MACRA: Why It Matters for Your Practice and How You Can Save Money with Integrated Technology

By Seth Halpern

While patients and providers monitor the news for potential changes to healthcare in Washington, there is another piece of legislation that they need to be aware of, that has been passed by Congress already, MACRA . (No, it has nothing to do with Macroeconomics or your Apple computer, at least not directly. For more on that stay tuned for our post on Telehealth.) While the biggest changes under the ACA were made to private insurance, MACRA which stands for the Medicare and Children’s Health Insurance Program (CHIP) Reauthorization Act is intended to have a big impact on how physicians who care for Medicare beneficiaries are reimbursed. If you’re a physician who accepts Medicare or a Medicare recipient, understanding what MACRA is and how it will affect you in the coming months and years is critical. For those interested in understanding the full context of MACRA and how our healthcare system is inefficient and spends too much money, I’d recommend reading this policy brief produced by HealthAffairs.

Basically, if you are a physician who sees over 100 Medicare patients a year and charge the Center for Medicaid and Medicare Services (CMS) at least $30,000 for seeing those patients and performing services, you will be affected by the MACRA law. Though the American Medical Association (AMA) estimates that 30% of the nation’s physicians will be excluded from this minimum requirement, all physicians should be aware of the changes as they will likely be required to participate in the future.

Well what is MACRA?

MACRA is designed to help re-invent our healthcare system by incentivizing physicians to provide quality care that can be recorded, tracked and analyzed by patients, providers, insurers and Medicare. Before the ACA and MACRA, physicians could perform hundreds of procedures under a fee-for-service (FFS) landscape, where they would be paid for each service regardless of whether the patient received quality care or had an improved outcome. While many physicians will still operate under FFS, the new system tries to ensure that patient outcomes are prioritized and thus ties quality to payments.

The gist of the law is that if your practice focuses on participation in quality care, resource use, clinical practice improvement activities, and advancing care information by meeting certain benchmarks, you will be rewarded with an increase in reimbursement.

So why is this so complicated and how do you know if you’re meeting these benchmarks?

While MACRA was passed by Congress in 2015, physicians who meet the minimum qualifications as mentioned above will have until around the end of 2017 to start meeting the standards of care and Electronic Health Record (EHR) requirements of which they will be assessed and first be reimbursed in 2019. Because CMS and policymakers understand that not all physicians have the same access and resources to easily implement these changes, they created two paths doctors can choose. These two tracks are a part of the Quality Payment Program (QPP) that promotes “high quality and efficient care” not only for Medicare recipients but all patients in a clinical practice and include the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). Though there are many overlaps and similarities between the two programs, most physicians will begin by participating in MIPS.

What is the difference between MIPS and APMs?

MIPS is the program that will give physicians a score of 1–100 based on their participation and performance in four fields: quality, resource use, clinical practice improvement activities and advancing care information. While these are pretty vague, CMS has several priorities including improving the ability to “emphasize the therapeutic relationships between the clinician, patient, and family caregiver while recognizing personal and family choice and individual goals for treatment” as well as “address patient experience, care coordination, and appropriate use (e.g., overuse and underuse of clinical procedures).” As 2017 is a transition year into the new structure, CMS wants physicians to try and report quality measures that will be published in the Federal Register for a minimum of 90-days. There are certain benchmarks that are required if you are to receive increased reimbursement, but in order to not receive a negative reimbursement of 4% physicians are required to submit at least one measurement. To eventually force physicians to comply with these new standards, non-participation will result in a negative adjustment of 5% in 2020, 7% in 2021 and 9% in 2022. Don’t worry, compliance and proper reporting will lead to adjustments of the same percentages in the opposite, positive direction as well.

Alternative Payment Models are designed for practices already meeting these higher standards of care at better value for patients. These practices are likely a part of Accountable Care Organizations (ACOs) which are similar to traditional Health Maintenance Organizations (HMOs) in that they provide coordinated care for a specific population, in this case Medicare recipients. ACOs include group practices and hospitals but must serve at least 5000 Medicare patients. MACRA creates new subsets of APMs, called advanced APMs which have varying levels of risk and rewards for physicians based on different patient conditions. For example, one advanced APM is designed for providers that treat End-Stage Renal Disease by incentivizing better care-coordination. Participation in advanced APMs entitles physicians to receive 5% bonus.

Ok. I don’t want to be negatively affected, what do I do now?

While you technically do not need to have an EHR to comply with MACRA requirements, it is encouraged in order to provide patients coordinated care while reducing the burden of manually tracking and calculating quality measures. Twenty-five percent of a provider’s MIPS score will be from how they advance care information, which requires the use of electronic systems. Many providers in underserved and rural areas will qualify for technical assistance to help with the transition. Improvements providers may be required to perform include: providing patients electronic access to their health records, sharing health information with other physicians, and reporting public health information.

We at Ori believe integrated health systems are critical to improving the healthcare experience both for patients and providers. Increased reporting requirements may initially seem burdensome for providers and may lead to the perception that they cannot treat patients as well. It is our hope that with the proper technologies including artificial intelligence (AI), scheduling appointments, sharing electronic health records across platforms, and diagnosing diseases more efficiently will save both time and money.


Ensuring patients get the right care with the right provider is an error-prone, laborious process in medicine. enables scalable, AI-powered connectivity to help practices acquire and triage new/existing patients and then route them into the most appropriate, cost-effective care setting.

Ori is best described as an AI-powered care navigator in patients’ pockets. Because Ori integrates with the majority of electronic medical record systems in the U.S., staff members do not have to lift a finger or learn a new system. Interested in learning more? Contact today.

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