CMS Proposes Structure For MACRA Implementation

The Centers for Medicare and Medicaid Services (CMS) released proposed regulations on April 27 to implement the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). These regulations will establish rules for clinician participation in both the Merit-Based Incentive Payment System (MIPS) and qualifying for incentive payments based on participation in Advanced Alternative Payment Models (APMs) beginning with the 2019 payment year. Initial highlights include:


  • MIPS will streamline the existing Physician Quality Reporting System, Value-Based Modifier, and Meaningful Use (MU) programs into a single program that introduces a fourth component of clinical practice improvement activity (CPIA) participation. MIPS payment adjustments of up to +/-4 percent in 2019 will be based on a clinician's composite performance score (CPS) in the following categories in the 2017 performance year (Jan. 1 - Dec. 31):
    • Quality (50 percent of CPS): Most MIPS eligible clinicians will be required to report at least six measures, including at least one cross-cutting measure and one outcome measure.
    • Advancing Care Information (25 percent of CPS): Formerly recognized as MU, clinicians will report on measures focusing on interoperability and the use of technology to facilitate information exchange. Unlike the current Electronic Health Record (EHR) Incentive Program, there is no all-or-nothing EHR measurement or requirement to report additional quality measures. However, no changes will be made to the 2016 reporting requirements for the EHR Incentive Program.
    • Clinical Practice Improvement Activities (15 percent of CPS): CMS proposes that clinicians participate in CPIAs for a minimum of 90 days, with points assigned to over 90 activities, including participation in clinical data registries. While CMS proposes not to require a minimum number of activities to meet this requirement, the Agency does propose a score of 60 points to achieve full credit.
    • Resource Use (10 percent of CPS): CMS proposes to continue two measures from the current Value-Based Payment Modifier; total costs per capita for all attributed beneficiaries and the Medicare Spending per Beneficiary measure, with adjustments. In addition, applicable clinical episode-based measures will apply. Resource use data will be pulled from Medicare claims data and require no reporting by clinicians.
  • MIPS eligible clinicians will have the option to report as individuals, as a group practice or as an APM entity.
  • Beginning July 1, 2017, CMS proposes to provide clinicians with performance feedback on the quality and resource use categories of MIPS.


  • CMS defines criteria by which an APM entity can demonstrate that it meets the definition of an Advanced APM. CMS will post a list of qualifying Advanced APMs through which Qualifying Participants (QPs) can earn bonus payments prior to each performance period, starting no later than Jan. 1, 2017.
  • Most Advanced APMs will have to meet thresholds for marginal risk (>30 percent), minimum loss ratio (>4 percent), and total potential risk (calculated for each APM) to satisfy the law's "more than nominal" risk requirement. The first performance year for QPs in Advanced APMs will be 2017. QPs who obtain enough payments or patients through the Advanced APM will be eligible for a 5 percent lump sum Advanced APM Incentive Payment from 2019 through 2024 with higher fee schedule updates starting in 2026.
  • For 2019, performance will be based on participation in Medicare Advanced APMs. Starting in 2021, CMS will recognize the All-Payer Combination Option which allows clinicians to meet the participation threshold via Medicare Advanced APMs and/or Other Payer Advanced APMs.
  • CMS proposes a process for Advanced APM participants who do not meet the QP threshold and are considered "partial QPs" to choose whether or not to be subject to the MIPS payment adjustment.
  • CMS proposes to define a "physician-focused payment model" (PFPM) as "an Alternative Payment Model wherein Medicare is a payer, which includes physician group practices or individual physicians as APM Entities and targets the quality and costs of physician services." PFPMs would be required to be designed with Medicare as a payer.

Get up to speed on the background of the law and continue to watch for new updates on the ACC's MACRA Information Hub. The proposed regulations are open for public comment for 60 days. Additional information will be forthcoming as your ACC, committees and councils review and analyze the proposals. The College will submit comments that support members' ability to succeed in the programs through the delivery of high quality cardiovascular care.

Keywords: Access to Information, Centers for Medicare and Medicaid Services (U.S.), Electronic Health Records, Fee Schedules, Mandatory Reporting, Meaningful Use, Medicaid, Medicare, Outcome Assessment (Health Care), Registries

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