Internists ‘Encouraged’ by Proposed Rule to Implement the Medicare Access and CHIP Reauthorization Act (MACRA)

Attributable to:
Wayne J. Riley, MD, MPH, MBA, MACP
President, American College of Physicians (ACP)

April 28, 2016

The American College of Physicians (ACP) is greatly encouraged that the proposed rule to implement the Medicare Access and CHIP Reauthorization Act (MACRA), released yesterday by the Centers for Medicare and Medicaid Services (CMS), makes significant improvements in simplifying the administrative burden of quality reporting and introducing greater flexibility in meeting federal requirements relating to use of Electronic Health Records (EHR).  As Congress intended in enacting MACRA and as ACP has consistently advocated in comments to CMS and recent testimony at a hearing convened by the House Energy and Commerce Committee, the proposed rule:

  • Begins to transition the current Medicare quality reporting programs into a less burdensome and more flexible Quality Reporting Program including the following improvements,  as advocated by ACP:
    • Reduction in the number of clinical quality measures that need to be reported from nine down to six. These six measures must include one cross-cutting measure and one outcome measure.  If an outcome measure is not available, then a clinician can select a “high priority measure” (e.g., appropriate use, patient safety, efficiency, patient experience, and care coordination measures). ACP strongly supports the use of outcome measures; however, we had specifically asked CMS to allow flexibility in terms of their use, particularly in the first year of the program.

    • Measures can be selected individually or from a specialty-specific measure set.  Participants in the Quality Reporting Program have flexibility to determine the most meaningful measures for their practice. ACP had asked CMS to allow clinicians to only use the measures most applicable to their patient population.
    • There are opportunities provided for qualified clinical data registries (QCDRs) to submit new and innovative measures for consideration—which is aligned with ACP’s call for CMS to move toward creating a learning health and health care system.
    • For the purposes of reporting on clinical practice improvement activities (CPIA) as required by MACRA, CMS is providing a list of more than 90 options for clinicians to select from, including activities focused on care coordination, beneficiary engagement, and patient safety.  Patient-Centered Medical Homes (PCMHs) will count for full credit if it is a nationally recognized accredited PCMH (by NCQA, AAAHC, TJC, or URAC), a Medicaid Medical Home, or a Medical Home.


  • Replaces the flawed EHR Meaningful Use program with a new Advancing Care Information Program including the following improvements, as advocated by ACP:
    • Threshold measure requirements of meaningful use (MU) are eliminated.  Reporting requires only the numerator and denominator of each measure where appropriate.
    • Considerable flexibility has been added. The all-or-nothing requirement has been eliminated and measures have been simplified and made optional.
    • Incentives for use of health IT in other categories of Quality Reporting Program are provided, with a bonus point available for reporting quality measures via certified EHR technology. Additionally, some of the clinical practice improvement activities involve enhanced use of certified EHR technology.
    • CMS intends to monitor the performance category and adjust future requirements based upon current activities—again, indicating movement toward facilitating learning and innovation.
    • In addition to previously available methods, measures can also be reported via QCDRs.
  • The proposed rule also clarifies how innovative models of healthcare delivery, called Advanced Alternative Payment Models (APMs), can qualify for higher fee-for-services (FFS) bonus payments.  The ACP is encouraged that the proposed rule provides an opportunity for certain medical home practices to qualify as an Advanced APM - under the proposal, practices that participate in the new Comprehensive Primary Care Plus program can become Advanced  APMs starting in 2019.  However, because the CPC+ program is only expected to be available to only 5000 practices nationwide, additional steps will need to be taken to ensure that other PCMHs can qualify as APMs.
  • ACP will be reviewing the proposal in more detail and providing comments on additional steps that CMS can take to reduce, simplify and harmonize quality reporting and to create multiple pathways for innovative delivery models to become APMs.


The American College of Physicians is the largest medical specialty organization and the second-largest physician group in the United States. ACP members include 143,000 internal medicine physicians (internists), related subspecialists, and medical students. Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. Follow ACP on Twitter and Facebook.

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