MACRA 2017 and Beyond

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a federal legislation signed into law on April 16, 2015 to establish new methods of payment to clinicians for caring for Medicare patients. This is the next shift in healthcare also known as Value Based Care. MACRA leverages certified Electronic Health Record (EHR) systems for tracking and measuring the Advancing Care Information category under the Quality Payment Program. According to CMS Acting Administrator, Mr. Andy Slavitt, “The Advancing Care Information category will modernize, streamline and replace the Medicare EHR Incentive Program for eligible professionals (also known as ‘Meaningful Use’)”. He added, “The Quality Payment Program advances the use of certified EHRs and health IT as tools to improve the flow of health information among clinicians and, ultimately, improve the quality of care provided to patients.”

Specifically, the Quality Payment Program has two payment options for the clinicians and they have to select one. The first and the most popular will be the Merit-based Incentive Payment System (MIPS), meanwhile the one that relates more to Value Based Care is called Alternate Payment Models (APMs). CMS will require use of certified EHR technology to exchange information with the provider community and with patients to validate improved care delivery, including patient engagement and care coordination.

The Office of the National Coordinator (ONC) for Health IT is considering certifying EHR systems and forcing the companies that are unable to certify to pull noncompliant products. If the ONC decertified a product, its developer would be required to notify affected customers and providers who purchased the products. The ONC would also issue a cease-and-desist notice to prevent the future sale or marketing of the product. This is being disputed at this time due to potential hardship to some physician organizations and EHR vendors.


Merit-Based Incentive Program (MIPS)

All clinicians, which includes physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists who bill Medicare more than $30,000 a year or provide care for at least 100 patients, will be subject to MACRA’s Merit-Based Incentive Payment System (MIPS) beginning January 1. MIPS has four components:

1. Quality
2. Resource Use
3. Clinical Practice Improvement Activities
4. Advancing Care Information

Each component will receive a weighted score that will be totaled and a composite performance score will be calculated. This score will then determine provider reimbursements and incentives.

CMS intends to make this transition as smooth as possible by providing some flexibility. Under the final rule, providers can opt out and not send CMS any data in 2017, which would result in an automatic 4% payment reduction in 2019. Providers can avoid this penalty by submitting data for just one quality measure or improvement activity. Also, CMS allows some third party vendors to submit data on behalf of clinicians to help with the process and to avoid the 4% penalty.

Alternative Payment Method (APM)

APM is the true shift from Fee for Service to Value Based Care whereby clinicians or organizations must meet the following criteria:

1. Under APM, practitioners must take some financial risk. The final ruling calls for a minimum loss ratio no greater than 4% of expected expenditures or total potential risk of at least 4%.
2. Payments must be calculated using evidence-based quality measures that are reliable and valid.
3. At least 50% of participants must use certified Electronic Health Record (EHR) technology to document and communicate clinical care information in the first performance year (this increases to 75% participation in the second performance year).

To qualify as an APM, participants must meet revenue targets which are:

• By 2019-20 participants must have 25% of Medicare payments from an advance APM model. That increases to 50% in 2021-2022 and

• 75% in 2023 and beyond. Participants can partially qualify for APM by hitting 20% in 2019-20, 40% in 2021-22, and 50% in 2023 and beyond. Being partially qualified exempts participants from some of the MIPS requirements.

* CHIP – Children Health Insurance Program


Zand, Peyman. Mon, 31 Oct 2016. “MACRA 2017 and Beyond.” Retrieved from:

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