Doctors reviewing their CG CAHPS analtyics

We hope this isn’t news to you – MACRA is going to be big in healthcare. The program continues to move the healthcare industry away from fee-for-service in favor of quality-based outcomes for Medicare Part B eligible clinicians.

The Centers for Medicare & Medicaid Services (CMS) has published a proposed rule that includes reimbursement for most clinicians based on a composite score made up of 4 components and weighted according to the current relevance of each clinical outcome performance.

  • Quality performance (50%)—this category replaces PQRS and will continue to measure clinical outcomes and performance
  • Advancing care information (25%)—this category is a more flexible version of the current Meaningful Use (MU) reporting category
  • Resource use (10%)—this category will measure savings resulting from resource use, replacing the value-based payment modifier (VBM)
  • Clinical practice improvement (15%)—a new category that encourages expanded clinical practice activities that allow more access to care and improved reporting of test results


MACRA clinical improvement puzzle


MACRA is a solution to the familiar and ongoing problems with the sustainable growth rate (SGR) but, as with any new program, it will take time to become standardized across the healthcare industry.

This adoption time is understandable, but waiting is not advisable for healthcare providers who want to maximize reimbursement under the coming MACRA reimbursement models. The proposed payment adjustments and reimbursements have the potential to be very significant.

Reimbursement Timeline Does Not Change

While MACRA legislation will change many things about the ways healthcare is delivered and reported, one part that will not change is the 2-year lookback period for performance. There is a misconception that MACRA begins with the sun setting of initial value-based metrics (PQRS, MU, and VBM) in 2019. The reality is that 2017 is the first year for reporting of metrics that make up the composite score for the Merit-based Incentive Payment System (MIPS). You need to know that performance for the Quality Payment Program (QPP) begins in 2017 with the first reimbursement payment occurring in 2019 for 2017 reported performance.

Under MIPS, payment adjustments will range from +4% to -4% in 2019 for clinicians’ performance in 2017. This adjustment increases through 2022 as demonstrated below.

Graphic illustrating MACRA fee adjustment

Exceptional Pay for Exceptional Performers

To further reward optimal outcomes from providers, CMS has announced an additional multiplier that can adjust positive adjustments for exceptional performance as much as three times the upward adjustment for “exceptional performers”. Here is the earning opportunity from 2019 through 2022 for these exceptional performers.
An additional $500 million bonus pot of money is available annually through 2024 for rewarding exceptional performers.

Graphic of MACRA Multiplier adjustment

MIPS has implications for clinicians across the spectrum of performance, including low performing providers. Negative reimbursement will not be subject to any kind of multiplier, but the lowest performing providers will make it possible for the multiplier to be awarded to the exceptional performers.

By definition, the additional 3x payment for exceptional performance will be difficult to achieve. Clinicians can improve their chances of attaining the 3x multiplier with early adoption of the MIPS process. By knowing where you stand and understanding the reporting process, you can make improvements in performance and outcomes going forward, making it easier to attain a positive reimbursement adjustment and possibly earn an exceptional performer multiplier on top of the positive adjustment.

Be Ready Now Even Though MACRA Isn’t 

The final rule on MACRA is expected to come in the fall. The potential for positive payment adjustments and reimbursement is the best reason for Medicare Part B eligible clinicians to begin working on value-based metrics, especially if they have been hesitant to do so before. For small practices, the Department of Health and Human Services has a $20 million initiative to fund movement towards the QPP.

Regardless of practice size, clinicians need to know if they will be eligible for MIPS and are advised to know where they stand on each component of the categories that make up the Composite Performance Score. With this knowledge, providers will be ready for the latest legislation and position themselves to maximize the opportunities that MACRA will bring.

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