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MACRA/Quality Payment Program Questions and Answers

Understand your options under the Quality Payment Program (QPP) that was created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Learn how to succeed in either of the two payment tracks. Find answers to commonly asked MACRA and Quality Payment Program questions below.

What is MACRA?

The Medicare Access and CHIP Reauthorization Act of 2015 was signed into law on April 16, 2015, and became final in October 2016. The law eliminated the sustainable growth rate (SGR) formula that had previously been used to calculate Medicare payments to physicians and had resulted in repeated threats of severe payment cuts. The law provides a more predictable Medicare payment schedule for physicians and other clinicians, while moving the payment system away from a volume-based system toward a system that rewards value.

What is the Quality Payment Program?

The Quality Payment Program (QPP) is the name for the Medicare Part B physician payment system that was established by the MACRA law. The final rule implementing the QPP, issued in October 2016, incorporates many improvements to policies that were initially proposed based on comments received from ACP and others. Our suggestions to CMS paid particular attention to how small practices and subspecialists can succeed in the new program.

What are the different payment tracks in MACRA?

Starting in 2017 physicians will begin participating in either the Merit-Based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (APM) to earn additional increases in their Medicare payments in 2019. Physicians, or their practices, will have the opportunity to decide annually the program in which they will be participating.

Does this program apply to me?

MACRA applies to all physicians and other certain other types of clinicians (nurse practitioners, physician assistants, certified registered nurse anesthetists, and clinical nurse specialists) who participate in Medicare Part B, unless they meet one of the exclusion criteria.

There are three groups of physicians and other clinicians who will not be subject to MIPS:

  • Those who are in their first year of Medicare participation.
  • Those who are participants in eligible APMs and who are QPs.
  • Those who fall under a low-volume threshold for treating Medicare patients bill $30,000 or less in Part B allowed charges OR 100 or fewer Part B patients).

What if I’m not ready to start now?

In 2017, CMS is allowing ECs to “pick their pace” by creating different levels of participation to allow flexibility during the transition year. If an Eligible Clinician is not in any type of APM arrangement, during 2017 there are three paths to participation in MIPS:

  1. Full Participation: Participate fully as an individual or in a group and receive a payment adjustment in 2019 based on performance for at least 90 consecutive days or, ideally, for the entire year. The 90-day period can be the same or different for the performance categories. Full participants will be eligible to earn a positive adjustment. Positive adjustments will be based on the performance score of data submitted, not the amount or length of time submitted. However, longer performance periods may yield better results due to a larger pool of patients in the sample for certain quality measures.
  2. Partial Participation: Submit individually or in a group for at least 90 days but less than a full year on a limited set of measures: more than one quality measure, or attestation to more than one improvement activity, or report on all five base measures plus at least one additional performance measure in the Advancing Care Information category. Partial participation may result in neutral or positive adjust.
  3. Test: Submit a single Quality measure, or attest to a single Improvement Activity, or submit the 4 or 5 (dependent on edition of Certified EHR Technology) required base measures from the Advancing Care Information Category in 2017. This option does not earn any positive adjustments in 2019 – payment will remain neutral. There is no requirement regarding participation for any length of time. This option is intended to allow ECs the chance to experiment with the new program.

Note: During 2017, the transition year, there will be no negative adjustments as long as one of the above options is chosen. However, practices are encouraged to participate to the fullest extent possible to prepare for participation in 2018 and onward.

What is MIPS?

The Merit-Based Incentive Payment System (MIPS) builds on traditional fee-for-service payments by adjusting them up or down based on a physician’s performance in a new reporting system. This new reporting system will combine several existing Medicare reporting programs; the Physician Quality Reporting System (PQRS), the Medicare EHR Incentive Program (also known as Meaningful Use), and the Value-Based Payment Modifier Program—and also adds in a new component, Improvement Activities.

In Year 1 (2019 payments based on 2017 performance) physicians participating in MIPS will receive a composite score based on four weighted categories:

  • Quality = 60% (This percent will gradually decrease to 30% in future years.)
  • Resource Use (or cost) = 0% (This percent will gradually increase to 30%.)
  • Clinical Practice Improvement Activities=15%
  • Advancing Clinical Information (formerly known as meaningful use)=25%

These categories will be combined into one number called the MIPS Composite Performance Score.

How will they determine payments under MIPS?

MIPS payments will be the Medicare base rate (described above) in addition to a physician’s composite performance score adjusting his or her payments up or down.

  • In 2019, the first year of the program, payments can go up or down by 4 percent.
  • In 2020, physician payments can go up or down by 5 percent.
  • In 2021, physician payments can go up or down by 7 percent.
  • In 2022 and beyond, physician payments can go up or down by 9 percent.

Payments can never be reduced by more than the level set in the law. However, in order to make the adjustments budget neutral, the upward adjustments may have a scaling factor applied to make the total upward and downward adjustments equal to each other.

Additionally, physicians who are determined to be an exceptional performer will be eligible to receive an additional positive payment adjustment of up to 10 percent. This exceptional performance payment adjustment is not budget neutral but will come from a separate designated fund.

What is an APM?

Alternative Payment Models (APMs) are a new approach to paying for medical care that incentivizes quality and value. According to the law, initially Medicare APMs will include:

  • CMS Innovation Center models,
  • The Medicare Shared Savings Program,
  • Demonstrations under the Health Quality Demonstration Program, and
  • Other demonstrations initiated by Federal law.

