Medicare Access and CHIP Reauthorization Act (MACRA)

The Medicare Access and CHIP Reauthorization Act (MACRA) moves the fee-for-service Medicare program toward value-based care by paying clinicians based on the quality of services provided rather than simply the volume.

What Is MACRA?

MACRA became law in 2014 with broad support from medical societies, consumer advocates, insurance companies, and Democrats and Republicans alike. The law directs the Centers for Medicare and Medicaid Services (CMS) to reward efficient, patient-centered care by paying clinicians in traditional (fee-for-service) Medicare based, in part, on their performance on a range of quality metrics.

Visit NCQA’s MACRA Toolkit

MACRA & Clinician Payment

MACRA established the Quality Payment Program (QPP) within Medicare. Under the QPP, clinicians will receive payments through either the new Merit-based Incentive Payment System (MIPS) or Alternative Payment Models (APM) as of 2019.

A clinicians’ 2019 payment will be based on what they report in 2017. Most clinicians are expected to participate in the MIPS track.

Clinicians in APMs that meet specific thresholds for revenue and numbers of patients will receive an automatic 5% bonus.

Clinicians in MIPS will get bonuses or penalties to their fee-for-service payments based on measures in four areas. The weighting of the four areas that make up MIPS scores will scale up until 2021, when they become permanent.

Here’s the breakdown:

Payment YearResource Use/CostQualityAdvancing Care InformationClinical Practice Improvement Activities
20190%60%25%15%
202010%50%25%15%
2021+15%45%25%15%

More on MACRA

MIPS

  • One way CMS will pay providers under MACRA is through the Merit-Based Incentive Payment Systems (MIPS). Each provider must show their ability to meet goals in each of four sections: Quality Measures, Advancing Care Information, Resource Use Measures, Clinical Practice Improvement Activities.
  • Read more on how NCQA Patient-Centered Medical Home (PCMH) practices and Patient-Centered Specialty Practices (PCSP) receive automatic full credit for Clinical Practice Improvement Activities and do better in other MIPS categories here.

MIPS and NCQA Recognition

  • Clinicians in NCQA-Recognized PCMHs/PCSPs automatically get full credit in the MIPS Clinical Practice Improvement category, and will likely do well in other MIPS categories.
  • NCQA-Recognized Patient-Centered Connected Care practices receive some credit for the MIPS Clinical Practice Improvement category.

APMs

  • Alternative Payment Models (APM) move clinicians farther away from fee-for-service payments and toward quality and population-based payments. Clinicians who meet specific revenue and patient thresholds are considered to be participating in “Advanced APMs” and are exempt from having to report information in MIPS. They will also receive an automatic 5% bonus.
  • The following demonstration projects are approved as “Advanced APMs” for 2018:
    • Bundled Payments for Care Improvement Advancement Model (BPCI Advanced).
    • Comprehensive ESRD Care (CEC)-(Two-sided Risk).
    • Comprehensive Primary Care Plus (CPC+).
    • Medicare Accountable Care Organization (ACO) (Track 1+Model).
    • Next Generation ACO Model.
    • Medicare Shared Savings Program (Tracks 2 and 3).
    • Oncology Care Model (Two-Sided Risk).
    • Comprehensive Care for Join Replacement (CJR) Payment Model (Track 1-CEHRT).
  • For clinicians in APMs that do not meet the thresholds, the proposed MACRA rule rewards clinicians in APMs with NCQA-Recognized PCMHs/PCSPs. CMS scores each clinician individually, averaging scores for all clinicians in the APM, and applies the average score to each clinician. Clinicians in NCQA-Recognized PCMHs/PCSPs get automatic full CPIA credit.
  • Clinicians in practices that have not earned recognition get half CPIA credit for being in the APM, and then must earn additional points for individual CPIA activities. Having more PCMH/ PCSP clinicians in an APM automatically gives all APM clinicians higher MIPS scores.

Summary of 2018 Rule

NCQA Programs Included in MACRA

  • MACRA builds on work pioneered by NCQA for almost 30 years. MACRA rates clinicians based on quality metrics, including many of NCQA’s HEDIS® measures, and directly rewards clinicians who earn NCQA PCMH/PCSP Recognition and Patient-Centered Connected Care Recognition.
  • The law also rewards clinicians in many other ways for results they can achieve by being patient-centered. More on using NCQA Recognition to help achieve MACRA goals can be found here.

Virtual Groups for MACRA 2018

  • To ease the burden on small and rural practices, MACRA created a virtual group reporting option where practices can work together toward their MIPS report. Practices can select groups and identify participation by their Tax Identification Number (TIN). Find specifics on virtual groups here.

Additional MACRA Resources

  • NCQA produced a comprehensive summary of the final rule when it was published in 2016. You can find it here.
  • If you’re a clinician, check out NCQA’s MACRA Toolkit. It explains the rule and how the PCMH model of care aligns with MACRA. We also offer examples for implementing patient-centered approaches: videos, case studies and specialty-specific learning tools. The toolkit is free and can be accessed here.
  • The CMS “Quality Payment Program” website is designed to help practices understand MACRA. Check it out here.
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