MACRA Creates More Problems than It Cures?

On June 20, 2017, the Centers for Medicare and Medicaid Services (CMS) finally posted the 2018 Quality Payment Program (QPP) Proposed Rule established through the Medicare Access and CHIP Reauthorization Act (MACRA). The two tracks for Medicare physician payment established by the QPP are the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

The first year (2017), according to the release, is meant to be a transition year, but CMS now says 2018 will continue the slow ramp-up of the payment reform to encourage clinician participation.

According the American Law Review, some of the key proposed policies include:


  • Implementing virtual groups
  • Increasing the low-volume threshold to less than or equal to $90,000 in Medicare Part B allowed charges (from $30,000) or less than or equal to 200 Medicare Part B patients (from 100 patients)
  • Continuing to allow the use of 2014 Edition of CEHRT (Certified Electronic Health Record Technology), while encouraging the use of 2015 edition of CEHRT
  • Adding bonus points for caring for complex patients or using 2015 Edition CEHRT exclusively.

Advanced APMs

  • Extending the revenue-based nominal amount standard, which was previously finalized through performance year 2018 for two additional years
  • Changing the nominal standard for Medical Home Models so that the minimum required amount of total risk increases more slowly
  • Giving more detail about how the All-Payer Combination Option will be implemented
  • Giving more detail on how eligible clinicians participating in selected APMs will be assessed under the APM scoring standard

Healthcare Dive notes that the proposal will exclude about 134,000 clinicians from MIPS. Additionally, the site reported that the rule means more physicians can delay MACRA implementation; especially important for small and rural providers who have said they lack capital and resources make complying with the reporting requirements.

MACRA eliminates the sustainable growth formula, of course, and replaces it with a .5 percent annual rate increase through 2019. After that, physicians need to move to one of two QPP mentioned above. After exclusions, CMS estimates 36 percent of clinicians will be eligible for participation in 2018.

In a statement provided by American Medical Association president, David Barbe, praised the news: “Not all physicians and their practices were ready to make the leap, and many faced daunting challenges. This flexible approach will give physicians more options to participate in MACRA and takes into consideration the diversity of medical practices throughout the country.”

Additionally, CMS Administrator Seema Verma said in a statement, “We’ve heard the concerns that too many quality programs, technology requirements and measures get between the doctor and the patient. That’s why we’re taking a hard look at reducing burdens. By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork. CMS will continue to listen and take actionable steps toward alleviating burdens and improving health outcomes for all Americans that we serve.”

Playing into that hand, Walker Ray, MD and Tim Norbeck wrote in a piece for Forbes in June 2017 (before this rule was released) saying that the increased time physicians are having to devote to non-clinical issues has been recognized as a major factor in the epidemic of physician burnout and it’s likely that the reporting requirements under MIPS will only compound the problem.

“These types of activities also have the demoralizing effect of eroding physicians’ clinical autonomy while at the same time putting more pressure on their clinical accountability,” the authors wrote. “With the added administrative burden and economic uncertainty MACRA will place on already overwhelmed physicians, the cure MACRA provided to repeal the sustainable growth rate may in fact have more negative consequences – potentially contributing to the ever decreasing number of physicians in independent practices.”

Scott Rupp's picture

Scott Rupp


Scott E. Rupp is a writer and an award-winning journalist focused on healthcare technology. He has worked as a public relations executive for a major electronic health record/practice management vendor, and he currently manages his own agency, millerrupp. In addition to writing for a variety of publications, Scott also offers his insights on healthcare technology and its leaders on his site, Electronic Health Reporter.

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