The Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015 begins full implementation in 2019. Overall, the first round of MACRA’s Merit-based Incentive Payment System performance scores were positive, but significant changes are imminent.

On Nov. 1, 2018, the Centers for Medicare & Medicaid Services released the CY 2019 Quality Payment Program final rule under the MACRA law. Several of these changes include:

  • MIPS eligibility:
    • Exemptions – clinicians with $90,000 or less in Medicare payments per year, fewer than 200 Medicare patients, or clinicians who provide 200 or fewer covered professional services under the physician fee schedule
  • Participants now required to use 2015 Certified Electronic Health Record Technology under the Promoting Interoperability performance category (formerly Advancing Care Information)
  • Cost bucket begins to impact payment adjustments at 15 percent weight for 2020 payment adjustment
  • Clinicians and groups must earn at least 30 MIPS points, up from 15 points in 2018, to ensure a positive payment adjustment
  • Consumer transparency – The Physician Compare Website will become operational – Star rating system of 1-5 for Medicare physicians
    • CMS will publicly report the final overall MIPS score, individual, and group for each performance category
    • Reputational impact includes: overall physician/physician group reputation, recruitment, and affiliated health systems

Implementing MACRA has been a formidable challenge for physicians with many still trying to determine how to implement the required changes to be successful under the new payment incentive program. Nicole Harmon, senior director, practice advancement strategies, for the Healthcare Association of New York State, works with practices throughout the state to get them MACRA ready. Harmon describes many of the practices she currently works with as early innovators, which are practices embracing payment reform and participating in value-based initiatives. Harmon’s team works with practices to develop a strategy, implement work flow improvements, solidify team-based care, and help them submit quality measures to get them to their ultimate goal.

MACRA is not going away. The questions we ask are, What is your path? How are you performing? Where do you want to go?

Nicole Harmon, Senior director, Practice advancement strategies, Healthcare Association of New York State

The final scores for the 2017 MIPS reporting year analyzed by CMS indicated a mean final score between 63.50 and 68.90 points and a median score between 77.83 and 82.50 points. The payment adjustments varied between -4 percent and 1.88 percent. CMS estimates 91 percent of MIPS participants will receive positive or neutral payment adjustments.

Amy Ferguson-Victor, director of quality and performance excellence for the Mohawk Valley Health System Medical Group, Utica, N.Y., describes the practice as an early innovator in progressive payment models, which has helped them implement MACRA successfully in the first year. The practice, which is physician-led and administratively run, submits quality data under MIPS for 373 primarily employed physicians and is considering a transition into advanced payment models.

“We would have liked to see our group reporting score higher,” Ferguson-Victor said. “We went into our first MIPS year relying on our understanding of Meaningful Use and PQRS. We have obtained the group reporting functionality so we can report quality data for all providers for 2018.  It was a learning experience, but that previous experience served us well.”

For many physicians and eligible clinicians, MACRA is another type of quality incentive program to adjust to while trying to provide quality care to patients. But the adjustment period is over. The fee-for-service payment model will always exist on some level because there must be prospective payments to feed revenue and keep the lights on and the claims delay is inherent. But, value-based payments will be the overarching payment methodology. MACRA is not going away.


Valerie E. Pillo is a Market Analyst for Market Access Insights and specializes in the physician realm, among other topics. Her work appears regularity in Health Plan Analysis and Market Overviews. Follow her on Twitter @ValeriePilloDRG

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