MACRA Proposed Ruling: Medicare Quality Payment Program

MACRA Proposed Ruling: Medicare Quality Payment Program

On April 27, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) released a proposed ruling for a solution to replace the Medicare sustainable growth rate (SGR) which was repealed last April.  The ruling, which is open for commentary for two months, changes the payment model for Medicare beneficiaries starting in 2017. It does this by offering two paths, the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs)[i].

At a high level, the MIPS path funnels elements of existing programs. These include: Physician Quality Reporting System (PQRS), Value Modifier (VM), and Meaningful Use (MU). They’re funneled into one streamlined program that rewards providers for quality care.  Providers are evaluated on a combination of four performance categories: Quality, Advancing Clinical Information, Clinical Practice Improvement Activities, and Cost.  This model is intended to provide flexibility to physicians while reducing the reporting burden across organizations.


While the majority of healthcare providers will initially go the MIPS route, the Advanced APM program is an alternative path. It includes CMS Innovation Center models, Shared Savings Program tracks, and statutorily-required demonstrations[i].  It offers a higher (5%) Medicare Part B incentive payment and supersedes the MIPS metrics if a provider or organization opts to go that route. These are models qualifying under the APM program:

  • Comprehensive ESRD Care Model (Large Dialysis Organization arrangement)
  • Medicare Shared Savings Program—Track 3
  • Next Generation ACO Model
  • Comprehensive Primary Care Plus (CPC+)
  • Oncology Care Model Two-Sided Risk Arrangement
  • Medicare Shared Savings Program—Track 2 (available in 2018)

The general consensus of the proposed MACRA rule seems to be tempered optimism.  Many felt the SGR model was highly flawed, and the new ruling offers flexibility in demonstrating quality.  Without even realizing it, most organizations and providers are already demonstrating the elements required in the new MIPS pathway.  For example, providers participating in qualified Patient Centered Medical Homes (PCMH) automatically receive full credit for the “Clinical Practice Improvement Activities” category.  PCMH practices will have a significant advantage in maximizing MACRA payments.

If your organization is considering adopting a PCMH model, this could be the extra incentive needed to tip the scales.  To learn more about PCMHs, make sure to catch part three of our free four-part PCMH webcast series this Friday, May 13.

Missed the webcast? You can still watch it on our YouTube channel today!

We will continue to track any updates and share our feedback to the MACRA proposed ruling, but as always feel free to contact us below with any additional questions!



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