MACRA: Transitioning to VALUE-Based Care

Unless you get a tweet to the contrary, MACRA, with its newly finalized Quality Payment Program is now a reality.  To make sure clients and friends are prepared and stay up to date, ADVOCATE has developed a step-by-step MACRA Webinar Series.  Webinar Series goals will be to facilitate higher levels of physician participation and provide management monitoring tools to promote the highest possibility of groups receiving incentive bonus dollars. As always, ADVOCATE will be there at each step along the way providing updated information and support for our clients to succeed.

The first Webinar will be on December 15th.  A separate invitation will be sent soon.  Upon completion of this series, participants should be able to:

  • Gain experience in monitoring & analyzing compliance with the MACRA Quality Payment Program
  • Identify internal strengths and weaknesses in participation & reporting
  • Quantify & report on the potential impact of various scenarios & outcomes
  • Gain strategies to meet the new Clinical Practice Improvement Activities performance category.

The following is a brief overview of the Quality Payment Program (QPP).  The QPP was implemented as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) which ended the Sustainable Growth Rate formula. The bedrock of the Quality Payment Program is high-quality, patient-centered care followed by useful feedback, in a continuous cycle of improvement.  There are two pathways that Eligible Clinicians (ECs) can choose under the QPP: Merit-based Incentive Payment System (MIPS) or Alternative Payment Models (APMs).


There are 4 performance categories under MIPS and the below delineates their weight in the overall composite score:

  • Quality
  • Resource Use
  • Advancing Care Information
  • Clinical Practice Improvement Activities

Quality – 60%

The Quality category replaces the Physician Quality Reporting System program.  The reporting structure and mechanism will remain the same with the main different being that only 6 quality measures need to be reported on as opposed to the 9 as it was in 2016.  There are no new radiology specific quality measures but there are two measures being removed: measure #76 CVC insertion and measure #22 discontinuation of prophylactic antibiotic.  So, as far as providers are concerned, keep doing what you’re doing!

Resource Use – 0%

Also known as the “cost” category that replaces the Value Modifier program.  This category will not be factored into the ECs composite score in performance year 2017 but expect it to play an important role in future performance years.  In 2017, Medicare will be collecting data behind the scenes and will provide feedback to all ECs on their findings.

Advancing Care Information – 25%

The Advancing Care Information category replaces the EHR incentive program, otherwise known as Meaningful Use.  The CMS Final Rule indicates that MIPS ECs furnishing more than 75% of covered professional services in an inpatient hospital, on-campus outpatient hospital or emergency room setting will be exempt from this category.  Generally speaking, many radiologists are expected to be exempt from this MIPS category.

Clinical Practice Improvement Activities – 15%

The Clinical Practice Improvement Activities category is a new category under the Quality Payment Program.  In this category there are 9 broad domains with 90+ activities available.  ECs will have to attest to having completed 4 activities with special consideration given to groups with 15 or fewer ECs, rural/HPSA ECs, non-patient facing ECs, and providers in an APM or Certified Medical Home.

The guidelines in the Advancing Care Information and Clinical Practice Improvement Activities categories point to the differentiation between patient-facing and non-patient facing ECs.  At this point in time, CMS has yet to publish clarifying information as to which procedure codes determine if an encounter is patient-facing or non-patient facing.  Our hope is that this information is published in advance of the performance period, which begins on January 1, 2017, as indicated by CMS in the Final Rule.


APMs offer a pathway to incentives based on existing and shared risk, patient-centered care, and coordinated care approaches.  One of the criteria by which an APM is determined to be “advanced” is that the participating provider must bear more than nominal risk under the reimbursement model with the outcome being the ability to earn a 5% incentive payment in 2019.  The vast majority of radiologists will not fall into the APM pathway under the QPP however this is certainly the direction CMS is looking to for all ECs as CMS intends to broaden APM opportunities for clinicians, including both small practices and specialists.

Pick Your Pace

For 2017, CMS is allowing groups and ECs to choose how much and how often they report on all parts of the QPP.  CMS understands there are many changes and additions to the QPP from past programs and their development of “pick your pace” is their way of acknowledging that.  So, what do you have to do and how could it affect your 2019 payments?

  • Do nothing: expect a 4% negative payment adjustment
  • Test pace: submit something during the 2017 performance year and avoid a negative payment adjustment
  • Partial year: submit 90 days’ worth of data during the 2017 performance year and be eligible for a neutral or small positive payment adjustment
  • Full year: submit data for a full year during 2017 performance year and be eligible to earn a moderate positive payment adjustment

As always, ADVOCATE will keep you up to date on this and all issues impacting radiology as they become available.

Lauren Sloan, RD, LD, MHA
Process Improvement Specialist