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How to Prepare for MACRA

Washington, DC—On October 14, 2016, the Centers for Medicare & Medicaid Services (CMS) released its final rule implementing the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA),1 which was signed into law on April 16, 2015. The final rule marks the most significant reform to the US healthcare system since the enactment of the Affordable Care Act in 2010, providing Medicare incentives to reward quality and value—not volume—through the use of alternative payment models, such as accountable care organizations. At the 2016 Annual Meeting of the American College of Rheumatology (ACR), presenters discussed the implications of MACRA and what physicians and practice managers can do to ensure compliance with upcoming payment reforms.

“This legislation actually had bipartisan support, so unlike the Affordable Care Act, which has an uncertain fate at this point, I think MACRA is likely here to stay,” said Jinoos Yazdany, MD, MPH, Associate Professor of Medicine, University of California, San Francisco, and Chair, ACR Research and Publication Subcommittee, during a session titled, “Implementing Quality Measurement in Your Practice: How and Why.”2

According to Dr Yazdany, MACRA takes 3 existing programs for Quality Reporting (ie, The Physician Quality Reporting System, Value-Based Payment Modifier, and Medicare electronic health records incentive program) and streamlines them into the Merit-Based Incentive Payment System (MIPS).3

MIPS is reliant on the reporting of performance measures by qualified clinical data registries to the CMS, and on the Rheumatology Informatics System for Effectiveness (RISE) registry, which was developed as a qualified clinical data registry by the ACR.3-5

In addition, there is a second payment track under MACRA; namely, advanced alternate payment models.1 However, there was a focus on MIPS at the session, because very few examples exist of rheumatology practices that are going to partake in alternate payment models, which are better suited for larger practices, Dr Yazdany explained.2

The final rule has set a deadline of March 31, 2018, to report data to CMS, regardless of the amount of data being reported. In this first year of the program, the bar to avoid a penalty of a negative 4% adjustment in payment in MIPS will be very low, requiring the reporting of at least 1 quality measure or improvement activity.4

“Just engaging in this program in some way will avoid the penalty, but this will get less lenient,” Dr Yazdany cautioned.

During the same session, Alex Limanni, MD, a rheumatologist at Arthritis Centers of Texas, Dallas, discussed MIPS scores, which are based on a 100-point scale, and the outcome measures that govern them.2,3 The measures are categorized into 4 basic domains: quality improvement measures, advancing care information, clinical practice improvement activities, and quality resource use and utilization reporting.2,3

The focus of Dr Limanni’s presentation were the latter 2 outcome measures. The clinical practice improvement activities will account for 15% of the MIPS score3; currently, there is a menu of >90 activities in categories including patient satisfaction, patient access to care, and telehealth use.2,3 The quality resource and utilization reporting will eventually constitute 10% of the MIPS score, but does not contribute to the score in the first year.

“To put in a plug for RISE, if you are using a QCDR [qualified clinical data registry], you are getting points at almost every end of the MIPS system, both the meaningful use and quality as well as these kinds of CPIA [clinical practice improvement activities] activities,” Dr Limanni said.

An advantage to using RISE is the fact that it contains rheumatology-specific measures. For example, rheumatoid arthritis includes measures for disease activity, latent tuberculosis screening, functional status assessment, and the use of disease-modifying antirheumatic drugs.5


  1. Centers for Medicare & Medicaid Services. The quality payment program. October 25, 2016. www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-10-25.html. Accessed December 6, 2016.
  2. American College of Rheumatology. MACRA looks here to stay, so clinics need to be ready. November 15, 2016. www.acrdailynewslive.org/macra-looks-here-to-stay-so-clinics-need-to-be-ready. Accessed December 6, 2016.
  3. Centers for Medicare & Medicaid Services. Merit-based incentive payment system: clinical practice improvement activities performance category. www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/CPIA-Performance-Category-slide-deck.pdf. Accessed December 6, 2016.
  4. Department of Health & Human Services. What’s the quality payment program? https://qpp.cms.gov. Accessed December 6, 2016.
  5. American College of Rheumatology. RISE for practices. 2016. www.rheumatology.org/I-Am-A/Rheumatologist/Registries/RISE/RISE-for-Practices. Accessed December 6, 2016.

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