MACRA: Not going away any time soon


MACRA is now a fact of life.

Implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), the historic Medicare reform law that replaced the Sustainable Growth Rate (SGR) formula in 2015, began in January 2017. Patrick V. Bailey, MD, FACS, Medical Director, Advocacy, in the American College of Surgeons (ACS) Division of Advocacy and Health Policy (DAHP) office in Washington DC has, for the past several years, been involved with ensuring that the policy implemented takes into account the interests of surgeons and their patients. He has seen MACRA develop from its beginnings. Dr. Bailey, a pediatric surgeon, has deep knowledge about the program, both from the policy perspective and as a surgeon. We asked Dr. Bailey to share with us his insights on what surgeons can expect and what surgeons can do to avoid penalties.

1) Many surgeons are overwhelmed by the perceived complexity of the new MACRA law. What do you say to those who have so far tuned out much of the information they have been given?

A few thoughts. First, we really do understand that the concerns about the complexity are real. Some of those very real feelings come out of a basic aversion to change. Some come from the overall stress and uncertainty surrounding the constant changes in our health care system that have been ongoing for years. And some are the result of the continuously expanding administrative burden. We get it.

Is MACRA exactly what we surgeons would wish for? No, but those of us who have worked in the policy process feel our efforts had a positive impact on how this legislation played out. More importantly, we are absolutely confident that, for 2017, ALL surgeons can avoid a penalty.

From a pragmatic perspective, the implementation of MACRA is going forward, and burying one’s head in the sand will not make it go away. Therefore, it is imperative that surgeons devote some time to understanding the new Quality Payment Program, or QPP, which is the operationalization of the MACRA law. Even a very limited time investment will pay dividends in the Medicare payment they receive in 2019, based on their performance in 2017.

So, if you have avoided dealing with this up until now, I urge you to set aside an hour or so to look at the materials that the ACS has prepared. The reporting requirements may look much less daunting once you become familiar with them.

Again, I am confident that surgeons can and will be successful (as defined by either avoiding a penalty or receiving a small positive rate update), if they take some time to acquire some basic knowledge about the program, make an assessment of their individual practice situation, determine the best course for their individual situation, and take the necessary actions to meet the requirements for the choices they have made.

Fortunately, there is still more than ample time to get started and ACS has developed resources for Fellows to assist them in educating themselves about the program and making their individual choices about their level of participation.

2) With all the talk of change to the Affordable Care Act (ACA), how likely is it that all of this will simply “go away”?

The ACA and MACRA are separate and different pieces of legislation from a temporal, process, policy, and political perspective. In fact, despite the fact that the ACS and other medical specialty groups specifically advocated for language repealing the SGR be included in the ACA in 2010, that did not occur. Therefore, the efforts directed at repealing the SGR took another 5 years and ultimately culminated in the passage of MACRA in 2015.

Many will recall the contentious process and political repercussions that resulted in the passage of the ACA. In contrast, leaders from both political parties worked cooperatively on the SGR repeal legislation we now know as MACRA. This resulted in the MACRA legislation being passed in a very bipartisan manner with only 37 of the 435 members of the House and 8 of the 100 members of the Senate voting against the law.

Accordingly, while we believe there will be a need for some specific, targeted legislative “fixes” and regulatory relief actions from CMS (Centers for Medicare and Medicaid Services) to address faults in the QPP (and the ACS will continue our efforts in this direction), it is highly unlikely that MACRA will be repealed or that it will change significantly in the near-term future.

3) What is the starting point for surgeons who want to learn more and begin the process of determining how best to participate?

There is a relatively straightforward process, which revolves around a series of questions and individual decisions.

First, surgeons should determine if all their Merit-based Incentive Payment System (MIPS) data will be reported by their institution or group via a group reporting option (GPRO). For those surgeons, whose data are so reported, they are done and there is nothing further for them to do.

If their data are not reported for them via a GPRO, then they should determine if CMS has notified them that they are exempt from participating in MIPS due to the low volume threshold. If you see 100 or fewer Medicare patients annually or one submits $30,000 or less in Medicare claims, you are not eligible for MIPS incentives or subject to its penalties.

However, this is not a determination that individual Fellows can make on their own based on data they may have on hand based on prior calendar or fiscal years. Instead, CMS makes the determination based on a specific period and notifies individual providers who are so exempted. It is also our understanding that a website, where one can check whether they have been excluded based on the low volume threshold, is forthcoming from CMS. When this website becomes available, ACS will make sure Fellows are informed.

If your data are not reported via a GPRO and you do not receive notification from CMS that you are exempt based on the low-volume threshold, then you have choices to make – having choices is a good thing.

For those who want to compete for positive updates in their Medicare payment rates in 2019 based on their reporting in 2017, I recommend they first visit where we have made available a variety of resources in print, video, and PowerPoint formats to assist Fellows in making their plans for participating for either a full or partial year. The update received will depend on performance and not on the amount of data submitted or the time of participation. That said, for those who plan to fully engage, participation over a longer period of time provides more opportunity for improvement and, thus, increases the potential for better performance.

