Medicare Access and CHIP Reauthorization Act (MACRA)

The Medicare Access and CHIP Reauthorization Act (MACRA) is designed to reward quality, rather than quantity, of care. This approach replaces the sustainable growth rate (SGR) formula that governed Medicare reimbursement in the past.

At the outset, it would appear to be a confusing topic, and many physicians have eschewed learning about it. However, Medicare payment is being tied to physician participation in this program. Although this only involves reimbursement from the Centers for Medicare and Medicaid Service (CMS) presently, private payers are predicted to follow suit going forward. Additionally, the move towards viewing physician work in terms of outcome-based measures and quality metrics will start to impact the medical system as it evolves. For these reasons, it is useful for all physicians, regardless of insurance participation, to learn about MACRA.

The use of quality metrics to base payment has been around for some time. The CMS’s Value Based Payment Modifier (VBPM), Physician Quality Reporting System (PQRS) and EHR Meaningful Use are all such programs that have been utilized in the past. MACRA simply moves this concept forward, combines the programs, and does away with VBPM, PQRS, and Meaningful Use.

The MACRA program was implemented in 2017, and the level of your participation now will determine your reimbursement in 2019. This underscores the timeliness to register to participate by the end of September 2017. This will allow a 90-day window to report and avoid a penalty.

If you currently use an electronic health records system, reporting should be easy as most companies have been upgrading their systems to facilitate compliance with MACRA.

Some of the MACRA highlights for 2017:

  • CMS’s inclusion of a “pick-your-pace” policy that gives physicians the choice as to how fast they proceed. This includes an optional 90-day reporting period in 2017.
  • If a practice participates in the Merit-based Incentive Payment System (MIPS) for any period in 2017, no penalty will be assessed in 2019.
  • All physicians who participate in Medicare Part B will receive a positive 0.5 percent payment update for services provided in 2017.

Physicians should plan to participate in 2017 -- even if only by reporting on one measure or improvement activity. Failure to participate will result in a 4 percent negative adjustment in Medicare Part B payments 2019.

Physicians are exempt from MIPS requirements if they fall below the low volume threshold, are in their first year of Medicare participation or participate above prescribed thresholds in an Advanced Alternative Payment Model. Physicians who fully participate in an Advanced Alternative Payment Model in 2017 will receive a five percent bonus on their Medicare Part B payments in 2019.

For DOs who practice NMM/OMM, as well as many specialty practices, meeting the metrics can be challenging as many of the quality metrics are based on primary care models. However, with some creativity, there are ways to achieve success. For example, addressing smoking, depression screening, medication reconciliation, obesity screening and management are some of the metrics that could be incorporated into a pain-based OMM practice that would satisfy the requirements.

It behooves all osteopathic physicians to become educated about this trend regardless of reimbursement model or practice specialty. It appears for now that MACRA, and the turn towards quality-based performance review. is the direction of the future of medicine.


American Osteopathic Association
American College of Osteopathic Family Physicians
American Medical Association
Centers for Medicare and Medicaid Services