Note: This is the fifth and final part in a series on how physicians can prepare for MACRA, the new Medicare physician payment law. Read Part 1 for a breakdown of how the Merit-based Incentive Payment System (MIPS) works, Part 2 on applying change management to practices ahead of the new law, Part 3 on what is required to succeed in MIPS, and Part 4 on charting a path in the Advanced Alternative Payment Model track.

The recently released final rule for the Medicare Access and CHIP Reauthorization Act (MACRA) repeals the sustainable growth rate and introduces the Quality Payment Program (QPP), which is designed to encourage Medicare Part B providers to focus on care quality and keeping patients healthier. Although the future of the Affordable Care Act (ACA) is tenuous, MACRA seems to be on more solid ground given the bipartisan support it received in Congress. Eligible clinicians and medical groups should plan to move forward as the shift to value-based care is expected to continue, with a greater focus on payments based on quality reporting and patient outcomes.  

Key Changes in the Final Rule

Compared with the proposed rule released in April, the QPP final rule is flexible and seems intent on reducing the short-term administrative burden, with the Centers for Medicare & Medicaid Services (CMS) viewing 2017 as a transitional year and aiming to encourage and educate clinicians. Unlike in some other initiatives, CMS seems to be genuinely encouraging better quality and care coordination by rewarding providers not only based on various quality metrics but also for undertaking meaningful improvement activities. Many clinicians and groups are all too familiar with having to be accountable for a whole gamut of quality metrics to qualify for rewards. Although it cannot be predicted how this final rule may evolve, at least for 2017, clinicians and groups have flexible options.

As in the proposed rule, the QPP has two tracks: Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS). Clinicians are required to be in the QPP if they bill Medicare more than $30,000 and provide care for more than 100 Medicare patients annually or are in an advanced APM.

The final rule includes several key changes from the proposed rule.

Expansion of APMs. Groups that participate with sufficient volume (more than 25 percent of Medicare payments or 20 percent of Medicare patients) in advanced APMs in 2017 will qualify for a 5 percent incentive payment in 2019. CMS is encouraging advanced APM participation by designating new qualifying models that have lower risk levels or that are tailored to smaller practices or specialties (the final list is available on the QPP website). One important point is that clinicians who do not have sufficient volume to qualify for the Advanced APM track still would benefit from APM participation under the MIPS scoring system.

Although they may be focused on MIPS next year, clinicians and groups should be planning a transition to the Advanced APM track to potentially receive greater payments and to better position themselves in the marketplace. Such an approach is consistent with the opportunity to significantly and innovatively transform care delivery while also getting rewarded for the hard work required for organizational alignment.

Relaxation of MIPS criteria. MIPS aims to combine and align the current CMS quality programs, including the Physician Quality Reporting System (PQRS) and Meaningful Use (MU). It establishes four performance categories:  Quality, Advancing Care Information, Improvement Activities, and Cost (in the final rule, Cost was dropped as a category for 2017 but will be added in 2018).

Scoring in 2017 will be based on a 100-point scale, with Quality comprising 60 percent of the score, Advancing Care Information 25 percent, and Improvement Activities 15 percent.   

Eligible clinicians who fully participate in each performance category will have the following typical requirements in 2017 (for groups in APMs that do not qualify for the Advanced APM track, special MIPS scoring will apply  in accordance with the APM scoring standard; these groups are considered MIPS APMs)

  • Quality: Six quality measures and an outcome measure or a specialty-specific measure set
  • Advancing Care Information: Five required measures, with up to nine additional measures selected by the clinician or group, and bonus points for reporting to public health or clinical data registries; clinicians may not need to submit ACI measures if the measures are not applicable
  • Improvement Activities: Two to four improvement activities, depending on weight; clinicians may automatically earn full credit in this category if they participate in a medical home

Because of past participation in PQRS and MU programs, most clinicians are completing 85 percent of the MIPS requirements for 2017. The remaining 15 percent (based on Improvement Activities) likely will be an easy task given that most clinicians are already engaged in some of the qualified improvement activities. The focus needs to be on performance.

