Eligible clinicians must participate in one of two tracks of what is called the Quality Payment Program.

One is the default Merit-based Incentive Payment System, or MIPS, which ties payment bonuses or penalties of up to 9 percent to performance on quality, cost, clinical practice improvement activities and the use of electronic health records.

The second more advanced track is through Alternative Payment Models, or APMs, in which clinicians participating in payment models meeting certain criteria can receive a 5 percent bonus until 2025.

American Hospital Association analysts Akin Demehin, director of policy, and Melissa Myers, senior associate director of policy, provided five high-level takeaways from the MACRA final rule that CEOs should know.

  1. Though the QPP will start in 2017, clinicians will be able to “pick their pace” of implementation in the first year. CMS adopted a number of policy changes intended to provide clinicians more flexibility in avoiding payment penalties and meeting QPP requirements. For example, instead of requiring the reporting of a full year of MIPS data during CY 2017, CMS will only require clinicians to report data from any continuous 90-day period in 2017. In addition, CMS will not score participating clinicians on the cost and resource performance in the first year of the program due to concerns about the readiness of the measures.
  2. There remain few advanced APMs that qualify for bonuses in the first year, but CMS is considering more options for future years. CMS’s final criteria for advanced APMs exclude many models in which hospitals are participating, such as Track 1 of the Medicare Shared Savings Program, because they do not require downside risk. However, CMS has signaled its interest in offering an additional APM — called Track 1+ — that includes downside risk and would qualify for APM bonuses. CMS will provide more details soon. Additionally, CMS plans to add the Comprehensive Care for Joint Replacement and proposed cardiac bundled payment models to the advanced APM track. Less than 10 percent of clinicians will qualify.
  3. The more MIPS data clinicians report in the first year, the better their chances of receiving positive payment adjustments. Eligible clinicians can get by with reporting only some data — for example, one quality measure or one clinical practice improvement activity — and avoid receiving a payment penalty. However, clinicians reporting more than the minimum amount of data will increase their chances of receiving a positive payment adjustment. Clinicians who meet or exceed the reporting requirements in all MIPS categories will have the best chance of receiving a positive payment adjustment.
  4. Fewer clinicians than expected will be required to participate in MIPS in the first year. CMS modified several policies in a way that reduces the number of clinicians required to participate in the MIPS in the first year. For example, CMS raised the volume threshold below which clinicians are NOT required to participate in the MIPS. In the first year, clinicians billing $30,000 or less in Medicare charges, or that see 100 or fewer Medicare patients, will not be required to participate in the MIPS. This change resulted in 380,000 fewer clinicians being required to participate in the MIPS.
  5. Expectations for participation will ramp up over time. CMS has indicated that it views the first year of the QPP as a “transition” period during which clinicians will become accustomed to the QPP requirements. The agency intends to require more clinicians to participate in the future, and to raise participation requirements (e.g., requiring a full year of data to be reported, rather than just 90 days' worth).

For more details on the MACRA, visit AHA.org/MACRA.