MACRA Impressions – Fact or Fiction

Now that everyone has sufficiently recovered from submitting 2016 PQRS and Meaningful Use data and thoughts have turned to earnest MACRA preparation and participation, we thought this would be a good time to address some of the many MACRA “impressions” we have heard and been asked to clarify.

As our webinars encourage, the time for MACRA preparedness is now – even though the MIPS reporting period does not start until January 2, 2018. To help, let’s cut through some common perceptions.

Impression:    MACRA changes how physicians get paid.

FICTION          Why?  MACRA does not change the mechanisms through which physicians and other providers get paid – but it may change the amount they get paid.

MIPS participants are still paid on a fee-for-service basis and APM participants are paid based on the APM model, most of which are still fee-for-service. MACRA does not change that.

Impression:    MACRA eliminates PQRS and Meaningful Use.

FACT               Why?  MACRA literally terminated PQRS and Meaningful Use (and the Value Based Modifier), effective December 31, 2016.

HOWEVER, many facets of these programs live on in a modified manner. So, figuratively, PQRS and Meaningful Use (and the Value Based Modifier) continue to exist under MACRA. Here’s how:

  • PQRS (and the quality/outcomes elements of the Value-Based Modifier) essentially becomes the Quality Performance Category.
  • Meaningful Use (Medicare EHR Incentive Program) essentially becomes the Advancing Care Information Performance Category.
  • The Value-Based Modifier cost element essentially becomes the Cost Performance Category.

Impression:    The MACRA performance elements are unrealistic and do not truly impact the quality of patient care.

FICTION         Why?  This is a hot topic of debate. The program’s measures are not perfect – just as they were historically perceived to be imperfect and too much work. However, the measures have all been vetted by reputable national organizations and they will likely improve over time.

The stated intent of the program is to improve patient care by incentivizing clinicians to engage in improvement activities that have a proven impact on patient health and safety and are relevant to their patient population. If pursued to improve care and not just to “check a box,” care can be transformed.

The program seeks to support healthcare that is patient-centered, evidence-based, prevention-oriented, outcome driven, efficient, and equitable – all laudable goals that are worth pursuing.

Impression:    MACRA is impossible to understand and implement.

FICTION         Why?  The Quality Payment Program is very complex – and it seems to become more complicated the deeper you delve into it. However, it can be understood and implemented through education, progressive exposure, and a methodical approach.

Start by building on past experiences with PQRS and Meaningful Use. Then determine the differences and methodically undertake process redesign.

MACRA requires the adoption of a different philosophical approach and mentality. Unlike its predecessors, which were primarily focused on reporting, performance does matter in MACRA. Continually improving performance and incorporating the program elements in daily operations will be keys to success.

Impression:    Since the 2017 performance year is a transition year, there isn’t any need to worry about MACRA until 2018.

FICTION – at least in most expert opinions. Why?   The intent of the transition year is to allow organizations and individuals more time to:

  • Become familiar with the program requirements,
  • Implement processes to be able to fully participate,
  • Incorporate program requirements into daily practice operations,
  • Improve performance to be more competitive,
  • Avoid negative payment adjustments, and
  • Strive for positive payment adjustments.

Be smart – maximize the opportunity … NOW!     Keep in mind:

  • MACRA implementation requires financial and personnel resources that are not likely in place for most employed practices. Systems must determine how they will address the support required in their employed practices to ensure MACRA success.
  • MACRA implementation requires financial and personnel resources that many independent practices do not possess. This is anticipated to be significant issue – especially for smaller practices. Systems need to be prepared to be approached for either MACRA implementation assistance or outright employment and how they will respond.

Impression:    With all of the MACRA APM/ACO advantages, the best approach must be to jump right in and participate.

FICTION         Why? While there are MACRA-related advantages for APM participants, accepting the downside risk required for the Advanced APM path is … well … risky. Most experts recommend becoming familiar with upside risk (shared savings) programs before embarking into downside risk arrangements to ensure the necessary framework is in place to support advanced risk sharing.

Decide to participate in APMs based on the benefits of APM participation. The APM’s impact on MACRA requirements should be very secondary.


Impression:    MACRA is going to inevitably drive independent physicians into employed relationships.

IT COULD – unless they have other options.   Why? Many experts feel that MACRA will drive a new wave of hospital and health system employment requests like the wave associated with Meaningful Use implementation.

Most health systems and large practices cannot afford to employ everyone that might desire to be employed. What other options are there? IT assistance (with technology, expertise, and HIE development arrangements) or MSO-like offerings (expertise and assistance with performance improvement, clinical practice transformation capabilities such as PCMH, PCSP, care management, and population health management).

Impression:    MACRA is trying to force small practices to close.

FICTION – though it may happen.   Why? MACRA and the associated Quality Payment Program regulations explicitly recognize the potential adverse impact on small and rural practices – many of which lack adequate personnel and financial resources.

The legislation and subsequent regulations include special considerations for small and rural practices including:

  • Low volume threshold exclusions;
  • Preferential scoring in the Improvement Activities Performance Category;
  • Funding $100 million in technical assistance programs; and
  • Future “virtual group” reporting options.

CMS anticipates that, for 2017 (2019 payment year), 90% of MIPS eligible clinicians will receive a positive or neutral payment adjustment and 80% of solo and small practice (0-9 clinicians) eligible clinicians will.

Impression:    Participating or not participating in MACRA only impacts Medicare Part B reimbursement.

FICTION         Why? Quality Payment Program (MACRA) results will be publicly reported on the Physician Compare website … so, reputations may be at stake.

Act now to avoid putting your reimbursement and professional reputation at risk. Start preparations for MACRA participation so that you are ready to thrive – not just survive – in the new program.

Practices should calculate the anticipated return on participation investment – or the financial risk of not participating.

Keep in mind that direct financial risk may only be part of the equation. Those practices that participate, that demonstrate sustainable improvement, that truly embrace clinical practice transformation – and achieve it – will be perceived as excellent practices with which to partner.