MACRA Updates

CMA Responds to Proposed MACRA Regulations

On April 27, the Centers for Medicare and Medicaid Services (CMS) issued proposed regulations to implement the MACRA Medicare payment reform legislation.  CMA formed a large MACRA Technical Advisory Committee, Chaired by Larry DeGhetaldi, MD, with wide representation from physicians across the state in various specialties and modes of practice.  The TAC developed a comprehensive report with nearly 40 recommendations to respond to the regulations. The report was approved by the CMA Executive Committee because of the tight deadlines and on June 24, 2016, CMA submitted extensive comments to CMS.  CMA also worked closely with the AMA MACRA Task Force, comprised of the major state medical associations and national specialty societies, to develop a uniform response.  Below is a summary of CMA’s concerns and recommendations for improvement.  

CMA will be aggressively advocating before CMS to make the changes listed below, as well as the additional changes recommended by AMA and the national specialty societies, before the final rule is published in October-November 2016.  

In the CMA letter, President Steve Larson told CMS Administrator Andy Slavitt that CMA believes MACRA is an improvement over the existing SGR law (with its burdensome reporting programs, large penalties and no bonus payments), and that while CMS made substantial changes to reduce the Medicare reporting burdens, CMS did not go nearly far enough “to fix the outlandish administrative burdens in the Medicare program as required by MACRA” and the “promising Alternative Payment Model track has been all but amputated.”  CMA wants an end to the regulatory morass.


1. The accommodations for solo, small and rural practices are inadequate. 
2. The MIPS reporting programs continue to be unnecessarily burdensome and complex, particularly the EHR Advancing Care Information category. 
3. There is no accountability for EHR vendor compliance and interoperability.
4. The MIPS Resource Use category will continue to discourage physicians from treating high-risk, vulnerable patients.  
5. The Advanced Alternative Payment Models are limited and the financial risk requirements severely inhibit the expansion of innovative APMs.
6. The performance reporting period starts too soon -  January 1, 2017.


1. The accommodations for solo, small and rural practices are inadequate. CMA Recommended Improvements:
A. Significantly expand the permanent MIPS low-volume exemption for small practice physicians and physicians located in Health Professional Shortage Areas (HPSAs). It should be voluntary for physicians.  
B. Create an additional phase-in pathway for small and rural practices to transition to MIPS.  It would exempt the 40th percentile of all small and rural practices in each specialty in Year 1; the 30th percentile of all small and rural practices in each specialty in Year 2; the 20th percentile of all small and rural practices in each specialty in Year 3; and the 10th percentile of all small and rural practices in each specialty in Year 4.  This phase-in is voluntary and would provide more time for resource-limited small practices to prepare, finance new systems and upgrades, change workflow, and transition to MIPS.
C. Exclude the Dual Eligible Medicare-Medicaid beneficiaries from all MIPS measure calculations for at least Years 1-4. California physicians have a substantial dual-eligible patient caseload that will hinder their ability to be successful under MIPS.  In 2/3rds of California’s counties, more than 20% of Medicare beneficiaries are dual eligible.  In fifteen of the largest California counties, more than 30% of the Medicare population is dual eligible. This exclusion would help small practices avoid penalties for treating high-risk, low-income patients and will ultimately protect access to care for these vulnerable patients. 
D. Immediately Allow virtual groups to report on behalf of small and HPSA practices starting in Year 1.  Virtual groups could provide the infrastructure to help small practices successfully report and meet the MIPS standards.
E. Exempt small practices from MIPS penalties until CMS authorizes virtual groups.  

2. The four MIPS reporting programs (Quality, EHR-Advancing Care Information (ACI), Resource Use, and the Clinical Improvement Activities (CIA)) continue to be unnecessarily burdensome and complex. CMA Recommended Improvements: 

A. Reduce the scoring complexity. The four reporting programs need to be more unified, with similar scoring methods to reduce the complexity of the composite score calculation so physicians can understand it and plan for the future.
B. Allow physician groups to use the group’s sub-tax identification numbers based on the Medicare physician fee schedule area or the hospital payment area in which they provide care. 
C. Telehealth services should be treated the same as all other in-person services for purposes of calculating MIPS program requirements.
D. For the Quality Category: 
Further reduce the number of required quality measures.
Maintain the existing requirement to only report on 50% of a physician’s patients vs. the proposed 80-90% of patients.  
Eliminate the manual chart audits for the quality measures.
Ensure quality measure uniformity between the Medicare MIPS program and the Medicare Advantage program.  
E. For the EHR-Advancing Care Information Category (ACI): 
Physicians should be given partial credit for the Base Score which should automatically advance physicians to the Performance Score component.  
Reinstate the 90-day performance reporting period instead of the proposed 365-day period for at least Years 1 and 2.
Maintain all existing Meaningful Use Program exclusions and hardship exemptions and provide additional exemptions for physicians close to retirement, subject to cyber attack or experiencing vendor problems.
Eliminate the irrelevant Meaningful Use Stage 3 measures related to “coordination of care through patient engagement” and “health information exchange.”    
Reduce the number of required Clinical Improvement Activities and provide more credit for the key patient quality activities.

