MACRA’s Biggest Chunk: Quality Measures

By David Thill

An explanation of one of the legislation’s most crucial components

MACRA stands for the Medicare Access and CHIP Reauthorization Act of 2015. It repeals the Medicare Sustainable Growth Rate – or SGR – methodology for updates to the Physician Fee Schedule (PFS). It replaces SGR with the Quality Payment Program, whose focus is on the quality, rather than the quantity, of services provided to patients.

Providers can be part of the Quality Payment Program if they bill Medicare more than $30,000 a year and provide care for more than 100 Medicare patients a year, and are a physician, physician assistant, nurse practitioner, clinical nurse specialist, or certified registered nurse anesthetist.

The Quality Payment Program comprises two parts:

  • MIPS, or the Merit-based Incentive Payment System (for practices participating in traditional Medicare Part B).
  • Advanced APMs, or advanced Alternative Payment Models (which provides added incentives to clinicians for taking on some risk related to patients’ outcomes).

Practices that elect to take part in MIPS must report on specific quality standards – which replace the former Physician Quality Reporting System, or PQRS – in order to earn a payment adjustment.

This quality component is one of four evidence-based categories in which physicians must submit information to the Centers for Medicare and Medicaid Services to qualify for payment adjustments under MIPS. At 60 percent of the evaluation, quality carries the most weight when CMS calculates adjustments.

The other categories include advancing care information – which accounts for 25 percent – and improvement activities, which accounts for 15 percent. Additionally, physicians are expected to report on a fourth category, cost, in 2017. But cost will not be used to calculate payment adjustments until 2018.

Practices were allowed to start collecting data as early as Jan. 1, 2017, and can choose to begin doing so, for full quarter reporting, anytime until Oct. 2, 2017. All data will need to be submitted by March 31, 2018, and the first payment adjustments based on performance go into effect Jan. 1, 2019.

Here are some things to know about the MIPS quality standards, and how they may affect providers.

How the new differs from the old
Whereas the former PQRS was a penalty-only “pass-fail” program, MIPS allows physicians to earn credit for every measure they report on successfully, a spokesperson from the American Medical Association told The Journal of Healthcare Contracting. Bonus points can be earned if physicians report through electronic capture and submission, such as through the electronic health record, clinical data registry, quality clinical data registry, or web-interface.

Amy Mullins, M.D., CPE, FAAFP, medical director for quality improvement at the American Academy of Family Physicians, points out that the new quality standards under MIPS are similar in some ways to the former PQRS standards, but there are some key differences. Doctors already reported on quality metrics under PQRS, and many of those metrics are available to report on in MIPS, she says.

Whereas physicians chose nine quality measures to report on under PQRS, MIPS requires them to report on at least six of 271 available measures. (The CMS website offers the full list of these measures, which can be filtered by practice specialty.) At least one of these six measures must be an outcome-based or high-priority measure.

Another difference Mullins notes is in the amount of reporting for each measure. Whereas PQRS required physicians to report on 20 patients under each measure, MIPS requires physicians to report on 50 percent of the patients they see that qualify for that measure, regardless of who their payer is. In other words, the MIPS quality measures account for more than just Medicare patients.

Mullins notes that under MIPS, physicians have a lot of flexibility to choose the measures that are applicable to their practice. (The CMS website states a disclaimer emphasizing that MIPS-eligible clinicians are expected to report on measures applicable to their practices.) Physicians have few limits on what they can or cannot report on, she says.

Nor does Mullins believe the changes should affect the way doctors deliver their care. Within the family physician specialty, for example, high quality care was already a goal, she says. The difference will be in how physicians collect data now versus how they did under PQRS.

Smaller practices may face more challenges in collecting the data – as was true under PQRS – simply because multi-doctor, multi-specialty practices typically have more infrastructure and support to assist physicians in data collection and reporting, says Mullins.

Meanwhile, the AMA believes that, while room for improvement remains, MIPS “has already reduced the burden” on physicians by streamlining and aligning existing programs.

The challenging part
At press time, one challenge Mullins observes is the absence of a resource – such as some kind of online data input portal – in which physicians can report their measurement data. So, while practices were allowed to begin collecting data on January 1, 2017, and can choose to begin doing so for full quarter reporting any time until October 2, 2017 – with a reporting deadline of March 31, 2018 – “we don’t know yet where [the data is] going to go,” says Mullins. “[T]here’s nowhere to put it.”

As to whether MIPS will result in better care and better patient outcomes, as it is intended to do? “That’s the big question,” says Mullins. While she hopes it will result in better care, it is too early to tell now. “We’ll have to wait and see.”

For a broader view of MIPS – as well as the full list of 271 quality measurements – JHC recommends readers visit