Although not a 2017 requirement, clinicians and groups should keep an eye on the cost category by obtaining and reviewing their QRUR report and claims data. The data will inform patient migration so that  tactics can be deployed to minimize leakage, allowing the organization to better manage overall costs. 

CMS developed an educational and interactive website on the QPP with detailed information about the program, including webinars, fact sheets, and a search tool for measures.  

Ability to pick your pace. Based on the quantity of data submitted in 2017, as well as performance, clinicians will have either a positive, neutral, or negative payment adjustment in 2019:

  • Fail to submit any data: A negative payment adjustment of 4 percent
  • Submit one data measure: No payment adjustment
  • Submit 90 days of data, with data collection starting no later than Oct. 2, 2017: No payment adjustment or a positive adjustment of less than 4 percent, depending on performance
  • Submit one year of data, with data collection starting Jan. 1, 2017: A positive payment adjustment of up to 4 percent, depending on performance (and potentially exceeding 4 percent for exceptional performers)

To maximize the chance for a positive adjustment, therefore, clinicians need to start collecting data on Jan. 1. Additionally, CMS is funding a pool of $500 million that will be distributed to organizations or individual clinicians that achieve exceptional performance, defined as a final MIPS score of 70 or greater. Performance in the Quality category matters because it represents the biggest opportunity to achieve a high score.

Why Go Strong in 2017?

As mentioned, clinicians, groups of independent providers and employed medical groups initially have several options for QPP participation. But going strong with implementation for 2017 should bring benefits in four areas.

Patient care. By identifying key quality measures and tracking performance, clinicians can make improvements in patient care by redesigning workflows, engaging patients, and exchanging health information to better coordinate care. Many such advancements in care would constitute improvement activities and also contribute to the Quality score, given that Quality scores are relative and based on performance compared with other enrolled providers in the same measures. In an era of increased transparency and public reporting, staying competitive requires providers and medical groups to pay particular attention to this aspect.

Social reputation. CMS established the Physician Compare website to allow individuals to research clinician’s quality score and participation in quality programs. Many physician practices in highly competitive environments depend on the ability to grow or at least preserve their patient volumes. Maintaining or, better yet, building patient loyalty thus becomes an important driver. Medicare patients tend to change their physicians less frequently than do younger individuals, while quality and coordination of care are perhaps even more crucial to seniors when choosing a physician. Consider what people will see when they view your clinicians or group on the CMS website. Will it persuade them to seek care with your practice, or will they go elsewhere?

Financial rewards. QPP presents a significant chance to not only earn up to a 4 percent positive Medicare fee adjustment in payment year 2019 but also to take advantage of additional positive adjustments for exceptional performance. By simply reporting performance on many of the measures, clinicians and groups may be able to share in the $500 million bonus pool that CMS is allocating to exceptional performers. Few experts believe that such generous incentives will remain in place year after year.

Readiness for the future. Future MACRA-related challenges undoubtedly lie ahead in areas such as complex and chronic population health management. To a certain degree the first year of MACRA is reminiscent of the first year of the Pioneer ACO model (performance year 2012), when participants were rewarded for adequately reporting quality data to CMS. The road became much more challenging in subsequent years, when specific quality outcomes were required to share in savings.

Participating fully in the QPP will position the clinician or group well for the future. In addition to mitigating the risk of missing out on bonuses (which only increase in future years), early participation will help clinicians feel more confident and will establish the infrastructure to participate in value-based programs with commercial health plans.

Implementing this roadmap takes a sense of purpose, a solid plan, and the right resources, including executive and physician leadership, key stakeholder engagement, communication plans, and operational and IT support. Clinicians and groups should perform an assessment and review current data to understand where they are, where they need to go, and where the gaps are. This approach will inform an actionable plan that may include provider education, development of comprehensive dashboard reports or scorecards, care redesign, and patient engagement activities.

This time, performance really does matter. To reap a positive payment adjustment in 2019 and build on that result in subsequent years, clinicians and groups will be well-served to go strong and aim for exceptional performance in 2017.


Lucy Zielinski and Mark Krivopal, MD, MBA, are vice presidents with GE Healthcare Camden Group.

Publication Date: Monday, December 05, 2016