MACRA Is a Marathon, Not a Sprint: Stay in the Race

Robin Diamond, MSN, JD, RN, Patient Safety and Risk Management Consultant, with contributions by Kim Hathaway, Healthcare Quality and Risk Consultant

To implement the second year of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program (QPP), the Centers for Medicare & Medicaid Services (CMS) released the final 2018 rule under MACRA, in November 2017. MACRA establishes a new reimbursement model for doctors who treat Medicare patients. The 2018 rule is intended to ease some of the burdens on small practices and groups and began its performance period in January 2018 by maintaining flexibility and adding more pathways for small practices and solo practitioners to successfully participate.

Physicians and practice managers who didn’t participate in MACRA in 2017 may feel as if they’re being left at the starting line. Although the bar has been raised in 2018, there is still plenty of time to put in a winning performance in the MACRA race. Here are some tips for a successful year:

On your mark . . .

  1. Assemble a team. A team is vital to tackle MACRA data collection, data analysis, and submission. Team members should come from various roles in the practice. For example, a team might include the practice manager, a physician, a clinical staff member, and an administrative staff member. The team should brainstorm strategies to incorporate metrics into existing workflow and optimize the workflow to include data collection. The team can also then educate the rest of the organization about MACRA and its role in the process.

Get set . . .

  1. Decide whether to report as a group or individual. An individual is defined as a single National Provider Identifier (NPI) tied to a single Tax Identification Number (TIN). A group is defined as a set of clinicians (identified by their NPIs) sharing a common TIN, regardless of their specialty or practice site. This is also important for the method of submission, because only clinicians reporting as individuals may use a claims submission method and the CMS Web Interface is only available to groups of 25 or more clinicians. Know the criteria, advantages, and disadvantages of reporting in each category—the Quality Payment Program (QPP) website is a helpful resource.
  1. Pick your pace. This year is still a transitional year for the QPP and Alternative Payment Models (APMs). CMS solicited feedback from stakeholders about the burden of reporting under MACRA and responded by making adjustments this year. Practices still have flexibility and can participate fully or just meet the minimum thresholds. However, the stakes are higher each year. It is still points-driven: The more participation, the more points earned. In 2017, three points avoided the four percent up or down payment adjustment. To meet the 2018 minimum threshold, it will take at least 15 points to avoid a penalty with the up down adjustment of five percent. The goal is to exceed 70 percent in the composite score to be considered for a bonus. The composite score is calculated from: Quality (50 percent) + Cost (10 percent) + Promoting Interoperability (formerly called Advancing Care Information) (15 percent) + Improvement Activities (25 percent).

    The main difference in 2018 is that the quality category must be six measures with one either an outcome measure or high priority and it must be for 365 days. The other very significant change is that cost is now part of the calculation for the composite score. Cost will be automatically calculated by CMS via claims data and requires no extra work. It does, however, count as a full 10 percent of the composite score and will increase in weight as the QPP program matures.

    Understand your participation options
    . For example, the rule reduces the number of clinicians subject to the Merit-Based Incentive Payment System (MIPS). For 2018 providers and groups with less than $90,000 in Medicare Part B allowable charges, or that care for less than 200 Medicare Part B patients, the rule excludes about 123,000 clinicians. Most clinicians will still report under MIPS versus an APM, but the number of clinicians in an APM track is expected to sharply increase; although there will be a small group of physicians in an APM who will only partially qualify, and thus need to report under MIPS. All these changes will make more competition in MIPS to achieve a bonus. It’s important to understand the eligibility requirements and report correctly to avoid a negative adjustment. The QPP website provides a look-up tool to assist in determining where you fit.
  1. Select measures and submission methodsChoose measures that best fit your practice. Understand that not all the measures are equal in value. Under the quality category, one measure could earn as many as 10 points. Take time to review your options or view the webinar QPP Year 2. The option to select only one measure in the quality category is gone in 2018; therefore, practices must select six measures to report over 365 days, which is a big change from last year. Several measures have been revised or removed and a few new measures were added. Be sure to check that your quality measures are still appropriate.

    There is no change in reporting—as in 2017, the measures may be reported in several ways, including through the electronic health record (EHR), a qualified registry, CMS Web Interface, and administrative claims data. Submission methods are particularly important because they will increase points, which affects the composite score and may assist in maximizing payment or earning a bonus.

    The EHR is one of the easiest ways to capture and report data. Consult your EHR vendor about functionality and creating a workflow for collecting data and reporting. EHR vendors are the primary source for ensuring the documentation of best practices data is accurately captured in the software and producing correct credits for the work provided.

    Regardless of how reporting is done, now is the time to work out the process and learn how easy or difficult it is to upload and track progress prior to final submission. At least 90 consecutive days of data is required to be considered for a positive upward or neutral adjustment.
  1. Review and improveEvaluate past performance in the Physician Quality Reporting System (PQRS), which now becomes the Quality Measures and will have the greatest weight (50 percent of the composite score and in 2019 is proposed to decrease to 30 percent as the cost category increases). Also, this year the performance period has increased from any 90-day minimum to a full 12 months.

    Review past performance in the Meaningful Use (MU) measures. Under the QPP, MU now becomes Promoting Interoperability (PI) and will require greater participation than in the past. Prior to 2017, measures had low thresholds and were easy to attain. As of 2017, it’s necessary to include as many patients as possible. In 2018, the performance period remains at 90 days. Practices will continue to have base measures to report, including: conducting or reviewing a security risk analysis; e-prescribing; and providing patients with access to view, download, and transmit their health information.

    A new performance category in 2017 was the Improvement Activities (IA). In 2018, CMS has added to existing activities for a total of 112 activities in the inventory. The 2018 reporting period remains at 90 days. Most groups will attest to completing four activities. Small groups with less than 15 physicians will attest to two activities. These activities focus on patient safety, care coordination, and engagement.

    The Cost category was not counted in 2017 and was added to the final version of the rule for 2018 at 10 percent of the composite score. In 2019, it may increase again. It is important to read and understand the details for the Quality Payment Program Year 2 in the Final Rule Fact Sheet.

Go . . .

  1. Start now. Report as many measures as possible to avoid a negative adjustment in 2020. Don’t stop there—take advantage of another transition year. Don’t aim for the bare minimum. Instead, use this time to learn as much as possible and close as many gaps before the year’s end. This time is designed for practices to implement workflows and processes to be successful in 2018 and beyond.

    Use this time to partner with your EHR vendor. Don’t wait until the third or fourth quarter to find out data is not calculating. Schedule weekly calls with your EHR account manager. Ask for a user guide, provide it to your team, and review it often to close gaps in documentation.

    If you are already reporting under MIPS, you’re halfway there. If you’re not reporting yet, then start now—the earlier, the better. The positive or neutral adjustments are only slightly more challenging to meet in 2018, and what is done this year will reflect in the 2020 public reporting and pay-for-performance. Delaying participation may make next year even more challenging.

For more information, go to the Medical Advantage Group website or contact The Doctors Company Patient Safety Department at

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.


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