Nale MD on October 25, 2016 at 01:08 PM CDT #

To clarify:

Advanced APM -- If you receive 25 percent of Medicare Part B 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.

Posted by Amy Nguyen Howell on October 25, 2016 at 01:13 PM CDT #

Dr. Hollywood outlines some additional options available for physicians. While I am not a strong advocate for physicians leaving the Medicare program altogether, there are options for each of you. Dr. Hollywood discusses direct primary care - a good option for some. The AAFP has done extensive work to promote and support DPC over the past 4 years - I have written on the subject twice:


Dr. Bowers asks about family physicians who only do home care or nursing home care. Participation is determined by how many Medicare patients you care for or your total billing. We have some good resources on home care:


Posted by Shawn Martin on October 25, 2016 at 02:43 PM CDT #

As a full-time practicing family doctor with interest and participation in health information technology advocacy, my main concern with MACRA lies in the fact that we do not yet have interoperability (standardization of health data storage or transfer); and without this critical piece being in place, widespread transfer of patient data is not safe for patients (privacy and security) or for doctors (liability). Even data reported in aggregate can be identified in many cases. I am very interested to hear whether MACRA will require actual patient data being transferred, or merely internal reports generated from within the organization. MACRA has some good intentions; but without interoperability and true security and privacy of our patient data, we cannot ethically participate.

Posted by J. Stefan Walker, M.D. on October 25, 2016 at 03:28 PM CDT #

If anyone wants direction, follow Jennifer's lead.
I teach med students and FP residents. Dear AAFP, you should see the look on their face when I make my lame attempt at explaining MACRA. The new guys and gals are shell-shocked by this. The graduating residents will just be trying to get their medical feet wet soon and will also have to deal with this? Poor schleps, feel bad for them. The faculty don't understand this stuff!
I still take the position of saying NO. Don't take the position of making this more palatable, Time for gargantuan gonads response. This is revolution-level infringement.
Dang...I kept getting the simple math question wrong and would have to re-type!

Posted by Karl Hanson, MD on October 25, 2016 at 07:07 PM CDT #

One huge frustration of mine is that in order to implement the MACRA legislation, we gave up a 10% primary care bonus. That bonus was given to us just for being family physicians. Now if we do everything correctly, we can make up to a 9% bonus--so even in the best situation, we still lose 1% from prior to MACRA. But the overhead necessary to do the database analysis and submission comes at a huge financial cost (studies I have seen range from $50,000-$105,000/physician/year). And, of course, those who do not want to participate stand to lose up to 19% from prior to MACRA (9% penalty along with the 10% bonus being removed).
Perhaps I am missing something, but it seems to me that to spend endlessly more time on administrative tasks so we can make less money as our overhead continues to escalate at a rate much faster than the 0.5%/year Medicare adjustment is more a recipe for disaster than a road to the future. The finances just do not add up.
15-20 years ago, prior to the start of the "quality" movement, Starfield proved that comprehensive family medicine was the key to a healthy and cost effective health care system. Too bad no one else believed her. As we have gone down this terrible path to prove our worth, an extinction event is happening to small family practices across the country. They are the canary in the coal mine. Family medicine has become unsustainable. MACRA simply adds fuel to that fire.

Posted by John Brady on October 25, 2016 at 08:55 PM CDT #

As a solo practitioner, this is complete BS. MACRA bonuses in 2019, based on 2017 chart reviews. I jumped through those hoops to get through Meaningless Use 1 & 2, to get a meager bonus, as a result of obtaining an EHR, with additional costs(though spending more time on clicking on useless/meaningless buttons to get through those hoops). Then my call group tells me that they need access to my EHR(incompatible to their's) 24/7 for their medical home culture, which I feel is additional BS, no change in patient care or outcomes, but more of a way to shelter themselves, or gain an edge to MACRA/MIPS(Meaningless Use 3). As a result I am on call 24/7.

This medical system is fouled up. When I speak to patients, whose premiums are rising from 25-50%, they are not happy, when I tell them I am getting minimal to no increase in payments, then they get more irritated. Not to mention the increase in time spent on increased prior authorizations and referrals, as a result of insurer's changing their rules based on deals they have made with pharmaceutical companies or on their own volition. This is a system no new medical graduate wants to go into, unless they are forced into, primary care is in sorry state.

We live in a capitalized country, and yet I am completely socialized. Maybe I should become a concierge physician. Without a union card, I cannot go on strike.

Posted by Matt O'Brien on October 25, 2016 at 10:59 PM CDT #

CMS Division of Physician Re-Education and Compliance Enforcement (formerly known as the AAFP).


Posted by R Stuart on October 27, 2016 at 09:06 AM CDT #

All the comments recommending opting out are spot on. Patients recognize what all these "quality measures" have done to the relationships with their physicians. During home and facility visits in the community based palliative care program I practice with, I hear every week from someone who has experienced the feeling that they receive "care" only when or if it will produce income for someone else. It is our responsibility to find a way to put the doctor-patient relationship back at the center of reimbursement systems. We are shoved aside as "high-cost" and forced to prove the value of something that is invaluable. The knowledge an individual physician carries about their patients cannot be found in any EHR with any amount of time to glean through pages and page of bloated notes. I say opt out and transform your own practice to take back what has been sacrificed. Use what is good from EHRs as a tool that helps you take care of people, rather than the means of earning s living.

On another tack, anyone who had an MAV evaluation under PQRS will be left wondering how CMS is going to keep track of the complicated scoring of MIPS, when they can't report comprehensibly on the fairly simple counting under PQRS. It is a shell game displayed before us by grifters, claiming to have listened to our cries from the "frontline".

Posted by Rebecca Love, MD on October 27, 2016 at 03:23 PM CDT #


Posted by Jeff M on October 28, 2016 at 07:12 AM CDT #

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About the Author

Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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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.