Health Policy

All About the Benjamins: What You Must Know About MACRA

MACRA is going to bring about change whether providers are ready for it or not.

The process in which health care providers and hospitals are reimbursed for the medical treatment of a patient is complex. It involves many parties, a lack of transparency, and an alphabet soup of letters (RVU, CMS, CPT, PQRS to name a few). To add to this complexity, a big change is in the works that is expected to have monumental effects on health care reimbursement.

The Medicare Access and CHIP Reauthorization Act, or MACRA, is a law passed on April 16, 2015, with the final ruling on Oct. 14, 2016. MACRA is set to transform the way health care providers are reimbursed for treating Medicare beneficiaries. It was passed separately from the Affordable Care and Patient Protection Act (“Obamacare”) and was done with bipartisan support, which means it is likely here to stay.

Out With the Old, In with the New

Medicare, a federal insurance program, is the largest insurer in the United States. MACRA has repealed the Sustainable Growth Rate, or SGR, which was the prior method that dictated physician service reimbursement for Medicare (remember hearing about the “doctor fix” every year?). As the replacement to the SGR, the Quality Payment Program (QPP) was created. Currently, Medicare is primarily a fee-for-service entity. Fee-for-service programs, a system in which providers are paid more for the more services they perform, are heavily criticized for a lack of incentive for decreasing costs and improving quality. The QPP aims to establish payment models that are based on quality measures. There will be two distinct models: Alternative Payment Method (APM) and Merit-Based Incentive Payment System (MIPS).

The Fine Print of the Law

The first portion of MACRA is straightforward: a 0.5% annual increase in all physician payments until 2019. However, complexity and rapid changes to payments follow in the remaining portions of the bill.

The payment system in which most providers are expected to qualify is the MIPS. At its core, it will add a performance-based adjustment to a fee-for-service payment model. It will be based on 4 performance categories: Quality, Resource Use, Clinical Practice Improvement Activities, and Advancing Care Information. Based on these measurements, bonuses and penalties on total annual Medicare payments will be assessed with a +/- 4% rate in 2019 up to a maximum adjustment of +/- 9% rate in 2022 and going forward. The annual increase in the physician fee schedule in this path will be 0.25% annually starting in 2026.

The APM model will provide an incentive payment for participating in an innovative payment model. An APM will be a payment model in which a provider or organization takes responsibility for patient care performance on cost and quality. These models can apply to a health population, a care episode, or a specific clinical condition. They will involve entities such as Accountable Care Organizations (ACOs). A much smaller portion of providers will fall into the APM model, but they will have access to more incentives — including an annual 5% bonus on Medicare payments from 2019-2024 and a 0.75% annual increase in physician fee schedule starting in 2026.

So When Does This Start?

It has already started! The first performance period began Jan. 1, 2017. Health care providers will be expected to begin reporting their outcomes data at some point between before Oct. 2, 2017, and those who do not will be penalized. Payments will be affected starting Jan. 1, 2019.

Does This Affect Emergency Medicine Providers?

Absolutely. There are some exceptions that will be excluded from the QPP, but it is very unlikely that any full-time ED provider will fall below these thresholds. Many details need to be figured out, including group vs. individual reporting and APM models for the ED. Regarding APMs, ACEP and the APM Task Force are working diligently to provide APM models for the ED going forward, but uncertainty ensues in the emergency medicine world with an unpredictable and varying patient population.

What Does This Mean Going Forward?

MACRA is going to bring about change whether providers are ready for it or not. A lot of details need to be resolved, but the largest insurer in the U.S. is now set to associate payments with quality. This will affect nearly every provider who participates in the care of Medicare beneficiaries, which means all of us. It is reasonable to expect this change to transform and involve private insurance payments in the future. It will be important for all of us to stay abreast of this and support the efforts of leaders in our field as they advocate for emergency medicine providers in this rapidly changing landscape.

Help for Data-Driven Reimbursement

As the policy climate evolves, with health care reimbursement increasingly dependent upon data-backed quality, the American College of Emergency Physicians is helping emergency physicians keep pace.

ACEP's Clinical Emergency Data Registry (CEDR) aims to improve public health, the health of individual patients, and the practices of the emergency physicians and APPs who are part of the registry. CEDR measures and verifies the high-quality practice of emergency physicians and their practice partners to facilitate fair payment to those physicians.

CEDR grew in 2016 to include more than 60 emergency departments, with nearly 3 million patient records now represented in the registry. The 2,500 physicians participating in CEDR last year have had their quality data successfully reported to CMS, not only protecting their revenue, but providing new insights into the quality of their patient care.

The 4 CEDR subcommittees (research, measures, education, and outreach) are driving key initiatives, including:

  • Developing a research infrastructure and protocols to allow researchers access to the de-identified CEDR database.

  • Working with the Quality and Patient Safety Committee, continuing to refine the CEDR measure set with EM-relevant reporting measures that can be used across all payers - one of the major advantages of a QCDR like CEDR in quality reporting to CMS.

  • Implementing MOC Part IV for our ABEM diplomates. That's correct — ABEM diplomates will be able to complete their MOC Part IV requirements right from their CEDR dashboard. We're about to begin beta testing, and you can look for this feature to roll out in late autumn this year.

After a 500% growth between 2015 and 2016, CEDR expects a similar growth pattern for 2017. With millions of patient visit records and 44 performance measures, CEDR will be able to provide quality metrics and share critical insights for improvements in operational, clinical, research, and education domains to improve quality of care and patient outcomes.


  1. MACRA: Delivery System Reform, Medicare Payment Reform. Center for Medicaid & Medicare Services website. Accessed on March 14, 2017.

  2. Quality Payment Program. Center for Medicaid & Medicare Services website. Accessed on March 14, 2017.

  3. MACRA Final Rule: CMS Strikes A Balance; Will Docs Hang On? Health Affairs Blog website. Accessed on March 12, 2017.