know about the macra final rule

Things You Need to Know about the MACRA Final Rule

Representing a departure from the volume based, fee-for-service model, MACRA replaces the SGR (sustainable growth rate) formula to control Medicare costs. Linking Medicare reimbursements to quality metrics with providers being rewarded for quality and value based care; MACRA repeals the set payment rates based on economic growth, which was the hallmark of SGR.

Post touring and listening to about 4000 public comments; CMS released the final rule for the Medicare Access and CHIP Reauthorization Act on October 14.  The announcement of this rule finalizes MACRA’s Quality Payment Program, aiming to reduce administrative burden on physicians so they can focus on care improvement, promote adoption of value-based care and smooth the transition to these new models of care. Providers will have the flexibility to choose their pace for the first performance year (beginning January 1, 2017).

Here are some of the important things to know about the final rule.


Any provider, who bills Medicare for more than $30,000 a year or provides care to 100 Medicare patients or more, qualifies for MACRA. However, those providers who will be new to Medicare in 2017 are not required to participate in MACRA for that year.


There are two options for providers – MIPS (Merit-Based Incentive Payment System) and APM (Advanced Alternative Payment Model). Providers will participate in either of the two depending upon the type of service they provide. Participation in MIPS will be for those providers who follow the fee-for-service model and APM will be for those who participate in specific value-based care models.


Bringing together three legacy CMS programs – Meaningful Use, the Physician Quality Reporting System and the Value-Based Payment Modifier, MIPS will allow physicians to earn payment adjustments based on performance in four categories linked to quality and value. For the first year, payment adjustments will be positive, neutral or negative up to 4% and will subsequently increase to 9% by 2022. Physicians have the following options in 2017 to participate.

  • No participation and an automatic 4 percent negative payment adjustment.
  • Submission of a minimum amount of data and a neutral payment adjustment.
  • Submission of 90 days of data for a potential small positive payment adjustment or a neutral adjustment.
  • Submission of a full year of data for the potential to earn a moderate positive payment adjustment.

Advanced APM

Physicians participating in the Advanced APM model can avoid MIPS reporting requirements and payment adjustments and earn a 5 percent lump sum incentive payment each year from 2019 through 2024. However, to qualify for the Advanced APM, physicians must meet three requirements – Use certified EHR technology, base payments on quality measures comparable to MIPS and bear more than nominal risk. The final rule identifies the following as advanced APMs for 2017:

  • Comprehensive ESRD Care Model (LDO and non-LDO two-sided risk arrangements)
  • Comprehensive Primary Care Plus Model
  • Medicare Shared Savings Program Tracks 2 and 3
  • Next Generation ACO Model

Further, CMS plans to create additional pathways for participating in the advanced APM track, that will include a new accountable care organization Track 1+ model, the Comprehensive Care for Joint Replacement and the Medicare Diabetes Prevention Program.

What about small providers

Based on the feedback received from providers, CMS has made the necessary adjustments to help small and independent providers participate in MACRA. While those who fall below the requirements of at least $30,000 Medicare Part B charges or 100 Medicare patients are exempt from participating in 2017, CMS is offering an option for small practices and solo physicians to join together in virtual groups and submit combined MIPS data. The final rule also allots $20 million a year for five years for training and education of physicians in practices of 15 or fewer and those who work in underserved areas.

According to CMS Acting Administrator Andy Slavitt, “It’s time to modernize the Medicare physician payment system to be more streamlined and effective at supporting high-quality patient care. To be successful, we must put patients and clinicians at the center of the Quality Payment Program. A critical feature of the program will be implementing these changes at a pace and with options that clinicians choose. Today’s policies are designed to get all eligible clinicians to participate in the program, so they are set up for successful care delivery as the program matures.”


  1. Andy Slavitt, A. A. (2016, October 14). A Letter from CMS to Medicare Clinicians in the Quality Payment Program: We Heard You and Will Continue Listening. Retrieved October 17, 2016, from
  2. Fields, C. (2016, October 10). MACRA: Top 10 FAQs. Retrieved October 17, 2016, from
  3. MACRA. (2016). Retrieved October 17, 2016, from
  4. Medicare Program; Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models. (2016). Retrieved October 17, 2016, from
  5. Quality Payment Program. (2016). Retrieved October 17, 2016, from
  6. Rappleye, E. (2016, October 14). CMS releases MACRA final rule: 10 things to know. Retrieved October 17, 2016, from

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