Healthcare Changes as a Result of MACRA

Since 2009, healthcare has been slowly evolving. Initially, there was a shift from paper records to EHR systems, which created the need for data capture and electronic copies of patients’ health records (Meaningful Use). Since then, the emphasis has shifted to interoperability, patient engagement, and health data exchange. To ensure better services for patients, the system is currently moving from free-grounded services to quality-grounded services. MACRA is the name given to this shift in healthcare. It is now up to providers to fully understand MACRA’s content and meaning. Aspects of the proposed rule show that it is vital that providers prepare and begin submitting data this year because it will be required next year because it will assist them to know which option works best for them, how the measures of quality will be weighted the initial year, and how their compensation will change with likely fines for not meeting the stated measures.

MACRA takes the place of the Sustainable Growth Rate (SGR) formula, which was greatly unsustainable (MACRA, 2016). Created in 1997, SGR was meant to limit increases in Medicare Part B costs and thus reducing payments to clinicians.It will be replacedwith a system, which seeks to prioritize quality over quantity. It also substitutes Medicare’s quality reporting programs for physicians with a Merit-Grounded Incentive Payment System commonly called (MIPS) (MACRA, 2017). There are several existing programs including the bundled payments, Accountable Care Organizations, and different value-grounded models for eligible practitioners and hospitals. These programs will continue running and their incentives or fines are unaffected by MACRA. Providers under MACRA will earn a yearly increase of 5 percent until 2019, a point at which they can select between two value-grounded payment tracks: Alterative Payment Models (APMs) or MIPS. There will still be Meaningful use in both tracks under MACRA.

Eligible clinicians affected by MIPS and APMs comprises of nurse practitioners, physicians and their assistants, certified RN anesthetists, and clinical nurse professionals (Brown, 2017). A review of selected elements of the suggested rule can assist clinicians to prepare for Advanced APMs and MIPS, which have already started this year 2017. Therefore, clinicians need to prepare for the changes. MIPS combines reporting under three prevailing Medicare programs Meaningful use of CEHRT, the Quality Reporting System of physicians (PQRS), and Value-grounded Modifier (VM) (Marron-Stearns, 2016). Four performance categories have replaced these three programs: resource use (previously (VM), quality (previously PQRS), advancing care data (previously the use of certified EHR to measure value and quantity of healthcare), and improvement activities of healthcare provision. Medicare will consider output data every qualified group or clinician practice has documented and establish a CPS (“Composite Performance Score”) of every qualified MIPS practitioner or team. The CPS runs from 0 -100 units, and the effect of every output list on the CPS will differ in different first years running the MIPS (Marron-Stearns, 2016).

Beginning 2017, several weights (categories) will apply i.e. Quality Measure Reporting (Fifty -50 %). Clinicians will be required to document on at least six parameters of MIPS quality, most of which are similar or almost similar to PQRS measures. According to Medicare, at least one of the parameters has to be regarded as “cross-cutting.” Crosscutting measures are those, which are widely considered as applying across several healthcare environments and qualified experts or team activities in several specialties (Brown, 2017).A noteworthy change to valuable reporting linked with using MIPS is the “all or nothing” requirement is no longer available as it was under the Meaningful Use and PQRS programs.

The other category of weighting is Advancement of Care Information (25 %). The idea isconsidered as a simple Meaningful Use type and is grounded on the ability of the medic to validate the application of valid (EHR) innovation on measures and objectives suggested under the new Stages 2 or 3of Meaningful Use this year and years later. However, this is dependent on if the qualified clinician used the 2015 or 2014EHR innovation. There is a substantialimportance on.Interoperability is important in enhancement practices of Clinical Practice (CPIAs)are weighted at 15 %. CPIAs encompass stretched hours of practice including other efforts, which enhance safety and care of patients. CMS will avail to the public a catalogue of high and medium classifiedCPIAs (Brown, 2017).The use of resources takes 10 %. Medi-care will optimize data claims and establish linked costs per appropriatepractitioner in Medicare A and B. Clinicians will not need to submit data. This category of performance is identical to Medicare’s VM-program, and data concerning expenses per clinician has been traced for numerous years. Nonetheless, this performance data remained confidential in the past.

