50% Practitioners not prepared for MACRA Quality Measures

It has been more than two years since Congress voted to enact the Medicare Access and CHIP Reauthorization Act of 2015 and subsequent deadlines for various aspects of the law were issued by the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS).

And yet, surveys conducted earlier this year and a few conducted more recently indicate that a large number of healthcare professionals are not familiar with the Medicare Access and CHIP Reauthorization Act (MACRA).

In this article, I will show you what MACRA is and why it matters for your practice. Consider this MACRA for dummies. Don’t worry, this is a MACRA summary with the most important information you need to know.

What is MACRA and Why is it Important?

What is MACRA in healthcare?

MACRA replaces the present Medicare reimbursement schedule with a new pay-for-performance program focused on value, quality and accountability.

What MACRA does is it enacts a payment framework where healthcare providers are rewarded for offering a higher quality of care, as opposed to the volume of service.

What does MACRA mean for You
What does MACRA mean for You

What does MACRA mean for You?

Basically, MACRA repeals the sustainable growth rate, which consist of several fixes from Congress that help in adjusting Medicare expenditures and provider reimbursement.

MACRA authorizes HHS to implement value-based initiatives meant to improve patient access to Medicare. However, MACRA is a lot more than that.

How so?

MACRA authorizes HHS to implement value-based initiatives aimed at improving care access for Medicare and CHIP beneficiaries. MACRA makes three important changes to how Medicare pays providers.

First, MACRA repeals the Sustainable Growth Rate formula that in the past determined Medicare payments for providers’ services.

Second, in MACRA, participating providers are paid based on the quality and effectiveness of care provided.

MACRA quality measures combine existing quality reporting programs into one new system.

Among the major provisions of the MACRA proposed rule, the most important one is the Quality Payment Program, which comprises of one of two paths for eligible clinicians:

The first is the the Merit-based Incentive Payment System (MIPs) and the second is the Alternative Payment Models (APMs).

What is the Quality Payment Program?

One of the major provisions in MACRA is the implementation of the Quality Payment Program. Its purpose is to ensure that quality reporting programs are collected under a single report.


The Quality Payment Program refers to the approach by the HHS to transition the healthcare industry from providing services for a fee, to providing services with value.

The provisions of the Quality Payment Program are that Medicare physicians, nurses and physician assistants have to take part in either APMs or MIPs.

MACRA rewards you for the quality of service you offer
MACRA rewards you for the quality of service you offer

Only then will they receive neutral, positive or negative medical payment adjustments in the future.

MACRA came into effect after President Obama signed it into law on 16th April 2015. MACRA passed with an overwhelming majority in both houses. The bipartisan support shows that MACRA is critical to US health reform.

Here’s the bottom line:

MACRA is a combination of Value-based Payment Modifier (VBM), Physician Quality Reporting System (PQRS) and the Medicare Electronic Health Record (EHR).

All these are combined into the Merit-based Incentive Payment System (MIPS).

I Now Understand MACRA. What About MIPS?

MIPS refers to the new program that will determine adjustments to Medicare payments. MIPS uses a composite performance score. This enables eligible professionals to receive payment bonuses or penalties.

The MIPS composite performance score is based on 4 performance categories. These are: resource use, quality, meaningful use of EHR and activities that enhance clinical practice.


MIPS became operational at the start of 2017. One of its goals is to conduct annual measurements the numbers of eligible providers in the 4 categories of performance to come up with a MIPS Score that is out of 100.

Importance of MIPS for Healthcare Providers

It’s important that every healthcare provider watches their MIPS score as it can have a significant effect on their Medicare reimbursement. This will range from -9% to +27% by 2022.

What is your MIPS score?
What is your MIPS score?

The overall score will be weighted based on 4 performance criteria. These include 50% for quality, 25% for meaningful use, 15% for the improvement of clinical practice and 10% for resource use.

Cost will be 10% of the total yearly score in one year, which replaces the cost component in the Value Modifier Program, also referred to as Resource Use.

This score is based on Medicare claims, meaning that there is little reporting requirements for clinicians. This category uses more than 40 episode-specific measures to account for inter-specialty differences.

Quality will account for 50% of the total yearly score. This replaces the Physician Quality Reporting System (PQRS) as well as the quality component of the Value Modifier Program.

This will give clinicians the opportunity to report 6 instead of the 9 measures currently required under the Physician Quality Reporting System.

Surveys Show that Healthcare Practitioners Understand What is Required to Comply with MACRA

According to the survey conducted by Integra Connect, covering approximately 800 specialty physicians; most recognize that financial, clinical and operational changes are required to be successful under MACRA regulations.

However, the majority of them have not yet invested in organizational, IT, or service improvements.

But here’s the shocker:

The most critical finding of the survey – 100 percent of survey respondents indicated they have not yet fully grasped MACRA’s impact on their practices.

While 71% of the respondents said that “I am learning but have a way to go,” 56% said that they were aiming for cost savings under MACRA through practice transformation to avoid unnecessary hospital stays and ER use.

Do you comply with MACRA requirements?
Do you comply with MACRA requirements?

But, 24% of these were not prepared and around 40% are taking an approach limited to their existing resources and tools.

NueMD’s 2017 MACRA survey conducted from April to June 2017 and covering 1,052 healthcare professionals, found similar uncertainty with 50% of respondents claiming that they are “not at all” familiar with MACRA.

