MACRA: What Is It, and What Does It Mean For You?

September 21, 2016 | Aaron P. Kithcart, MD, PhD

Long before many of us had started our medical training, Congress enacted the Balanced Budget Act of 1997, which created a formula inaccurately called the Sustainable Growth Rate (SGR) as a way to curb Medicare spending. The formula was the benchmark by which payments to physicians were made. While its intentions were noble, the growth rate was anything but sustainable, and by 2015 physicians were expected to take a 21 percent cut in reimbursements according to the SGR.

Fortunately, this was averted when Congress passed the Medicare Access and CHIP Reauthorization Act of 2015, which we now refer to as MACRA. This was significant as it eliminated cutbacks in physician reimbursement, and even included a modest gain for the first few years of implementation. However, critical to passage of MACRA was inclusion of several measures that emphasize quality over traditional fee-for-service models. This is important for FITs as the way we are reimbursed in the future will be directly tied to the quality of care we provide. Let me explain.

There are two major pathways within MACRA, and the choice was likely made by the organization that signs your paycheck. If you enter your own practice, you will be able to make this choice for yourself, but for the majority of those who are planning to be employed, make sure you ask about this while interviewing for your first job.

The first pathway is called Merit-based Incentive Payment System (MIPS). This is made up of a number of quality-based components, including existing Meaningful Use, Physician Quality Reporting System (PQRS), and Value-Based Modifier programs. MACRA adds a new component—clinical practice improvement—and creates a composite score out of 100 that will determine adjustments on top of the base pay physicians will receive. The important thing to know now is that the quality of care you provide will soon determine the rate you are paid. How quality will be measured is still being determined.

The second pathway is through an advanced alternative payment model (APM). These are usually aligned under accountable care organizations, so this is more likely going to be the choice for large healthcare organizations. For example, Partners Healthcare, which is the parent company of Brigham and Women's Hospital, participates in an alternative payment model. Many organizations that join APMs will have to meet certain criteria, such as participating in an approved electronic health record (EHR) and sharing risk, including monetary losses that may be imposed if quality measures are not met.

This summer, the College submitted comments regarding how MACRA will be implemented going forward. We expect a Final Rule this fall, but we already know quality measures will start being reported in 2017. For those FITs expecting to enter the workforce next year, it will be important that you discuss with your employer how MACRA will be implemented at their institution. If you're going into practice on your own, then it's important you know as much as you can about MACRA now. Many resources are available at ACC's MACRA Information Hub at You can also consider attending the CV Summit and Leadership Forum in Orlando Jan. 26 – 27, 2017 to learn more!

This article was authored by Aaron P. Kithcart, MD, PhD, a Fellow in Training (FIT) at Brigham & Women's Hospital and a member of ACC's Emerging Advocates program.