Given the copious amount of printed and blog space that has been devoted in recent months to MACRA – the Medicare Access and CHIP Reauthorization Act of 2015 – I felt no particular obligation to add to the din. Then I was startled to read a recent poll from Deloitte that found that half of all private-practice physicians had never heard of MACRA. Furthermore, only 21% of solo or small-group physicians, and 9% of those employed by hospitals or larger groups, were even somewhat familiar with its financial implications.

Since yet another significant percentage of your Medicare reimbursements will be at risk under this new bureaucracy, an introduction is in order.

Dr. Joseph S. Eastern

MACRA consolidates three existing quality reporting programs, all of which I have discussed in previous columns: the Physician Quality Reporting System (PQRS); the Value-Based Payment Modifier (VBM), and Meaningful Use (MU) regulations, and adds a “new” program called Clinical Practice Improvement Activities (CPIA), which is actually just another iteration of Maintenance of Certification (MOC).

When the new system is implemented in 2019, physicians must choose between two payment tracks: the Merit-Based Incentive System (MIPS) or one of the so-called Alternate Payment Models (APM).

The MIPS track will use the four reporting programs just mentioned to compile a composite score between 0 and 100 each year for every practitioner, based on four performance metrics: quality measures listed in Qualified Clinical Data Registries, such as Approved Quality Improvement; total resources used by each practitioner, as measured by VBM; “improvement activities” (MOC); and MU, in some new, as-yet-undefined form. You can earn a bonus of 4% of reimbursement in 2019, rising to 5% in 2020, 7% in 2021, and 9% in 2022 – or you can be penalized those amounts (“negative adjustments”) if your performance doesn’t measure up.

The Centers for Medicare & Medicaid Services initially estimated that most physicians in groups of 24 or fewer on the MIPS track would incur a penalty in 2019; but the final MACRA regulations, issued in mid-October, allow a more gradual implementation that should decrease the penalty burden for small practices, at least initially. For example, you can avoid a penalty – but not qualify for a bonus – in 2019 by reporting your performance in only one quality-of-care or practice-improvement category, or by reporting for only a portion of the year. A decrease in penalties, however, means a smaller pot for bonuses – and reprieves will be temporary.

The alternative, APM, is difficult to discuss at present as very few models have been presented, or even defined, to date. Only Accountable Care Organizations (ACOs) have been introduced in any quantity, and most have failed miserably in real-world settings. The Episode of Care model, which pays providers a fixed amount for all services rendered in a bundle (“episode”) of care, has been discussed at some length, but remains untested, and in the end, may turn out to be just another variant of capitation.

So, which to choose? Long term, I strongly suggest that everyone prepare for the APM track as soon as better, more efficient APMs become available, as it appears that there will be more financial security, with less risk of penalties; but you will probably need to start in the MIPS program, as most projections indicate that the great majority of practitioners, particularly those in smaller operations, will do.

While some may be prompted to join a larger organization or network to decrease their risk of MIPS penalties and gain quicker access to the APM track – which may well be one of CMS’ surreptitious goals in introducing MACRA in the first place – there are steps that those individuals and small groups who choose to remain independent can take now to maximize their chances of landing on the bonus side of the MIPS ledger.

First, make sure your practice data is accurate on the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) – where CMS will gather data for the VBM and Physician Feedback Reports. Study the quality benchmarks, and review your Quality Resource and Use Report (QRUR), which gathers information about each practice’s quality and performance rates for the VBM. (Both PECOS and QRUR can be downloaded at And, of course, report successfully for PQRS, which will avoid an automatic penalty of 4% 2 years hence.

If the alphabet soup above has your head swimming, join the club – you’re far from alone; but don’t be discouraged. CMS has already indicated its willingness to make changes aimed at decreasing the administrative burden and, in its words, “making the transition to MACRA as simple and as flexible as possible.”

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at .

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