Everything you need to know about MACRA implementation (but were afraid to ask)

By Elise Castelli posted 05-11-2016 21:45


By Katharine L. Krol, MD, FSIR
Chair, SIR Payment Research and Policy (PReP) Task Force

In April 2015 the Medicare Access and CHIP Reauthorization Act (MACRA) became law, substantially changing how Medicare payments will be made to all physicians, including interventional radiology and diagnostic radiology.  MACRA mandated Medicare payments be based on quality and created a new Quality Payment Program with two payment paths for providers—the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs).

On April 27, 2016, the Centers for Medicaid and Medicare Services (CMS) issued its long-awaited proposal to put meat on the bones of MACRA’s payment options, describing exactly how CMS envisions these two paths will work for providers.

CMS is accepting comments on its proposed rule until June 27, after which it will use the public’s feedback to craft a final rule. The final rule will determine exactly how you will be paid and measured starting as soon as next year, so SIR is already working on feedback to the proposed rule to ensure the rule treats interventional radiology fairly and correctly.

Who will be affected by MACRA?

All physicians, physician assistants, nurse practitioners, clinical nurse specialists and nurse anesthetists. Starting in 2017, all affected providers will be required to report MIPS. CMS will expand the list of eligible providers in 2019.

Why does this matter?

The fee-for-service system for physician payment that has been in place for most of our practices is being eliminated and replaced with a system that rewards quality—the Quality Payment Program. The Quality Payment Program is based on quality measurements for care that you and your team provide to patients, and are different than the current incentive programs, such as the Physician Quality Reporting System (PQRS). There are two payment models under the Quality Payment Program:  Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).

By tying payments to outcomes and quality of care, MACRA becomes bigger than just reimbursements. As part of the Affordable Care Act, the Department of Health and Human Services is encouraging providers to adopt the “patient-centered medical home” model of care delivered by physician teams, all of whom are responsible for and measured on patient outcomes. As reimbursement becomes increasingly tied to outcomes under the Quality Payment Program, interventional radiologists must demonstrate strong quality scores based on the measures outlined below to ensure referrals. Thus, not measuring up to MIPS standards doesn’t just mean reduced reimbursement; it could mean you don’t get called to provide care, with competitors getting those referrals that could have gone to you

What is the Merit-based Incentive Payment System (MIPS)?

MIPS is a new payment model option that provides physicians with financial incentives (and penalties) based on quality, outcomes and efficiency.  MIPS consolidates the existing quality reporting systems—the Physician Quality Reporting System (PQRS), the Value-based Modifier Program, and the Medicare Electronic Health Record (EHR) Incentive Program—into one system.  Based on the currently proposed rule, MIPS will attribute provider performance across four categories:

  • Quality (50 percent of total score in year 1 (2019); 30 percent after): You would choose six measures to report on from a pool of options.  CMS intends that these options will be designed to accommodate differences among specialties and practices.
  • Advancing care information/EHR meaningful use (25 percent of total score in year 1 (2019) and beyond): You would choose “customizable measures” that reflect your day-to-day use technology to manage and share patient information. CMS will place emphasis on “interoperability and information exchange,” with the goal of having a patient’s health records available across all systems to allow any provider needing to care for that patient to have open access to their medical history. CMS says that “unlike the existing reporting program, this category would not require all-or-nothing EHR measurement or redundant quality reporting.”
  • Clinical practice improvement activities (15 percent of total score in year 1 and beyond): You are rewarded for “clinical practice improvements, such as activities focused on care coordination, beneficiary engagement, and patient safety.”
  • Cost/resource use (10 percent of total score in year 1; 30 percent after): Your score would be based on Medicare claims, using “40 episode-specific measures to account for difference among specialties.”

Those four categories will be weighted accordingly and providers will be given a composite score from 0-100, which will then be used to determine their reimbursement rate. Providers falling within the mean will see a flat adjustment rate, while providers falling above or below the threshold will see their rates go either up or down accordingly. CMS anticipates most providers will participate in MIPS in the early years of MACRA implementation.

What does MIPS mean for you and your team?  

It is important to note that if there are not sufficient measures and activities available to apply to eligible clinicians involved in care, the rule would allow CMS to assign different scoring weights “including a weight of zero.” SIR has anticipated this change and is actively working to have quality measures for IR included. Because CMS will generate composite scores from the above categories based on the previous two years of an eligible provider’s performance on MIPS measures, it is imperative that you actively participate in all four categories and even in the sunsetting programs, such as PQRS, Value-based Modifier Program and EHR meaningful use. CMS will begin measuring quality performance through MIPS in 2017. Payments based on MIPS measures will start in 2019, with 2019 payments based on quality measures reported in 2017.

