Health care reimbursement is marching toward a value-based payment system and away from the fee-for-service model. As such, incremental shifts over the last decade have pushed medical practices to embrace electronic health records (EHRs), engage in the physician quality reporting system (PQRS) and meaningful use and, most recently, begin to implement the Medicare Access and CHIP Reauthorization Act (MACRA).

There has been much confusion and angst surrounding the MACRA regulation rollout. The rule is complex, requiring over 2000 pages to outline its details. Moreover, MACRA carries significant reimbursement implications over the next several years, with possible penalties of up to 9% of Medicare Part B revenue for non-participation or poor performance. However, taking a step back to understand what the rule truly is – and what it isn’t – can help give clarity and understanding about what MACRA means for providers and help determine appropriate next steps.

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MACRA is here to stay

First, MACRA has absolutely nothing to do with the Affordable Care Act, and it will not be held up in potential legislative gridlocks. The rule passed with strong bi-partisan support, and it is already underway in 2017. In other words, MACRA is here to stay.

CMS did listen to strong feedback from the medical community and relaxed the rules for 2017 – a 1-year grace period to prepare for the full transition in 2018 – by allowing providers to submit a minimal amount of data to avoid a payment penalty. Providers now only need to report 1 quality measure or 1 improvement activity or the required Advancing Care Information (ACI) measures to avoid a penalty. In sum, practices that are ready for MACRA this year can potentially receive the positive payment incentive. Yet, providers who are not fully prepared for MACRA in 2017 can use the minimal data submission period to meet reporting requirements and continue to prepare for full engagement in 2018.

Most nephrologists will participate in MIPS

Second, although MACRA contains 2 paths, the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs), the vast majority of nephrologists only need to be concerned with MIPS. Although CMS intends to shift the majority of payments into APM models in future years, for now, due to the limited ability for nephrologists to participate in risk-based programs for the majority of their patients, the current reality is that almost all nephrologists will be participating in MIPS. 

MIPS really isn’t new

Third, MIPS isn’t groundbreaking or new. The 4 categories of MIPS essentially take several existing programs, streamline their requirements, and combine them into a single umbrella program. The MIPS Cost Category, for example, reimagines the Value Based Modifier program, a category that won’t even count towards your score in 2017. The MIPS Quality Category simplifies the requirements of PQRS. The MIPS ACI Category modifies Meaningful Use (MU). And the MIPS Clinical Improvement Activities Category, while new, only requires attestation and allows providers to get credit for many of the quality-improvement activities they are doing anyway. 

MIPS is a process

Lastly, MIPS really is not a “thing.” Rather, it is a process. MIPS uses metrics and measures to allow providers to demonstrate quality clinical care. Therefore, seeking to understand every patient assignment algorithm or denominator criteria is not only futile, but also not necessary. Implement a good EHR partner and ask them tough questions about their readiness to help you succeed with MIPS. Empower your staff to understand the requirements of MIPS, and partner with your team to ensure you have the right processes in place to deliver the best clinical care possible. For instance, is your front desk staff registering patients for your patient portal as part of the new patient registration process? Is your staff requesting Hemoglobin A1C and other necessary lab results from referring providers if those are necessary to meet the relevant quality metrics you have selected?

There are numerous resources available to help from organizations such as the Medical Group Management Association (MGMA) and the American Medical Association (AMA). Resources also are available on the Quality Payment Program (QPP) website. Additionally, CMS will award $20 million each year for 5 years to fund training and education for Medicare clinicians in individual or small group practices of 15 clinicians or fewer and those working in underserved areas. Local, experienced organizations will use this funding to help small practices select appropriate quality measures and health IT to support their unique needs and train clinicians about the new improvement activities. Refer to the CMS website to find out what organizations have been selected to help in your area.


Take advantage of all these resources that are at your disposal. MACRA is here to stay, and it’s not as bad as you might think. Don’t let all of the acronyms scare you. Relax, practice great clinical care, leverage your resources to develop the right processes and begin to embrace the journey toward value-based reimbursement. 

Robert Provenzano, MD, is Vice President for Medical Affairs at DaVita Kidney Care in Denver. He also is on the editorial advisory board of Renal & Urology News. Charles Siebert is Vice President of Operations for Nephrology Practice Solutions in Denver.


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