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Quality improvement column

01-17-2017 13:45

The MACRA legislative process

How SIR and other societies are working with CMS to influence the implementation of MACRA


The Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015 (MACRA) is a landmark legislative achievement that received bipartisan support in both the House of Representatives and the Senate.

The payment reform proposed in the MACRA legislation replaces the flawed Sustainable Growth Rate floating formula for Medicare reimbursement, with a roadmap for re-aligning Medicare reimbursement to reward quality and value over volume. Along with these changes, the Centers for Medicare and Medicaid Services (CMS) has consolidated several quality programs into the Quality Payment Program (QPP) comprising the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).

As part of this process, MACRA sunsets the physician quality reporting system (PQRS), value-based modifier and the Medicare electronic health records incentive program. Health care providers who are eligible clinicians under MIPS will report a composite score comprised of four components:

  • Quality
  • Cost
  • Advancing care information (meaningful use)
  • Clinical practice improvement activities

The legislation also lays out the rules governing advanced APMs, highlighting that a key requirement is accepting a component of financial risk.

To a clinician taking care of patients, learning the relevant intricacies of legislation such as MACRA is daunting. Fortunately, SIR is appraising this legislation for its members, identifying areas of concern and using governmental contacts and available mechanisms to provide feedback to CMS.

In this article, we will explore the MACRA legislative process to highlight opportunities for stakeholders to engage CMS before, during and after rulemaking.

Opportunities before rulemaking

Prior to rulemaking, CMS may solicit input from individual stakeholders; however, there are no formal open calls for input. Input during this phase of the legislation stems from existing professional relationships with lawmakers, who may reach out regarding specific issues as they arise during the drafting process.

The legislation is initially released as a proposed rule, with a mandatory open public comment period. The MACRA proposed rule was initially published on the CMS website on April 26, 2016, with an open call for comments closing June 27, 2016.

In response to this call, professional societies, payers and other stakeholders began assessing the bill’s impact on their membership. Letters highlighted legislative components that could have unintended consequences or perhaps be unworkable from clinical or administrative perspectives.

For example, SIR brought together the SIR Economics Division, the Performance and Quality Improvement Division, and economics and health policy staff, to hold a summit on MACRA and its economic impact on our specialty. Representatives from the American College of Radiology and an individual knowledgeable about the Physician-focused Payment Model Technical Advisory Committee (PTAC; the process CMS has endorsed for moving specialty-proposed advanced APMs forward for consideration) were invited to participate.

On June 27, SIR submitted to CMS a letter summarizing this discussion. Although CMS is under no obligation to address specific concerns highlighted in such comment letters, it is clear from prior interactions that CMS is attentive to issues raised by stakeholders that impact issues of importance to CMS, including patient access, cost and quality.

Opportunities during rulemaking

Following the public comment period, CMS enters the period of rule-making, where the final rule is defined. CMS continues to engage stakeholder groups during this period, often through “listening sessions.” These sessions are an opportunity for a stakeholder to highlight a few items that are of particular interest to their membership and to specifically define the critical role that a particular specialty plays in patient care.

For example, SIR highlighted the wide scope of practice of IRs and our essential role in both in- and outpatient settings. In particular, the SIR comment letter expressed concerns regarding the proposed strategy to limit the number of performance measures that could be defined within a registry mechanism (Qualified Clinical Data Registry) allowed to submit measures to CMS for reporting purposes. To this end, SIR highlighted the role that the IR National Quality Registry will play in data collection at a reasonable cost to practitioners.

In addition, SIR emphasized that proposed rules for “patient-facing” versus “non-patient-facing” physicians were likely to have unintended effects on patient access in small community hospitals where both diagnostic radiologists and interventional radiologists perform image-guided procedures. SIR also highlighted concerns regarding the proposed MACRA start date of Jan. 1, 2017, as there was little time from the release of the final rule to the start of the reporting period.

Opportunities after rulemaking

At the time this article was submitted, the final rule had just been published on the CMS website (on Oct. 14, 2016). Ahead of schedule by about two weeks, this publication gives SIR and other stakeholders 2 months to understand the changes made to the proposed rule and consider the impact of these changes on our specialty and the practice of medicine at large.

However, in the interim, CMS released guidance regarding several options for practitioners to meet MIPS requirements for the initial reporting period. Although the reporting period will start as planned on Jan. 1, 2017, providers can avoid a negative payment update by simply sending data to CMS or can quality for a positive payment update by reporting all necessary data for at least a portion of 2017.

MACRA does not introduce policy mandates for private payers though, in general, private payers follow CMS’s lead regarding payment reform. Aligning health care quality and value over volume makes sense; however, how private payers define these terms could substantially impact the longer-term outcomes of policy reforms.

It is critical that physicians engage their health care system in defining quality and value as it relates to the patient experience and patient care. We must demonstrate high-quality care while addressing concerns regarding cost and maintaining access to care. Interventional radiology is well positioned to thrive in this new environment, and SIR is committed to support members during this critical transition to MIPS. Advanced APM options, potentially in partnership with other specialties, are also being considered in a range of domains relevant to IR practices.

As we transition to a health care reimbursement system that increasingly emphasizes care quality over quantity, it is critical that our specialty has access to data that highlights our value proposition: excellent patient outcomes at low cost.

To this end, it is critical that all IRs participate in registries and collect data. Without data, we will be hard pressed to demonstrate the quality product that we provide to patients. We therefore encourage all members to participate in the IR National Quality Registry, which uses standardized reporting to collect data during routine clinical patient care activities. Additional information regarding the IR National Quality Registry can be found on the SIR website at

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Interested in learning more about MACRA and the economics of interventional radiology in this new payment environment? Plan to attend the Economics Summit, which will be headlined by former Senate Majority Leader Tom Daschle, held on Thursday, March 9, 2017, at the SIR 2017 Annual Scientific Meeting. Read more at

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