CMS Finalizes MACRA Regulation Outlining New Medicare Payment System Implementation

The Centers for Medicare and Medicaid Services (CMS) on Oct. 14 released final regulations to implement the Quality Payment Program (QPP) created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) beginning with the 2019 payment year. These regulations establish rules for clinician participation in the Merit-Based Incentive Payment System (MIPS). They also detail how to qualify for incentive payments based on participation in Advanced Alternative Payment Models (APMs). Through its advocacy efforts, the College has worked with CMS and other health care organizations since day one to help shape the new Medicare payment system and ensure cardiovascular professionals can succeed in the new program.

“This final rule demonstrates the complexity of moving to a value-based payment system under Medicare; however, we are encouraged to see that CMS has made several changes in the final rule based on comments by the clinician community. The College urges CMS to continue providing effective education and assistance to clinicians and their practices to ensure that this transition does not interfere with their ability to focus on their most important job: providing patient-centered care,” said ACC President Richard A. Chazal, MD, FACC.

ACC Advocacy has reviewed the final rule and compiled a list of important highlights:

Program Flexibility

  • As CMS previously announced, eligible clinicians can pick their pace in 2017 by (1) submitting one Quality measure, one Improvement Activity, or minimum Advancing Care Information (ACI) activities to avoid a negative MIPS adjustment; (2) reporting more than one Quality measure, more than one Improvement Activity, or more than minimum ACI activities to avoid a negative MIPS payment adjustment and possibly obtain a positive payment adjustment; (3) fully participate in the Quality, Improvement Activities and ACI categories for at least 90 days; or (4) sufficiently participating in an Advanced APM.
  • By increasing the low-volume dollar threshold from $10,000 to $30,000, CMS estimates 32 percent of clinicians will be exempt from QPP requirements in the first year of the program.
  • $100 million for technical assistance through contracts with regional organizations will be available to small practices of 15 or fewer MIPS eligible clinicians, rural areas, health professional shortage areas and Indian Health Services clinics, with priority given to rural areas, medically underserved areas and practices with low MIPS scores.


  • MIPS streamlines the existing Physician Quality Reporting System, Value-Based Modifier, and Electronic Health Record (EHR) Incentive programs into a single program that introduces a fourth component of Improvement Activities. Depending on a clinician’s decision regarding their “Pick Your Pace” level of 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 (60 percent of CPS): MIPS eligible clinicians attempting full participation will be required to report at least six measures during a continuous 90-day performance period, including at least one cross-cutting measure and one outcome measure.
    • ACI (25 percent of CPS): CMS has reduced the number of measures originally proposed by half. By reporting on five measures, rather than 11, eligible clinicians will earn 50 percent of the ACI score. The remaining measures will be optional, but reporting on them can assist eligible clinicians in earning a higher score. There will also be the opportunity to use success in certain quality improvement activities and registry reporting to earn bonus points towards the ACI score. The College is still awaiting final rulemaking on changes proposed to the EHR Incentive Program penalties faced by physicians who have not participated in the program prior to 2017 and who are transitioning to MIPS.
    • Improvement Activities (15 percent of CPS): CMS reduced the threshold for full credit to participation in four medium-weighted activities or two high-weighted activities. To receive credit for an activity, clinicians would have to participate in the activity for a minimum of 90 days. Clinicians in APMs, non-patient facing clinicians and clinicians in small and rural practices will see additional threshold flexibility. CMS finalized the list of eligible CPIAs in the final rule.
    • Cost (0 percent of CPS): CMS will not include cost measures as a factor during the 2017 transition year. Clinicians will receive data on their Cost performance in 2017, but these data will not be calculated into their MIPS score until the 2018 performance year. Reference scores will be calculated for 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, 10 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 Cost categories of MIPS.

Advanced APMs

  • CMS is still finalizing the list qualifying Advanced APMs through which qualifying participants (QPs) can earn a 5 percent lump sum bonus payment on Medicare Part B services in 2019-2024, an exemption from MIPS reporting requirements, and higher fee schedule updates in future years. This list will be released before Jan 1, 2017. CMS is considering the Medicare Accountable Care Organization Track 1 Plus (ACO Track 1+) as an Advanced APM. The ACO Track 1+ model is anticipated to begin in 2018 and will be the next phase for ACOs currently participating in Track 1 of the Medicare Shared Savings Program.
  • CMS finalized an accelerated review process for Advanced APM QP determinations so that clinicians will know their MIPS exemption status as soon as possible prior to any MIPS reporting deadlines.
  • CMS finalized the QP thresholds for 2019 at 25 percent of Medicare Part B payments for services furnished through the APM or 20 percent of patients attributed to the Advanced APM. CMS established lower thresholds for clinicians would qualify as “partial QPs” who would not be eligible for the 5 percent bonus, but could choose whether to be subject to MIPS payment adjustments.
  • CMS finalized the definition of the “physician-focused payment model” (PFPM) as “an Alternative Payment Model wherein Medicare is a payer and participating clinicians play a core role in implementing the model's payment methodology and the quality and costs of services provided or ordered." The Physician Focused-Payment Model Technical Advisory Committee will review PFPMs proposed by the public.

Regardless of MIPs or APM participation, clinicians will be required to meet two additional health IT-related requirements in addition to the ACI requirements described above. Clinicians must assist the government in monitoring health IT vendors’ compliance with requirements when requested to do so. More details on this provision are spelled out in a separate rulemaking also issued on Oct. 14. Clinicians must also attest that they are not engaged in information blocking and are acting in good faith to implement and use certified EHR technology in a manner that supports interoperability and the appropriate exchange of electronic health information.

The ACC Advocacy team will review the final rule in depth and provide more details in the coming weeks. Stay tuned to and the Advocate newsletter for more information.

The following resources are available to help you successfully participate in the QPP in 2017 and beyond:

Keywords: Medicare, Medicaid, Medicare Access and CHIP Reauthorization Act of 2015

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