MACRA overview: Demystifying its risks and rewards

By nThrive | Posted: 02/20/2017

Based on more than 2,400 pages of regulations, the Medicare Access and CHIP Reauthorization Act of 2015, otherwise known as MACRA, is indisputably a force to be reckoned with. With 2017 designated as the first reporting year under the act, clinicians have no time to waste getting up to speed on the new QPP requirements, including associated penalty risks.

To help health care professionals learn more about MACRA, nThrive partnered with Becker’s Hospital Review on Feb. 9 to host a webcast entitled, “Are you positioned to shine or fade under MACRA?” This complimentary webinar covered the risks and rewards of the act as well as how to approach its regulations from a strategy, technology and education standpoint.

Over 900 registered for the live session, which can be viewed here. The webcast featured industry experts Michael Marron-Stearns, CPC, CFPC, MD, a physician informaticist, certified professional coder (CPC) and health information technology and health care compliance consulting professional, and Moshe Starkman, nThrive’s senior consultant over value-based care. Caleb Manscill, nThrive’s vice president of product for the Analytics division, moderated the session in which he likened MACRA to a marathon.

“The MACRA Quality Payment Program is much like training for a marathon,” Manscill explained. “You can’t simply wish to do well under this initiative, especially considering its competitive nature. It is something that you need to prepare for to see the financial and quality returns on your investment.”

What is MACRA? What isn't it?

Technically speaking, MACRA is the legislation passed in April 2015 that created the Quality Payment Program (QPP) and repeals the Sustainable Growth Rate (SGR) Formula. Launched in January 2017, the QPP is administered by the Centers for Medicare & Medicaid Services (CMS) and includes two payment reporting pathways for which qualifying clinicians must choose: Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs).

MIPS streamlines the Physician Quality Reporting System (PQRS), Value-Based Modifier and Meaningful Use programs and adds a new Improvement Activities program to the mix, while the Advanced APM pathway includes value-based models. “The Quality Payment Program is what we are under now,” Starkman said, calling it a “paradigm shift in the way value-based reimbursements will be approached moving forward.” Dr. Stearns noted that MIPS and Advanced APMs are both designed to “make Medicare better by helping clinicians focus on care quality.”

Choosing your path - MIPS or AAPM

It is estimated that 90 percent of clinicians will participate in MIPS in the first few years.  Under MIPS, a clinician’s reimbursement will tie to their individual performance in four key categories: Quality, Cost, Improvement Activities and Advancing Care Information. The other 10 percent are expected to participate in an Advanced APM.

“Unfortunately,” explained Dr. Stearns, “there are not a lot of Advanced APMs available right now, regionally and by specialty.” However, he emphasized that clinicians can expect the numbers to grow. “They require shared risk and will be advancing significantly in number and specialty type over the next several years,” he said.

Going for gold

It is important to understand the contrasts between MIPS and APMs in terms of incentives, with Starkman characterizing MIPS as the “more dynamic” option of the two. Stearns broke down the incentive structures, noting that there is “significant money out there,” especially for clinicians with exceptional performance.

“With MIPS,” said Stearns, “payment percentages increase each year for the first four years of the program (four, five, seven and nine percent, respectively), with nine percent continuing indefinitely thereafter. Depending on funds available from the penalized side of the equation, this can be increased by a factor of three based on performance.”

“If you add it all together, in theory, you could get as high as a 37 percent increase in positive payment adjustments through MIPS by the year 2022,” explained Stearns, “which would be very significant for MIPS participants.”

In contrast, APMs will earn five percent per year over the first six years of the program, with the incentives reducing to less than one percent thereafter.

Competing on a national scale

While CMS seems to be “putting their money where their mouth is,” Starkman cautioned that the QPP also ups the rules of the game. “When you are considering this program, keep in mind that what you’ve done in any one given year is not necessarily a good strategy for the subsequent year. As with a marathon, it is not a fixed experience; you’ll confront hill and turns, unlike running on a treadmill.”

Choosing which quality measures to report under MIPS can get complicated, added Stearns. “You really have to crunch the numbers and try to attain top scores,” with thresholds changing yearly based on fluctuations in national averages.  In 2017, for instance, clinician performance will be compared with a 2015 baseline. Every two years the bar presumably goes up, helping to drive continuous improvement.

Know your numbers

As a first step in 2017, clinicians are encouraged to check out the 2015 baseline numbers, which are available on the CMS website at and contrast those with their current measures. “You really don’t want to wait until 2018 to find out how you did last year,” Starkman emphasized.

Deciding on the number of measures to report is also important. “While reporting one measure is the minimum in 2017 to avoid a penalty, I recommend doing more than six,” Dr. Stearns said. “Medicare will take your top six to determine your total score.”  He noted that the higher the score the better, as MIPS scores will be publically displayed. “If you are competing with other health care providers, a lower score could be used on websites that rank physicians and hospitals,” explained Stearns.

Timing is also critical. “Medicare has stated that you can get the highest scores – potentially 100 on MIPS – if you report for a minimum of 90 days. Some measures require at least 20 patients, which may require 90 days or longer to meet,” cautioned Stearns.

Get started today

Along with determining applicable measures to report against your baseline, time and attention should also be given to technology, education and workflows.

“What we are recommending is to dive into MACRA as quickly as possible,” said Dr. Stearns. “Do some practice runs, see where your problems are and define your reporting period, allowing for at least 90 days.

From a planning standpoint, think top down, assessing your technology and education requirements.

“One thing we can’t over emphasize is identifying your sources of data,” Starkman explained. He emphasized the importance of having a strong technology structure by asking the question, “How can that information be integrated and essentially mapped to a single source for further analysis and reporting?”

Starkman added that education tailored to specific audiences is also an essential part to finding success under MACRA. “Any time you have a significant regulatory change in health care, education is at the heart of success. If you don’t understand what is being asked of you, or you don’t understand why it is necessary, you’ll have reluctance which results in lower adoption rates.”

If you'd like to learn more about how nThrive can help you achieve your MACRA goals, click here to visit our MACRA Management Solutions page or contact us at

To view the webcast recording, click here.