Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

In spring 2015, Congress passed—and President Obama signed into law—legislation to transition Medicare to a value-based healthcare system. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate (SGR) formula for determining Medicare payments for the delivery of care, and it established a new framework for rewarding physicians for providing better care, not just more care. MACRA also streamlined quality reporting programs into one new system.

Under MACRA, there are two paths available to physicians to be paid for the care they give Medicare beneficiaries—Alternative Payment Models (APMs) and the Merit-Based Incentive Payment System (MIPS). Implementation of these new paths will take place in 2019; however, the performance year that will determine physician payments in 2019 will begin in 2017. It is important to arm yourself now with an understanding of each path, and—starting today—to take the action necessary to be successful under MACRA.

Alternative Payment Models (APMs)

APMs provide new ways to pay physicians for quality and value. Some examples of APMs are Center for Medicare and Medicaid Innovation Models, Medicare Shared Savings Program Accountable Care Organizations, and CMS Demonstration Projects.

To participate in APMs and be exempt from MIPS payment adjustments, physicians must meet certain thresholds. The Centers for Medicare and Medicaid Services (CMS) will provide incentive payments to some participating physicians in a lump sum. However, not all APMs provide an incentive, so it is essential to know the requirements before choosing an APM.

Merit-Based Incentive Payment System (MIPS)

The goal of MIPS is to promote better care, healthier people, and smarter spending by evaluating performance on quality, resource use, clinical practice improvement activities, and meaningful use of certified electronic health records. Thus, MIPS combines parts of the current Physician Quality Reporting System (PQRS), the Value Modifier (VM or Value-based Payment Modifier) and the Medicare Electronic Health Record (EHR) incentive program (also called the Meaningful Use program) into one single program.

CMS will define an annual performance threshold, on a scale from 1 to 100, and physicians will be ranked on this continuum. Ranking will determine whether a physician receives an upward payment adjustment, a downward payment adjustment, or no payment adjustment. The incentive or penalty increases the further the points earned are away from the threshold determined by CMS. Improving performance in the categories that comprise the MIPS score should be a core focus for physicians in 2016.

In addition to impacting fee schedules, MIPS will also publicly report physicians’ scores on the CMS Physician Compare website. Consumers will see that Dr. A earned 88 points out of 100, for example, whereas Dr. B earned only 43 points. A MIPS score will be in place for one year, but it may take years to reverse reputational damage caused by a low score.

Although details about both payment paths are still being determined, AAFP encourages Family Physicians to being implementing quality improvement and other measures now since perfmance beginning as early as 2017 may impact payment adjustments in 2019.

Transforming Clinical Practices Initiative

CMS has launched the Transforming Clinical Practices Initiative, which establishes Practice Transformation Networks (PTNs) where Quality Improvement Advisors provide no-cost, direct technical assistance to help physicians and their practices position themselves for succes in MIPS or when transitioning to an APM. But hurry...a limited number of spots are available with enrollment now open. To learn more or sign up, visit:

Great Lakes Practice Transformation Network
Phone: 734.302.5632

— OR —

National Rural Accountable Care Consortium
Phone: 916.500.4777