Value Based Payment (MACRA) & Alternative Payment Models

MACRA (Medicare Access and CHIP Reauthorization Act)

Success in Quality Payment Webinar Series
Part 1: MACRA Program Overview, originally aired Dec. 8, 3pm ET
Part 2: Making MIPS Work, originally aired Dec. 14, 12pm ET

MACRA Resources:

5 Things you need to know about MACRA
Merit Based Incentive Payment System Performance Categories 

CMS MACRA Resource Center 
A Guide to Physician-Focused Alternative Payment Models
Implementing Alternative Payment Model under MACRA: How the Federal Government can Accelerate Successful Health Care Payment Reform

CMS Web Resources:

MIPS Overview
Quality Measures- Review and identify measures that fit your practice
Advancing Care Information
Improvement Activities


President Obama signed the Medicare Access and CHIP Reauthorization Act (MACRA) into law on April 16, 2015. Congress passed the bill as a fix for the Sustainable Growth Rate (SGR) which was implemented in the 1990s to determine payment for clinicians’ services. MACRA represents a shift from a volume- to value-based based payment. The next few years bring a number of changes to Medicare Part B physician reimbursement including:
  • repeal of the SGR Formula 
  • a period of stable payments which include a .5% update from 2015- 2019 
  • implementation of the Merit Based Incentive Payment System (MIPS) and Alternative Payment Models (APM); and 
2016
  • MACRA provides funding from CY2016 to CY2020 to help small practices participate in APMS and MIPS.
  • Physicians may participate in Physician Quality Reporting System  via Qualified Clincial Data Registries ( like ImageGuide)
  • Part D claims must list the prescribers National Provider Identifier.    

2017

  • Performance period for MIPS and APMs.
2018
  • Claims must identify care episode, patient’s condition, and patient relationship to the clinican to attribute resource use 
  • Separate reporting penalties levied under PQRS, MU, VBM sunset on December 31, 2018. 
2019
  • Physician payments based on MIPS performance and participation in APMs.


MACRA has two pathways for clinicians. The first is the Merit Based Incentive Payment System and the second is an Alternative Payment Model. Physicians not in an alternative payment model will be evaluated under MIPS.


Summary of Provisions

MIPS (Merit Based Incentive Payment System)


MIPS repalces quality reporting programs currently administered under CMS. MIPS will apply to MD or DO, DDS, or DDM, DPM, OD, Chiropractors, PA, NP or clinical nurse specailists, and RN anesthetists at the outset. The statute gives the Secretary authority to expand the program to other professsionals billing under the fee schedule in 2021. 

MIPS is comprised of the following four categories on which physician performance will be score and will form the basis of Part B payments beginning Jan. 1, 2019:
Negative adjustments for physicians who do not meet performance benchmarks will be capped at 4% in 2019, 5% in 2020, 7% in 2021, and 9% in 2022 and beyond. Positive adjustments are available for physicians who achieve scores above national benchmarks and will be limited to three times the cap on negative adjustments.

APMs (Alternative Payment Models)


Physicians who participate in alternative payment models will not be subject to MIPS. 

Qualified APMS are further required to use a certified EHR, have quality measures similar to those in the MIPS program, and bear financial risk above a nominal amount. ACOs, patient centered medical homes, and model payment are examples of entities that could be considered APMs.