MACRA Explained:

3 Tips to Master Quality

Healthcare providers need to make an intelligent decision on MACRA. According to Deloitte Research. 74 percent of surveyed physicians believe that performance reporting is burdensome and 79 percent do not support tying compensation to quality, both requirements under the payment reform legislation. 1


To ensure optimized payments under Advanced APMs, MIPS and APMs subject to MIPS, eligible healthcare providers and physicians need to focus on the key areas that have immediate impact on improving quality and cost.

Effective January 1, 2017, CMS has outlined a plan to simplify existing Medicare programs like Meaningful Use, PQRS, and the Value Modifier program in 2018 and combine many of their components into a single framework called the Quality Payment Program.2 The replacement to Meaningful Use, known as Advancing Care Information, includes less processes than the existing program. Advancing Care Information (ACI) is one of four performance categories that will be considered when determining payment adjustments under MIPS. The ACI category will count for 25% of MIPS Composite Performance Score. 2

Similarly, PQRS will change into one of the four components of MIPS, the Quality Component. There are many ways eligible providers can prepare for MACRA’s effect on physician quality reporting and reimbursement prior to November 1, 2016.




Practice leaders consult with all experts to determine whether potential choices are aligned with the strategic direction of the organization.


  1. Reflect the Types of Clinical Care. Because physicians and practices are allowed to choose which measures to use. They should examine the options and figure out where they might do well.
  1. Keep doing what is best. Physicians and practices will choose from among 90 activities designed to measure capabilities in areas such as care coordination, beneficiary engagement and patient safety.3 There are no specialty-specific activities practices should enhance in on because that focus will depend on several issues local to the practice, its capabilities and past performance.
  2. Educate Care Team. Physicians and practices should take small steps and not try to do everything at once. Care team need to know what the payment track is going to be measured, and what the outcomes will be like as well.




  1. Reporting should Meet Successful Criteria for Eligible Clinicians by Participating in Advancing Care Information


Reporting Eligibility Criteria. Start 2017, most clinicians will be required to report quality data under MIPS. It will apply to other clinicians, such as physician assistants and nurse practitioners. However, many thousands of practitioners will be exempt from these requirements, if they meet certain criteria.

CMS is replacing the term eligible professional, or EP, with eligible clinicians or EC.2 However, participation is optional for NPs, PAs, Clinical Nurse Specialists, and CRNAs. In addition, Skilled Nursing and similar facilities, are considered ineligible to participate in ACI.




In 2019, MIPS may grow to other providers, such as physical and occupational therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, dietitians and nutrition professionals. 2

MIPS eligible clinicians who are non-patient-facing are not accepted from MIPS. MIPS defines non-patient-facing as those who bill 25 or fewer patient-facing encounters during a performance period. 4 Such encounters include general office visits, outpatient visits and surgical procedures billed under the Medicare Physician Fee Schedule. They can include telehealth services. 4


Identify Improvements to Earn Higher Score

Meaningful use will soon become advancing care information (ACI). Significantly, the Merit-based Incentive Payment System (MIPS) and the Alternative Payment Models (APMs) have the same performance year. It is assumed that most provider will assume MIPS.

There are 3 components to the ACI score. The base score, performance score, and bonus point. Once the score 100 for the ACI composite scoring, hospital will receive the full 25 points for the ACI performance. 2

The data submission criteria for the advancing care information performance category would be the same when submitted at the individual and group level, but the data submitted would be combined for all MIPS eligible clinicians.

Ideally, a hospital can earn up to 131 points. The goal is to have flexibility and it enables focus on measures that are most relevant to practice. EPs will have streamlined measures-from 18 now to 11 under the Advancing Care Information program, emphasizing interoperability, information exchange, security and patient access to their health information through application programming interfaces (APIs). 5 Thus, strive to get more than 100 points is the main goal.




Interestingly, weight on each category contributes to performance score.  If hospital/clinicians have a valid reason no report one of the MIPS categories, the remaining 3 are over weighted.




This makes it even more important to carefully select the quality measures intend to report. Failure to meet the base score will result in a 0 for the ACI performance category. 6 Emphasis on the patient engagement and interoperability can earn additional points above the base score and can earn up to 80 points to add to ACI composite score. It is important to consider tips to earn more points:


  • Study Medicare Quality and Resource Use Reports (QRURs). Understand current rating on cost and quality and find areas where improvement is possible. See how the quality and cost measures are combined to determine your quality tier for the value modifier, which is 30% of your MIPS composite score.
  • Identify any Internal Workflow Changes that can be made to support care delivery plans.
  • Identify Potential Partners outside of practice to advance a coordinated care plan example is to network with other specialists to who refer patients.


  1. Try to Report all Measures Relative to Specialty Practice

Hospital can choose which measures to report. For the Quality category, it is best to measures what are relevant to practice by selecting from the 6 quality measures.

Hospital need to select 6 measures and within the 6 measures one crosscutting and one outcome. If no outcome measure, then one high priority measure. Plus 4 individual or specialty set measures for the total of 6. 2




A failing grade for reporting less than 6 measures. CMS will determine whether or not there were appropriate measures for practice.

