Home Advocacy Comment Letters & Resources MACRA and Quality Payment Program

MACRA and Quality Payment Program

In 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) eliminated the much-maligned sustainable growth rate (SGR) payment formula for Medicare and replaced it with the Quality Payment Program, which includes two paths for physician reimbursement: the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). There are two types of APMs: Advanced and non-Advanced.

Under MIPS, payment adjustments for the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier (VM), and the Medicare and Medicaid Electronic Health Record (EHR) Incentive Program ended, but key components of these programs were consolidated and carried forward into MIPS. There are four distinct areas of the MIPS of which providers should be aware:

  • Quality Reporting (replaced the Physician Quality Reporting System, or PQRS)
  • Improvement Activities (a new category)
  • Promoting Interoperability (formerly Advancing Care Information; replaced Meaningful Use)
  • Cost (replaced Resource Use)

In 2021, the MIPS program will make up to positive or negative 7 percent adjustments to a physician’s payment based on a composite score of their performance in 2019 across these four performance categories.

Merit-Based Incentive Payment SystemClick to Expand

In contrast, physicians who qualify to participate in an Advanced APM are exempt from MIPS and are eligible for a five percent lump sum bonus payment on Medicare Part B services from 2019 – 2024, and will receive higher annual increases in their payments starting in 2026 and onward. Participants in an Advanced APM must take on more than nominal risk (or be part of a medical home), report quality measures comparable to those adopted under MIPS, and use certified EHR technology. Only risk-bearing ACOs, patient-centered medical homes, and certain bundled payment models qualify as Advanced APMs. Physicians participating in non-Advanced APMs are subject to MIPS and are ineligible for the five percent lump sum bonus payment.

Quality Payment Program Resources




Background on MACRA



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