4) What about surgeons who simply want to avoid a penalty and forgo any chance for a positive update?

If your goal for 2017 is to simply avoid a penalty, CMS only requires data be submitted for only one of the three components of MIPS that will be reported this year. Here again for 2017, you have a choice to submit:

A) The required base score measures for your EHR (now known as Advancing Care Information) OR

B) Participation in one Improvement Activity for 90 days, which is reported by simple attestation OR

C) Submit one Quality measure on one patient, which may be reported by a registry, a qualified clinical data registry (QCDR), an EHR or, traditional claims

One very important point to note is that one is NOT required to have a certified EHR to avoid a penalty for 2017. I believe this point alone has been the source of a lot of misunderstanding and anxiety about the QPP and MIPS.

Another key point is that, by simply engaging in one Improvement Activity (such as Maintenance of Certification Part IV, registering with your state’s prescription drug monitoring program, or use of the ACS’ Surgical Risk Calculator) and attesting to having done so with the ACS Surgeon Specific Registry (SSR) or the CMS web portal, one can avoid a penalty.

Alternatively, using the SSR to submit one Quality measure on one patient will also suffice to prevent one from receiving a penalty in 2019 based on their 2017 performance.

It is relatively easy to avoid any negative financial implications of MIPS in 2017, but it does require some effort, albeit minimal. It is also important for Fellows to remember that, since MIPS is essentially a tournament model, those who choose not to participate will take the penalty that provides the funds used to reward those who do participate. I think most surgeons will want to participate, even if only at the minimal levels outlined above, in order to avoid “paying for” another provider’s positive update.

5) What are the consequences of not participating at the minimal levels you just described and choosing to submit no data?

That question is perhaps best addressed in the form of a comparison between 2016 and 2017.

In 2016, if one did not report any PQRS (Physician Quality Reporting System) data and did not participate in the electronic health record meaningful use program, their lack of participation would result in a 10% negative payment adjustment in 2018. In 2017, if one chooses not to submit the minimal amount of data for either the ACI, Improvement Activity, or Quality components as discussed previously, that lack of participation will lead to a 4% negative payment adjustment in 2019.

In effect, those who have never participated and continue to not do so will see a 6% increase in their Medicare reimbursement in 2019 compared to what they receive in 2018.

However, we DO NOT recommend this option because, in future years, the negative payment adjustments will gradually increase to 9%. Accordingly, we encourage Fellows to use 2017 as a period to learn and get familiar and more comfortable with the reporting of data so that they will be better prepared to be successful in those future years when the stakes are higher.

6) You have mentioned the resources ACS has prepared to assist Fellows with this transition. Can you be more specific about what is available?

The ACS one-stop shop is the Quality Payment Program Resource Center found at

Fellows who attended the Clinical Congress in Washington last October likely received a copy of the MACRA Quality Payment Manual which was developed to help educate Fellows about the QPP. That manual has subsequently been totally revamped and updated to reflect the changes to the QPP as reflected in the final rule. We highly encourage Fellows to obtain and read the latest version – it is available as individual sections or as the complete publication on the webpage.

Also available on the QPP webpage is the second generation of the video series we first created last fall. There are now a total of 6 videos with a run time for the entire series of approximately 30 minutes. The videos cover a wide spectrum of topics including the historical background and context of MACRA, an introduction to MIPS, and three individual videos dedicated to MIPS components: Quality, Advancing Care Information and Improvement Activity, and a video outlining the options for participation in 2017.

The PowerPoint presentations seen in the videos are also available, as are links to specific CMS web pages and more information on ACS’ efforts to develop advanced alternative payment models (APMs) for surgeons.

We will continue to update the website throughout the year in our ongoing efforts to refine the resources to be the most useful to Fellows.

I would encourage all Fellows to visit the website, watch the videos, and read the manual. I realize time is a precious commodity, but with a total time investment of 60-90 minutes, one can acquire an operational knowledge of the QPP and make a determination as to how they wish to participate.

Again, no Fellow should settle for accepting a penalty in 2019 based on what they do this year. With the multiple options available, it is simply too easy to avoid and to do so would effectively serve to put their money in someone else’s pocket. For those who feel more prepared (that is, they have previously reported PQRS data and have a 2014 or 2015 edition EHR) and wish to seek a positive rate update, investment of more time will obviously be required. However, in addition to the small positive payment update they will likely receive, probably the most substantial benefit to be derived is their preparation for future years when the incentives and penalties increase to +/- 9%.

Finally, ACS “has your back” on coping with MACRA and as always, ACS staff in Chicago and Washington are available to assist Fellows with their preparation, to answer questions about the program and the reporting requirements, or to provide general or specific direction in their efforts to navigate the QPP.

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