Some APMs will qualify as “Advanced APMs." Over time, additional types of Advanced APM options will become available. Advanced APMs largely involve accepting risk based on the quality and effectiveness of care provided, like in an accountable care organization (ACO). However, Medical Homes (initially as expanded under the CMS Innovation Center—currently there are none) can qualify as an APM without taking on financial risk.

What is an Advanced APM?

Some APM participants will qualify to receive an additional 5% lump sum payment and a higher fee schedule in future years.  For 2017, only participation in the following programs will qualify as Advanced APMs:

Over time, as CMS modifies and expands the criteria, more models will qualify as Advanced APMs. ACP is working to expand the options for advanced APMs, especially so that it will be easier for small practices to participate.

What is the difference between an APM, an Advanced APM, and a Qualifying APM participant?

As noted above, an APM is defined as a new approach to paying for medical care through Medicare that incentivizes quality and value.  However, not all APMs are “Advanced APMs.” Advanced APMs meet the following criteria:

  • They base payment on quality measures comparable to those in MIPS.
  • They require the use of certified EHR technology.
  • They either (1) bear more than nominal financial risk for monetary losses OR (2) are a Medical Home Model as expanded under the CMS Innovation Center authority.

Qualifying APM participants (or QPs) are the clinicians who have a certain percentage of their patients or payments through an eligible Advanced APM.

How will physicians be evaluated under an APM?

Physicians who participate in an APM that is not determined to be an Advanced APM will be participants in the MIPS program; however, they will receive favorable scoring under MIPS.

Those that participate in an Advanced APM—i.e., physicians who are QPs—will:

  • Be paid according to the rules established as part of their APM (e.g., care coordination or infrastructure payments, shared savings, bundled payments, etc.).
  • Not be subject to MIPS.
  • Receive a 5 percent lump sum bonus payment on their fee-for-service reimbursements for years 2019-2024.
  • Receive a higher fee schedule update for years 2026 and beyond (0.75 percent).

Not all clinicians in an Advanced APM will qualify – they must have a certain number of patients or payments from the Advanced APM.  The proposed thresholds are a calculated ratio and increase each year of the program.  

How do I know if my ACO or APM meets the criteria of an Advanced APM?

Check to see if you are a member of any of the following entities that qualify:

Do clinicians qualify as individuals or as part of a group?

Eligible clinicians can participate in MIPS either as an individual or under the TIN of their group. If reporting as a group, all clinicians with NPIs assigned to the TIN must participate as a group and report on the same measures and activities.

What should I be doing now to succeed in the new Quality Payment Program?

See ACP’s list of 10 things to do for MACRA.

My practice is a certified Patient-Centered Medical Home (PCMH or Patient-Centered Specialty Practice).  Where does that fit into this new program?

Patient-Centered Medical Homes (PCMHs) are strongly incentivized under both pathways in the following ways:

  • Within MIPs, all certified PCMHs (and Patient-Centered Specialty Practices) will receive full credit for the clinical practice improvement activities category (i.e., you will receive the 15 percent credit for this item toward your overall MIPS composite score).
  • Within APMs, the following options are available:
    • The Comprehensive Primary Care Plus (CPC+) program is an advanced primary care medical home model being implemented by the CMS Innovation Center in 14 regions of the country in 2017. CMS intends to open applications to participants in 10 additional regions in 2017.
    • Medical Home Models are identified as being able to qualify (initially via expansion of CMS Innovation Center programs) as eligible APMs without having to bear financial risk. CMS has not yet specified any models that fall within this definition. These models may include state Medicaid models and private payer models in the future.

However, as defined by the rule, for a Medical Home Model to be defined as an Advanced APM, it must have the following features: 

  • Participants include primary care practices or multispecialty practices that include primary care physicians and other clinicians and offer primary care services.
  • Patients are empaneled to a primary clinician; and
  • At least four of the following:
    • Planned coordination of chronic and preventive care.
    • Patient access and continuity of care.
    • Risk-stratified care management.
    • Coordination of care across the medical neighborhood.
    • Patient and caregiver engagement.
    • Shared decision-making.
    • Payment arrangements in addition to, or substituting for, fee-for-service payments.

What else can I do to qualify as an eligible professional in an Advanced APM?

You could also begin to investigate if there are APM options in your area that are underway or being initiated by private payers or other stakeholders—getting involved in these programs, which could provide some supports and helpful services to transition to a more value-based payment system, may be beneficial to your success in either MIPS or APMs down the line.

Does the Quality Payment Program apply to private insurance companies?

No. This program only applies to Medicare Part B fee-for-service at this time.  However, some APMs may include Medicaid and private payer models in the future.

Does the medical home size limitation mean that larger systems could not use CPC+ to count as an Advanced APM?

As the current rule is written, it does restrict larger groups (>50 clinicians) in CPC+ from qualifying as an Advanced APM beginning in 2018. This is generally, CMS defines this as limiting the Advanced APM designation in CPC+ to those practice sites that are part of a parent organization with 50 or fewer eligible clinicians. CPC+ practices that are part of a parent organization with more than 50 eligible clinicians may participate in CPC+ but will not receive the Advance APM designation or the additional 5 percent bonus associated with Advanced APMs.

My question was not answered here. Where can I ask additional questions? 

ACP members can post a question or comment in the College’s MACRA forum or email ACP staff at macra@acponline.org.

CMS also maintains a QPP support center. Questions can be directed to QPP@cms.hhs.gov or 1-866-288-8292.

Updated March 2017