41% stated having some degree of familiarity and a mere 9% claiming to be “very familiar”.

The answer most common to every question in the survey was “I’m not sure.”

This is the shocking part:

Around 56% of the surveyed respondents did not know if they qualified for MACRA’s Quality Payment Program and MACRA Medicare.

Information about MACRA also seemed hard to find, according to the respondents, with 49% stating that they had not encountered any information on MACRA.

Asked how they expected MACRA to impact their practice over the next three years, 63% respondents were not sure, 15% felt that it would have a negative effect and only 9% believed MACRA will positively impact their practice.

What the Survey Indicates

The findings indicate that while specialty practices do realize that MACRA presents a substantial clinical and financial opportunity, very few are well-positioned to realize optimal benefits.

Due to unpreparedness and limited investment in capabilities to manage attributed patient populations holistically and deliver both cost and quality improvements.

The findings also indicate that the top three barriers to MIPS success include having the right people/skills (23%), understanding the requirements (20%), and cultural shift required to assume accountability for patients (19 %).

While 62 percent of respondents either don’t know how, or have no plans, to fund these new upfront investments to enable MIPS success;

And that’s not all…

51 percent of respondents believe their current EMR is not prepared for value-based care, including APMs such as the Oncology Care Model, MIPS, and other bundled payment programs.

Reporting Options and How they Affect Your Practice

Clinicians have a number of reporting options to choose from so as to accommodate for the differences in practice and specialty.

15% of the score will go to clinical practice improvement activities. Under this category, clinicians are rewarded for the improvements they make to their clinical practice.

These include activities directed towards care coordination, patient safety and beneficiary engagement. Clinicians have the opportunity to select activities that suit their practice from at least 90 options.

Clinicians would receive credit for taking part in Alternative Payment Models as well as Patient-Centered Medical Homes.

25% of the score would come from advanced care information. This replaces the Medicare EHR Incentive Program for physicians also referred to as “Meaningful Use.”


Clinicians can report customizable measures that reflect how they use EHR technology in their daily practice. There is a particular emphasis on information exchange and interoperability.

This is different from the Meaningful Use program used in the past because it does not require an all-or-nothing measure of EHR and quarterly reporting.

Over time, the points allocated to each category will change. The changes will, however, be more focused on resource utilization over time.

What You Need to Report to Meet MIPS

So as to meet the requirements for the quality performance category, clinicians who are MIPS-eligible should give reports on 6 clinical quality measures in a one-year performance period.

To determine the resource use, CMS will use the total per capita cost measure, the Medicare Spending per Beneficiary (MSPM) as well as other episode-based measures to assess the level of service that MIPS-eligible clinicians offer during the full performance period.

What should you report?
What should you report?

The MACRA proposed rule incorporates provisions that will support critical access hospitals, rural access clinics as well as federal health centers that meet certain criteria.

There is a likelihood that many providers like CAHs will opt out of MIPS and other programs and due to a lack of resources and patients. Those providers will miss out on opportunities to get rewards from the system.

MACRA’s final rule is that the HHS will require that exempt providers contribute data to MIPS performance, even though they do not participate in the program.

This will help in the collection of more data on performance and help them increase their familiarity with the MIPS.

Progress Made in the US Healthcare Sector

The United States has made massive leaps in healthcare by creating a healthcare system that pays for quality, encourages coordinated care and smarter spending, creating better outcomes for patients.

Now, its time for MACRA healthcare.

Accountable care organizations, bundled payments and comprehensive primary care models are becoming more and more attractive.

For example, the Medicare FFS program currently has at least 30% of payment programs like this, and the number is on the rise.

Advanced APMs exist in two varieties: the first is advanced APMs administered by CMS or Other Payer Advanced APMs by private payers.

What to Do to Prepare for MACRA and MIPS

As organizations prepare for MACRA and MIPS, it is important that they work towards satisfying stage 2 requirements and try to achieve PQRS requirements.

According to CMS, providers that continue to attest to PQRS and Meaningful Use will have very few extra requirements to fulfill.

What Should You Do?

Data shows that an increasing number of specialty physicians are realizing that the transition to more holistic management of patients in support of MACRA will require fundamental changes in their workflow.

The problem is that only a few are taking the necessary actions to ensure success.

To maximize clinical and financial returns under MACRA, practices will need to use technology designed for their needs, execute process improvements and have dramatic cultural changes such as care management and navigation.

Outsourcing your requirements is one of the best ways to ensure that your practice is fully prepared to maximize the financial returns under MACRA.

An efficient medical billing company can help ensure that your billing processes comply with MACRA guidelines, thus ensuring that your healthcare establishment continues to operate without any fear of penalties due to faulty billing mechanisms.




  • Landi, H. (2017, August 28). Survey Finds Half of Healthcare Professionals “Not At All” Familiar with MACRA. Retrieved September 08, 2017, from
  • MACRA (Medicare Access and CHIP Reauthorization Act of 2015). (2017). Retrieved September 08, 2017, from
  • MACRA. (2017). Retrieved September 08, 2017, from
  • Specialty Practices Unprepared for MACRA Requirements, According to Integra Connect Data. (2017, September 06). Retrieved September 08, 2017, from

About the Author:MedConverge

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