Medicare P4P Quality

What is MACRA?

MACRA is the Medicare Access & CHIP Reauthorization Act, also know colloquially as the ‘permanent doc fix’.  Although MACRA is know for repealing the Sustainable Growth Rate (SGR) provisions that would have significantly cut physicians salaries (but was reversed every December), there are other provisions.

Although physicians may take comfort in avoiding the year end doc fix looming this year, more and more of Medicare physician’s payment will be tied to performance. As I reported back in April, the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Models are two ways that physician payments will change. The NCQA 2015 State of Health Care Quality report provides some additional details.


MIPS payments will be adjusted by 4 percent of clinicians’ total Medicare payments in 2019; adjustments increase to plus or minus 9 percent by 2021.MACRA’s second track, Alternative Payment Models (APM), may sound familiar. At the beginning of 2015 and before MACRA passed, HHS announced its intention to havealternative payment models covering 30 percent of Medicare fees by 2016 and 50 percent by 2018. At the same time, a coalition of private insurers, providers, purchasers and consumers announced a similar goal for 75 percent of payments by 2020.

The MIPS program rates providers along four dimensions: clinical quality, resource use, health IT meaningful use and clinical practice improvement activities (CPIA).  Note that certain types of providers (e.g., patient centered medical homes (PCMH) and patient-centered specialty practices (PCSP) automatically qualify for CPIA status. NCQA expands.

Under MACRA, practices can propose APMs to CMS that accept two-sided financial risk and use electronic health records and quality measures.Clinicians in Medicare-approved APMs receive bonuses totaling 5 percent of their Medicare pay—substantial incentive to develop systems that have a greater ability to improve quality. Practices in Medicare PCMH demonstration programs shown to improve quality and reduce costs qualify as APMs and are eligible for the bonus. Other PCMH and PCSP practices are natural platforms for building additional APM proposals.


What other MACRA provisions are there besides MIPS, APM and the repeal of the SGR?  MACRA also has a number of other quality improvement initiatives.

In 2016, Medicare is required to develop a plan to fill gaps in measurement and align measurement across payers…To help clinicians make the overdue transition to value-based pay, in 2018 Medicare is required to start giving clinicians information on care their patients receive from other providers and suppliers… MACRA also requires Medicare to give clinicians feedback on their performance compared with local and national benchmarks.

One thing is for certain, change is coming.



  1. another way for the government to not pay physicians for their work. we are actually the ones that are doing all the work. the goals become so unreachable for most practices that many docs, perhaps even this one, will be opting out of medicare. access to care will suffer and many patients will not be able to get in to see their physicians. gov’t does not know how to fix this problem. want to cut costs, start with tort reform. you cant have a healthcare system without doctors.

  2. When the Federal Government gets involved in any social services, medical, or educational program, the quality and outcomes decline. The push by the Federal Government, as well as the commercial insurance carriers, to eliminate the private health provider has taken longer than they anticipated, but at some point, a private practice, be it solo or group, will not be financially sustainable. Timely access to care will diminish, corporate and government-based healthcare will continue to increase, and the public will increasingly miss the Doctor-Patient relationship. As one looks over the landscape of Federal overreach and over-involvement in healthcare, it begs the question: What has anyone gained from all of this?

  3. I believe you are correct – this is another way for the government to get their hands on medical field. Doctors go to school forever, have loans and work hard. I am so against this. Why be a doctor government has taken the professionalism out of medical care. Doctors deserve to receive their salaries just like congress and government officials -except doctors are not crooks. Our government is an embarrassment.
    Government had no business getting involved. They destroy everything they touch and take the money and run. When is enough enough.

  4. It is all doctors fault they should never agree to any thing like this in the 1st place. All these things are making fool of doctors like signing with date and time when all this is there on a dictated report
    They put pitfalls in your way to deny payment

  5. The medical industry would do well if it was to control its own functional and financial destiny rather than allow governmental entities to try and regulate it for its own nonaltuistic purposes. Unfortunately physicians have not done a good job nor have they understood the business of medicine thus the public health concerns that the government has under its purview has metastasize to envelop all areas of medicine. Cost containment being the ruse or excuse, and may be considered valid, is now the prime motivation. It isn’t that the government wants physician to earn what they deserve, the government wants to decide what physicians deserve. Unlike other businesses where it is not acceptable for the government to determine payment and price for services, at least in a free society, it should not be acceptable for the gov’t to do this but “the train has already left the station”. Quality is always a goal and payment may be allocated based on quality of care delivered but outcomes and quality are not always linked fairly. Well this SGR was not useful and it has been abolished but let’s hope that this new surrogate is not a poor replacement.

  6. The government and our president lied about us…we purposely/wrongly cut off feet and pulled out tonsils only to make a lot of money. They lied about the number of uninsured to create a sense of urgency. They lied about the nature of Obamacare and healthcare reform. Our medical societies failed to protect us from this assault. . The government and insurance companies want all of our authority and none of our responsibility. And we rolled over because we can’t unite; indeed doctors are so overwhelmed with patient care, documentation, Mocs, phone calls, denial follow ups , and making sure payment is made, etc. that we failed to lead or even follow these changes closely.
    And the rules will continue to come down from Washington DC, justifying hundreds of bureaucratic jobs, and keeping us off balance in order to deny payment.

  7. They can and will continue to control us by replacing us with FMG’s, FNP’s, and DO’s etc. Until we get control over who can provide Healthcare and Tort Reform we will continue to lose these battles/decisions. The public has been duped into accepting lower quality and trained caregivers to the point they aren’t even realizing it anymore. The “Medical Societies ” are bought off or just don’t care. We must learn to speak as a common voice to the right people. Luckily I’m closer to retirement than starting a practice. I wouldn’t or couldn’t continue on the declining path for too much longer and never encourage young people into being MD’s any longer, including my own kids. The Govt pays the aforementioned groups just about as much now so hardly worth it to go the full way.

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