Internists Offer Practical Alternatives to Simplify Implementation of the Medicare Access and CHIP Reauthorization Act (MACRA)

(Washington, June 27, 2016)—The American College of Physicians (ACP) offered its recommendations for improvements to the proposed rule to implement the Medicare Access and CHIP Reauthorization Act (MACRA) in a letter submitted today to the Centers for Medicare and Medicaid Services (CMS) Acting Administrator, Andy Slavitt.  If accepted by CMS, the College’s recommendations would replace an unnecessarily complex quality scoring system with a much simpler and understandable approach,  revamp how use of health information technology is reported to make it less burdensome and more relevant to clinicians, offer safe harbors for smaller practices until a “virtual reporting” system is established, and provide expanded choices and opportunities for physician-led models to qualify for higher payments as “alternative Advanced Payment Models”—including three new pathways for Patient-Centered Medical Home Practices.

ACP’s specific recommendations are aligned with three guiding principles that the College recommended CMS consider as it finalizes the rule:

  • That the new payment systems should reflect the lessons from current and past programs and effectively allow for ongoing innovation and learning.  The agency must constantly monitor the evolving measurement system to identify and mitigate any potential unintended consequences.
  • CMS should work to ensure that patients, families, and their relationships with their physicians are at the forefront of thinking in developing the new payment systems.
  • CMS should collaborate with specialty societies, frontline clinicians, and EHR vendors in the development, testing, and implementation of measures with a focus on decreasing clinician burden and integrating the measurement of and reporting on performance with quality improvement and care delivery.

“It is critically important to recognize that the legislative intent of MACRA is to truly improve care for Medicare beneficiaries and thus, the policy that is developed to guide these new value-based payment programs must be thoughtfully considered in that context,” said Robert McLean, MD, FACP, chair of ACP’s Medical Practice and Quality Committee.  “Our comments to CMS go beyond pointing out the problems with the proposed rule; we offer concrete suggestions on how to fix it so that it will truly achieve the goals of Congress, physicians—and of Acting CMS Administrator Slavitt—to simplify reporting of quality measures and provide more choices and opportunities for physicians in all specialties and practice sizes to be successful.”

Among the detailed suggestions that the letter offers to CMS:

  • For the Merit-Based Incentive Payment System, the College proposed a distinctive alternative scoring methodology, developed by ACP, which combines, simplifies, aligns and reduces the complexity of the four reporting categories that will qualify physicians for FFS payment adjustments in 2019.  The scoring approach included in the proposed rule had different points systems and scales for each of the four reporting categories, making it unnecessarily complicated; ACP’s alternative would put the points all on the same scale, combining them into one simplified and harmonized program as Congress intended.
  • The College proposed specific alternatives to CMS’s Advancing Care Information program that is to replace the current Meaningful Use program.  The ACP alternative would make it easier for physicians to report on and be successful in this category, in line with Administrator Slavitt’s promise to revamp the program to simplify reporting and make it more meaningful for clinicians.
  • ACP proposed additional improvements to simplify the reporting requirements for the Quality, Advancing Care Information and Clinical Practice Improvement categories.  The College’s suggested changes to the Resource Use category also included suggestions to reduce unintended adverse impacts on physicians and their practices.
  • ACP urged CMS to immediately create virtual reporting options and to create safe harbors for smaller practices until such options are available.  The College recommended that practices with 9 or fewer clinicians, should be held harmless from payment reductions that would otherwise occur until the virtual reporting option is available.  ACP also suggested that a virtual reporting option could be based on linking primary care Patient-Centered Medical Homes with Patient-Centered Specialty Homes, a concept long championed by ACP.
  • The letter also proposed more options and flexibility, instead of a one-size fits all approach, for practices to be certified as Patient-Centered Medical Homes or Patient-Centered Medical Home specialty practices, qualifying them for the highest possible score for the Clinical Practice Improvement Activity reporting category.
  • ACP proposed four different options for Medical Home practices to qualify as advanced Alternative Payment Models, instead of the single option proposed by CMS, including options to allow PCMHs to qualify without taking financial risk.  These additional options would potentially allow many thousands more practices to qualify and earn the 5 percent bonus on FFS payments 
  • Finally, the letter suggested other changes that would make more advanced Alternative Payment Models available for physicians in all specialties, especially including those in internal medicine and its subspecialties.

“The recommendations we offered to CMS today would simplify the quality reporting program, reduce the burden on physicians and especially smaller practices, and propose more options and flexibility for physicians to qualify for higher payments by recognizing their ongoing efforts to improve care to their patients.  With these improvements, implementation of the new payment systems would go a long way to achieving Congress’ goal of aligning payments with quality without imposing more unnecessary administrative burden on physicians,” concluded Dr. McLean.  


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.

David Kinsman, (202) 261-4554
Laura Baldwin, (215) 351-2668