MIPS Composite Performance




2022 & Subsequent Yrs

Less than ¼ of the MIPS Performance Threshold

4% Reduction (Maximum)

5% Reduction


7 % Reduction


9% Reduction (Maximum)

Between ¼ of MIPS Performance Threshold and Score Equal to MIPS Performance Threshold

No Adjustment

No Adjustment

No Adjustment

No Adjustment

Above MIPS Performance Threshold

Positive Adjustment

(12% Maximum)

Positive Adjustment

(15% Maximum)

Positive Adjustment

(21% Maximum)

Positive Adjustment

(27% Maximum)


Remember, this is more than just payment adjustments, penalties and rewards. Accountability and scoring will be applied across a multi-specialty team and team players will be chosen accordingly. In future years, a physician’s quality and cost rankings will be publicly available on the national federal website, Physician Compare.  With everyone on the team depending on high quality scores to achieve higher payments, the team will need to know the costs, quality and outcomes of specialists (including IR) to assure they make the most effective referrals.

What are Alternative Payment Models (APMs)?

MACRA built on Affordable Care Act incentives that seek to transform care and delivery by rewarding the adoption of alternative payment models, such as accountable care organizations (ACOs), bundled payment models, patient-centered medical homes, and other shared savings programs where clinicians accept both risk and reward for providing coordinated, high-quality, and efficient care. Thus, while most providers are expected to adopt MIPS at first, the other way MACRA will provide payment incentives is through Advanced APMs. Specifically, physicians who “participate to a sufficient extent” in APMs that meet criteria for payment based on quality (Advanced APMs) would be exempt from MIPS reporting requirements and qualify for a lump-sum incentive bonus on the following schedule:

  • In 2019 and 2020, at least 25 percent of Medicare payments attributable to services provided through a qualifying APM
  • In 2021 and 2022, at least 50 percent of Medicare payments attributable to services provided through a qualifying APM, or at least 50 percent of payments from all payers and 25 percent of Medicare payments attributable to services provided through a qualifying APM
  • In 2023 and beyond, at least 75 percent of Medicare payments Medicare payments attributable to services provided through a qualifying APM, or at least 75 percent of payments from all payers and 25 percent of Medicare payments attributable to services provided through a qualifying APM.
  • Starting in 2026, APMs will offer some participating health care providers higher annual payments.

CMS believes many physicians will not initially be able to meet some of MACRA’s APM requirements for sufficient participation, so the proposed rule provides financial rewards within MIPS and the ability to switch between the components of the Quality Payment Program as the program matures. CMS is aiming to have 85 percent of U.S. health care expenditures proceed through APMs by 2022.

What is the path forward for IRs and APMs?

CMS has focused on primary care rather than specialty care for their work to date on APMs, and primary care APMs are already quite advanced. Going forward, when primary care needs to refer patients to specialists, they will be looking closely at cost, quality and outcomes before making that referral. IRs must be able to prove they can compete across all areas, even if it is not yet clear how IR will fit in the APM model.

In addition, private payers are leading the way on APMs, and, in some markets, are further along in their development and implementation of this payment model. CMS is expected to look to the work of the private payers to help them develop CMS-specific APMs. CMS has also determined that by 2021 they will consider a physician’s participation in APMs in both the CMS and in private payer systems to determine whether a physician qualifies for the CMS bonus payment for APM participation.

What happens next?

With the unveiling of the proposed rule, we now have an opportunity to offer feedback to CMS to improve the programs as detailed. SIR is preparing the comments and will submit them by the June 27 deadline. We are also commenting on Alternative Payment Models, and new “patient relationship codes” that have been drafted by CMS.

In addition, SIR is developing tool kits and educational sessions to help you navigate the new payment models, with the ultimate goal of ensuring patient choice is preserved so IRs can continue improving lives through  high-quality, innovative, minimally invasive care. 

The new IR Structured Reports are scheduled to be piloted in 2016, as are several pilot sites for the new IR Registry. The IR Structured Reports and IR Registry are critical to your ability to succeed in this new payment system. The structured reports will capture all of your quality measurements and automatically extract them and send them to CMS. All SIR members should continue to work closely with your administrators and coders to ensure that you are participating in PQRS and EHR meaningful use for 2016, 2017, and 2018. The quality incentive payments you receive will be based on measures reported two years previously, and this is not changed by MACRA or the new proposed rule.

Stay tuned to the SIR MACRA webpage for more information as we continue to assess the impact of MIPS on our specialty.

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