3. There is no accountability for EHR vendor compliance and interoperability. CMA Recommended Improvements:

A. Vendors must be held accountable for compliance and interoperability with stronger enforcement penalties.  
B. Certify only those EHRs with the ability to satisfy all MIPS measures requirements in its basic package, including the ability to securely interface with health information exchanges, registries and hospitals.
C. All software vendors should have a standardized implementation timeline for interoperability that is clearly outlined in a vendor’s contract with physicians. 
D. Interoperability should be a software vendor’s basic responsibility and there should be no additional cost to physicians for interoperability to either State or Regional Health Information Organizations (RHIOs).  
E. Remove the proposed Advancing Care Information (ACI) mandate for physicians to attest on data blocking.  This is a vendor responsibility.  Instead, CMS should institute a mandatory revocation of vendor certification for systems that are not interoperable.  
F. Physicians contracting with vendors that lose their certification should be made whole by those vendors and granted an automatic hardship exemption by CMS if  the system is not updated to compliance within 90 days.
G. Clarify that physicians do not need to develop EHR communication interfaces with patient electronic health monitoring devices, such as FitBit. 

4. The MIPS Resource Use category will continue to discourage physicians from treating high-risk, vulnerable patients. CMA Recommended Improvements:

A. A specific adjustment should be made for the number of Dual Eligible Medicare- Medicaid beneficiaries in a physician’s practice to protect physicians from penalties for treating these complex patients and to protect access to care for those most in need.  
B. Bonus points should be awarded to physicians treating a certain threshold of Medicare-Medicaid dual-eligible patients to ensure that physicians are not discouraged from treating fragile, costly, high-risk patients and to protect access to care. In 2/3rds of California’s counties, more than 20% of Medicare beneficiaries are dual eligible.
C. Eliminate the Medicare deductible for Medicare-Medicaid Dual Eligible beneficiaries who are not enrolled in health plans so physicians are not  disincented from caring for these patients.   
D. Vast methodology improvements should be made to the Resource Use category including better adjustment for 1) subspecialty physician expenditure comparisons, 2) geographic cost adjustment factors and 3) socioeconomic status of the patient (race, ethnicity, income, previous insurance coverage).  
E. The total per capita cost and the Medicare spending per beneficiary (MSPB) measures for individual physicians should be removed until better measures are developed.  The proposed episode groupers should be thoroughly pilot tested before being implemented.
F. Physicians within 1-2 standard deviations of the national average should be rewarded and the all-or-nothing component removed.

5. The Alternative Payment Models are limited and the financial risk requirements severely inhibit the expansion of innovative APMs.  CMA Recommended Improvements:

A. Multiple APM pathways should be provided so that more physician organizations can participate.  Track 1 Shared-Savings ACOs should be included.  
B. Physician APMs should only be at risk for costs they can control.  
C. Varying levels of financial risk should be established for different types of APMs:
Path 1:  1% total financial risk for a Part A and Part B expenditure benchmark.
Path 2: 2.5% total financial risk for a Part B expenditure benchmark.
Path 3:  Upside only Shared-Savings organizations. Shared-Savings risk includes start-up and administrative costs, and the 18-month waiting period for potential shared savings.
D. Alternatively, financial risk could be set at 2.5% of an APM’s Medicare Part B revenue vs. the proposed 4% of an APM’s total Medicare expenditures.  The percent can be increased for integrated physician-hospital APMs.
E. Medical Homes:  
No additional downside financial risk should be imposed on Medical Homes beyond the initial standard due to their rigorous regulatory requirements, high start-up costs, and the need to promote access to primary care. 
Eligibility should be expanded to specialty medical homes. 
The 50-clinician cap should be eliminated.
F. A Division of Financial Responsibility (DOFR) should be created for APMs modeled after the California health plan-medical group risk arrangements that exclude from the expenditure benchmark calculation the following services:  out-of-area emergency services, out-of-area urgent care services, pre-existing cancer conditions, cancer care, mental and behavioral health care services, burn cases, transplants, cases costing over $100,000 annually, and Medicare Part B and Part D prescription drug costs.
G. The APM Minimum Loss Ratio should be increased from 4% to 10% of the APM’s benchmark.  A reasonable MLR will help small APMs manage the substantial start-up and administrative costs that consume a large percentage of their budgets.  
H. Most important for California, the APM expenditure benchmarks must be set at the national mean of Medicare expenditures per beneficiary so that efficient physicians are not penalized  and discouraged from participating.  Otherwise, physician groups who have consistently provided high value care (high quality/ low spending), such as California’s medical groups, will not be able to participate in the APM track. The APM expenditure benchmark must include any current year inflation-related Medicare Physician Fee Schedule payment increases, such as the conversion factor, the geographic practice cost index (GPCI), and the CBSA hospital wage index updates.  
 I. The Advanced APM Comprehensive Primary Care Plus Initiative application deadlines need to be extended to allow California primary care physicians time to collaborate with the private payers to develop robust, multi-payer medical homes.
J. Multiple Physician-Focused Payment Models should be approved and expedited by the Technical Advisory Committee and CMS.

6. The performance reporting period starts too soon -  January 1, 2017 CMA Recommended Improvements
The performance reporting period should start on January 1, 2018 instead of January 1, 2017 to give all physicians, vendors, and registries time to prepare and update their systems since the final program requirements will not be published until October or November 2016. 

MACRA Education and Assistance for Physicians

CMA has created a MACRA Resource Center on the CMA website  
In addition to providing CMA information, it contains links to the CMS information, extensive AMA resources, including the STEPS Forward program, and additional resources provided by the national specialty societies, with information about their clinical data registries.  CMA hosted two webinars in early July about the implementation and the steps physicians can take now to be ready.  

CMA will continue to provide education, information, tools and resources, and assistance to help practices prepare for MACRA.   

CMA will continue our extensive regulatory and legislative advocacy to continue to improve MACRA for the practicing physician.  


While the MACRA regulations are not yet final, CMA is urging physicians to take steps now to  ease the transition for physician practices. Because some of the program requirements are likely to change, please watch for announcements and new educational materials from CMA, AMA and your specialty society this fall.  But most important, CMA is urging physicians to