MACRA, MIPS, how they affect your practice and the role of PROs

by | Articles


MACRA (Medicare Access and CHIP Reauthorization Act of 2015) has been described as the most significant piece of healthcare legislation passed in the last 25 years and is expected to have a profound effect on the way US healthcare is reimbursed. Surveys show, however, that very few physicians are familiar with the legislation and the impact it will have on their practice. Awareness is gradually building, but at a time of unprecedented change, intense pricing pressure and ever more complicated reporting requirements it is no surprise that many clinicians are reluctant to engage.

So why does it really matter? For clinicians who receive reimbursement under Medicare Part B, MACRA will tie an increasing amount of that payment to quality and value as defined by their Quality Reporting Program (QPP). The program is cost neutral meaning there will be winners and losers and by 2022 there will be a 18% differential in payment made to the top performers versus the lowest performers. Medicare further intends to publish the data so that it can be used by Physician Compare and other third parties to drive patient choice. This data is also likely to drive private payers as they define networks and enter in to contract negotiations. Lastly, MIPS payment adjustments will follow providers for two-years if they switch practices, meaning practices may think twice if you’re a low MIPS performer and it may affect your mobility.

Financial Impact of MIPS on Medicare Part B Payments

The Act was passed with strong bipartisan support and despite the commotion around the repeal and replacement of the ACA, the word on the street is that MACRA is here to stay and the shift from volume to value will continue to march on.

Why MACRA exists

MACRA repealed the Sustainable Growth Rate formula for controlling the annual budget for physician Medicare payments and ties an increasing percentage of Medicare payments to quality through the Quality Payment Program (QPP) to help reach CMS’ goal of a major shift to value-based models of care. The QPP program has two main tracks – Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS).

Two tracks for providers

The first big question to ask is which of these buckets your practice falls in to. If you’re part of an Accountable Care Organization, Patient-Centered Medical Home or bundled payment program you may well fall under the APM bucket. These programs are deemed to have quality and value baked-in, and thus being in an APM model minimizes any additional reporting requirements and qualifies you for a 5% bonus payment on top of any shared-savings that you might earn under those risk-sharing models.

If you don’t quality as an APM, then you’ll be in the MIPS track – which unsurprisingly includes the vast majority of clinicians (83-90% by CMS’ estimates).

MIPS replaces the existing programs – Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VBPM) and Meaningful Use (MU) and in many ways carries forward what those programs represent, attempting to make them more progressive while also reducing administrative burden.

The Details

MIPS is a single reporting program comprised of four areas – Quality, Advancing Care Information (ACI), Improvement Activities (IA) and Resource Use. Your score across these areas is rolled up in to an overall composite performance score that ranges from 0-100. The weightings across these four categories is set to change as the program is progresses but in the first reporting year, 2017 will be as follows:

  • Quality (60%)
  • Resource Use / Cost (0%)
  • Improvement Activities (15%)
  • Advancing Care Information (25%)
  • While Cost is calculated from your claims data and requires no further reporting, the other categories have a selection of measures that you can report on to claim credit. The Quality Payment Program website has a list of measures listed here. In the Quality category you will need to report on at at least 6 measures, including one or more outcome measures to get full credit. Under the Improvement Activities category you can attest that you completed up to 4 activities over a period of at least 90 days. In Advancing Care Information which replaces Meaningful Use there are 5 qualifying requirements and the option to submit up to 9 additional measures for additional credit.

    How reporting works

    Clinicians can submit performance data individually or as a group, but they must report the same way across all four categories. Reporting options vary depending on the MIPS category and individual quality measure in question but range from EHR submission of data through to self attestation of having performed certain activities.

    The role of PROs in MACRA

    With CMS’ emphasis on patient-centered quality measures, it’s no surprise that PROs and the kind of solution we offer here at feature heavily in the QPP and can directly win you points in three of the four categories. For example in the Quality category, there are over 10 individual measures for functional, health-related quality-of-life or symptomatic assessment. In the Improvement Activities category, there is a measure that is specifically for capturing patient-reported outcomes. Under Advancing Care Information there is a measure for capturing patient-generated health data and another for providing electronic patient-specific education.


    MACRA is a piece of legislation that has huge impacts to physician Medicare reimbursement and is here to stay. It introduces the Quality Payment Program that replaces the Physician Quality Reporting System, Meaningful Use and the Value-based Payment Modifier and ties an increasing amount of payment to this quality framework. The vast majority of clinicians will fall under the Merit-based Payment System track of the QPP that will eventually lead to a 18% differential in Part B payments at the top and bottom of the performance spectrum.

    There are no two ways about it – providers who fail to engage with MACRA and MIPS will be setting themselves up for significant reductions in Medicare payments. Furthermore as data from the program is made publicly available, there’s a risk that it could drive future patient volumes away from low performers. Where CMS starts, private payers often follow – so expect that same data to be used to define networks and set prices, and for private payers to implement similar quality reporting programs.

    Clearly this program requires a multi-faceted approach that starting by taking a long hard look at the measures across the three categories to understand which make sense for your practice. Patient-reported outcomes can be an easy part of that strategy, and not just for the sake of protecting Medicare revenue by ticking boxes, but to help your practice provide more joined-up, data-drive care that will position you well for the future.

    If you’d like to talk more about any of these topics be sure to get in touch. We’ll be publishing more articles on this important topic so please subscribe to our mailing list, and if there’s anything you’d like to see written about let us know and we’ll try to make it happen. Below are a few other resources that you might find helpful on your quest to better understand MACRA, MIPS and more.

    Further Resources:

  • The CMS Quality Payment Program website
  • Deloitte’s overview of MACRA
  • CMS Presentation on MIPS Scoring Methodology
  • The Advisory Board Company on MACRA
  • icon helps healthcare providers routinely capture and use patient-reported
    outcomes in their practice. Learn more about our product or get in touch to learn more!