MACRA will affect the clinician’s pay and compensation. Starting on January 1, 2019, a practitioner may earn a positive adjustment in payment with MIPS or a 5-% incentive payment with the data they submit between 1 January 2017 and 31 March 2018. The size of the clinician’s payment will vary depending on the quantity of data they deliver and their quality of results. The proportionate weighting of each category of performance could alter with in due course. For instance, using resources will rise to thirty percent of the CPS within several years and quality will drop to below 30 percent (MACRA, 2016). Upon the determination of an eligible practitioner’s or group’s score on composite performance, the measure will be compared to the MIPS data of performance established by CMS. A score of CPS above or below the output threshold will generate amodification in payment of -/+ 4 % (in 2019, grounded on output data recorded in 2017. Adjustment of the payment will raise it over the subsequent three years to -/+ 9 % (in 2022 and thereafter).

There are additional features of the proposed rule, which include testing for compliance with certification requirements for Health information technology. The Nationwide Coordinator’s office for Health Informatics would terminate or suspend the certification condition of HIT items, which are considered as failing below criteria. The impact of this on providers using the technology is a topic of debate for several groups (MACRA, 2017). Medicare is pursuing stakeholders’ input on this including other parts of the proposed rule, and their explanationsare anticipated later on this year.

Ultimately, providers will need to examine other considerations of the new rules. For instance, the issue of timelines given that the Advanced APM and the MIPS programs have already began this year. Stakeholders in healthcare with critical Medicare Part B patients will have to start preparations (Brown, 2017). The other considerations are influence on trivial activities given the necessity for healthcare to use skilled resources in attaining high EHR platform measures, which may challenge small group or solitary actions to succeed in the technical aspects linked with data documentation via EHRs. The other point to consider is the CPS influence and the influence of adjustment in payments on physicians wanting to admit Medicare clients.

Given the change in the present U.S. government and the repeal of sections of Obamacare, providers might assume that this will be wished away or not affect them. Notwithstanding, MACRA passedwith overwhelming support from the Congress on April 16, 2015. Both sides of the house supported the new policy owing to the rising Healthcare costs. Presently, the U.S. spends eighteen cents of each dollar on healthcare, and the number puts the country on course to be at 34 cents by 2040. The emphasis of quality over quantity by the new system ensures that physicians are paidfor doing that, which they already intend to do i.e. providing the best healthcare for their patients.

To sum up, it is critical for providers to understand MACRA to enable them to prepare and submit data this year. By understanding MACRA, clinicians and healthcare providers will know better the option that works best for them and how the quality measurements are weighted the first year. Understanding the policy will also make clinicians to know the trends their compensation will take with possible fines for not attaining the needed measures.Therefore, providers need to prepare by working on the measures they will be able to meet andto report data. A point to note is that the provider’s compensation and reimbursements will be change depending drastically depending on their performance or choice of not participating. MACRA is here to stay and will not be wished away. The provision of quality care to patients does not only give improved and ensuring health to the patient, but it also plays a part in ensuring low expenditures in healthcare.


Brown, B. (2017). The 7 Best Ways to Prepare for MACRA Today. Health Catalyst. Retrieved 26 January 2017, from

MACRA,. (2016). MACRA: MIPS & APMs – Centers for Medicare & Medicaid Services. Retrieved 26 January 2017, from

MACRA,. (2017). MACRA Frequently Asked Questions. Retrieved 26 January 2017, from

Marron-Stearns, M. (2016). MACRA, MIPS, and Advanced APMs: Time to Prepare | Journal of AHIMA. Journal of AHIMA. Retrieved 26 January 2017, from

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