EHR should be able to run reports on quality. Hospital can also obtain Quality and Resource Use Reports (QRUR) from CMS. These provide feedback on quality and help show how the value based care will impact.


Understand the Importance of Reporting Measures. Unlike PQRS, achievement within the Quality Performance Category will be expressed in a performance score, rather than by pass or fail.




The Physician Quality Reporting System (PQRS) quality score is 30% of MIPS composite score. Having a robust qualified registry, EHR, QCDR, attestation and CMS Web Interface submission methods will earn additional points associated measures under the Patient Electronic Access, Coordination of Care through Patient Engagement, and Health Information Exchange objectives. EHR incentive program did not apply in the past to the Meaningful Use to eligible clinicians.




MIPS broadens the Measure-Applicability Validation (MAV) process which provides another way for clinicians to report fewer than the required 6 measures for the registry, EHR and QCDR reporting methods. MAV is a validation process used by CMS to determine satisfactory reporting to PQRS. It determines if clinicians is eligible for reporting less than 6 measures. 2

Heading into the final stages of meaningful use and the implementation of MACRA, more and more providers are concerned with changes of MACRA. According to Frost & Sullivan report, EHR usability is the primary concern for healthcare chief information officers. 7

 In order to receive rewards and avoid penalties in MACRA, physicians must score high on PQRS quality measures while keeping overall cost of care low.


The following strategies can help clinicians achieve these goals:


  • Focus on Patient Attribution. If patient sees other doctors, the quality and cost of that care will be attributed to the hospital. CMS will use the Achievable Benchmark of Care method to compute quality benchmarks in 2017 and create a five-star rating system on Physician Compare. 8
  • Improve Patient Access. Provide a way for patients to reach practice.
    • Encourage use of Patient Portals
    • Consider appointment reminders for all patients in 2017
  • Enhance PQRS Participation. All physicians must report PQRS data or face Medicare penalties. Review the proposed rule’s list of clinical practice improvement activities (CPIAs) to evaluate what activities and adjustments were completed to guide additional activities in 2017. 2


Make every effort to Earn the Bonus Point

In 2017 providers will be required to report one outcome or other high-priority measure if no outcome measure is applicable.  Each eligible provider needs to include one crosscutting measure and one outcome measure. Performance on each measure, as compared to competitors can significantly impact scoring. 9




It is important that hospital strive to earn bonus points. Hospital can receive up to 10% extra credit total in bonus points. For additional high priority measures, they can get up to 5% of the possible total and using certified EHR technology for reporting measures earns 1 point bonus for each measure, so there are advantages to using the EHR technology. 9 Strategies to earn bonus are suggested:


  1. Move Away from Claims-based reporting. This year there were very few high performers but a significant number of non-reporters (over 5,000 groups). 10 By 2022, more providers will have invested in quality reporting. Fewer non-reporting providers means less penalty money to distribute among high performers. 10
  1. Study Calculated Measures. CMS will add in two or three measures to Quality Category Performance Score. 10These will be calculated from the claims data submitted to CMS. 11 The CMS-calculated measures include scores for the Acute Conditions Composite and the Chronic Conditions Composite measure. 11
  1. Compare the of Clinical Practice Improvement Activities (CPIAs). Comparing the score to the national benchmark can earn up to 10 points depending on which decile of performance score falls in. 9 For example, if the score is in the 50% percentile, facility will earn 5 points for reporting that quality measure.





MACRA will start making waves next year but it’s not scheduled to go into effect till 2019. MIPS is revenue-neutral, which means if one clinician is making more in fees, another is making less. As more physician assume MIPS track next year. Taking steps can help ease the transition practice and position to earn financial rewards.  It is always best to start on the activities under the clinical practice improvement category that have the potential drive improvements.



  1. Deloitte. Are physicians ready for MACRA and its changes?Perspectives from the Deloitte Center for Health Solutions 2016 Survey of US Physicians. 2016.
  2. Federal Register. Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models. May 5, 2016.
  3. Medical Economics. MACRA Economics. August 10, 2016.
  4. Advisory Board. Your questions about the MACRA proposed rule–answered. June 07, 2016.
  5. Policymed. Understanding the CMS Proposed Rule for the Medicare Access and CHIP Reauthorization (MACRA) and the Merit-Based Incentive Payment System (MIPS). May 24, 2016.
  6. AdvanceMD. MIPS: Quality & ACI Categories. 2016.
  7. Frost & Sullivan. EHR Usability – CIOs Weigh in On What’s Needed to Improve Information Retrieval. 2016.
  8. ArnoldPorter. Medicare physician payment: Prepare to ‘MACRA-mize’ your practice. february 18, 2016.
  9. SAIgnite. 10 FAQs About the Merit-Based Incentive Payment System (MIPS). September 2016.
  10. Healthmonix. 10 PRO Tips for Conquering the Quality Performance Category of MIPS. September 15, 2016.
  11. CMS. Quality Performance Category. 2016.

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