MACRA New Rule Debrief | Geneia

MACRA: New Rule Debrief

December 05, 2017
Heather Lavoie, Chief Strategy Officer

Male doctor speaking to female patient in office 

On Nov. 2, the Centers for Medicare and Medicaid Services (CMS) announced the final rule with comment period for year two (2018) of the Quality Payment Program (QPP) of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The QPP includes the Merit-based Incentive Program (MIPS) and the Alternative Payment Model (APM) tracks.

Citing a desire to recognize feedback from the healthcare community, minimize administrative burden and prepare clinicians for a “more robust program” in year three, the final rule continues and expands on the flexibility offered in the 2017 transitional year.

MIPS Track

For physicians on the MIPS track, highlights include:

Expanded flexibility for small practices (as defined by 1-15 eligible clinicians):

  • Low-volume threshold increased to $90,000 or less in Medicare Part B allowable charges or 200 or fewer Medicare beneficiaries. The 2017 limits were $30,000 or 100 respectively.
  • Low-volume clinicians may opt out of having their data publically reported on Physician Compare.
  • Virtual group reporting for solo and small practices.
  • Significant hardship exemption from advancing care information performance category for MIPS-eligible small practice clinicians, awarding points even if submitted data doesn’t meet data completeness standards.

Other key points:

  • Advancing care information, improvement activities and cost category reporting remains at 90-day periods.
  • Quality category shifted to a single, full-year reporting period.
  • Quality category weight shifted from 60 to 50 percent of MIPS total score.
  • Cost category weight shifted from 0 to 10 percent of MIPS total score.
  • Advancing care information and improvement activities remain at 25 and 15 percent of MIPS total score respectively
  • Quality, advancing care information and improvement activities automatically shifted to weight of zero for those providers impacted by Hurricanes Irma, Harvey, Maria and by other widespread natural disasters.
  • EHR flexibility extended with a bonus to those using 2015 Certified EHR Technology (CEHRT) exclusively.
  • Treatment of complex patients earns up to five bonus points.
  • Telehealth services received increasing support through new billing codes.


Low-Volume Threshold

By law, MACRA must be fully implemented in 2019. The additional flexibilities offered for 2018 give providers one more year to prepare and ramp up. Some argue the pace is too slow and doesn’t do enough to further the objectives of value-based care. Others hail this as a big win for small practices.

CMS estimates the new low-volume threshold will apply to about 540,000 clinicians, leaving around 622,000 others subject to MIPS reporting requirements in 2018. Altogether, these exemptions mean roughly 64 percent of physicians are automatically excluded from MACRA reporting. There is no mechanism for physicians at or below the threshold to opt in. This means low-volume physicians have no access to potential value-based payment incentives or increases for their Medicare patients over the next several years.

Virtual Groups

One encouraging new channel for provider participation is virtual group reporting. The 2018 rule allows eligible solo and small group practitioners to band together to participate in the MIPS program as virtual groups. This is a good idea and commended by many. But, despite its heft -- more than 1600 pages -- the new rule is light on details about how providers will be incentivized to join virtual groups or how those groups will actually work.

EHR Flexibility

Participating clinicians may continue to use either 2014 or 2015 EHR technology in 2018, driving alignment with CMS hospital programs and giving providers more time to implement 2015 CEHRT. Practices relying exclusively on 2015 CEHRT earn a 10 percent bonus. The extended EHR flexibility will be a considerable relief to physicians and is indicative of CMS’s pledge to reduce administrative burden.

Technology: Telehealth Services and Remote Patient Monitoring Activities

The new MACRA rule makes it easier for clinicians to get paid for delivering telehealth services, including risk assessments, consultations, care planning for chronic conditions and remote patient monitoring activities. The rule encourages and promotes the use of technology to engage patients and improve health and cost outcomes.

According to CMS, “We believe that the use of digital technologies that provide either one-way or two-way data between MIPS eligible clinicians and patients is valuable, including for the purposes of promoting patient self-management, enabling remote monitoring, and detecting early indicators of treatment failure.

We believe MIPS eligible clinicians will use health IT including providing patients access to health information and educational resources as well as incorporating PGHD [patient generated health data] for this activity to include standardized data capture and incorporating patient generated health data[i].”

I have seen, first-hand, the power of technologies like remote patient monitoring to improve the lives of our most vulnerable populations. By providing a new series of billing codes, CMS recognizes the tremendous benefit of telehealth services to patients and providers alike. Enabling elderly, rural and chronically ill patients to remain at home while receiving necessary healthcare services is a boon to everyone involved.

APM Track

From the beginning, MACRA promised to reward high-performing clinicians and offers a 5 percent incentive bonus payment for qualified practitioners (QPs) in the APM track. QPs are exempt from MIPS reporting, and CMS estimates that 185,000 to 250,000 physicians will qualify as QPs in 2018.

Key changes heading into 2018 include:

  • Continues the ‘nominal’ risk standard of 8 percent through performance year 2020.
  • Implements the ‘All Payer Combination Option,’ which allows QPs to leverage their participation in value-based arrangements with entities beyond CMS.
  • Provides more details on how QPs will be assessed under the APM track. 


By law, MACRA requires non-medical home model, advanced APM entities to bear risk beyond a nominal amount. The 2018 final rule extends this nominal amount threshold of 8 percent through performance year 2020. By way of comparison, the medical home model risk threshold is 2.5 percent.

The all-payer option allows clinicians to qualify as APM participants through submission of data gathered for populations beyond Medicare. The value-based arrangements covering these populations must utilize EHRs, contain MIPS-comparable quality measures and include the bearing of downside financial risk. This option allows physicians to combine data from commercial and Medicare populations to earn financial incentives and bonuses on the advanced APM track.

The additional detail for APM scoring methodology is intended to reduce the administrative burden for clinicians participating in APMs who do not yet qualify as QPs and therefore fall into the category of MIPS APMs and are subject to MIPS reporting. 

For more information

Geneia will continue to keep you abreast of MACRA news and analysis for health plans and physicians. Visit our resource center for additional information, including information on how to avoid penalties if you have not yet completed your minimal reporting requirements for 2017. Although the clock is ticking, you still have a small window of time left.  



[i] Medicare Access and CHIP Reauthorization Act of 2015, Nov 2 final rule and comment period for measurement year 2018, page 1622.

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