CMS released the MACRA final rule last week and the industry response seems positive so far. They made good on their promise to consider stakeholder feedback and they addressed many of the concerns that were voiced over the proposed rule. Most notably, they’ve provided relief for small practices and injected flexibility that allows all physicians to ease into the new MACRA/ MIPS model. There’s a myriad of great resources and articles that explain those changes in detail and I won’t duplicate them here (check out HealthcareDIVE’s summary; it’s clear and concise). Instead, I’m going to share a few off-the-beaten-path observations I had while reading the CMS’ 24-page Executive Summary.

1: The MACRA language is very patient-centered

Federal regulations are complex and technical and they tend to be communicated in a complex and technical way. The underlying intent gets lost in the weeds and we forget what we’re actually trying to accomplish. That’s not what I found in the MACRA Executive Summary. The word “patient” appears 46 times in the 24-page document and we see comments like this throughout:

“By driving significant changes in how care is delivered to make the health care system more responsive to patients and families, we believe the Quality Payment Program supports eligible clinicians in improving the health of their patients”


“The bedrock of the Quality Payment Program is high-quality, patient-centered care followed by useful feedback, in a continuous cycle of improvement.”

Whether or not you agree with the law or the final rule, it’s clear that policy-makers kept the underlying intent of the law in the front of their minds while finalizing the rule.

2: CMS repeatedly commits to keeping the dialogue open with providers

Andy Slavitt and the rest of the CMS team were very aggressive in soliciting feedback throughout the proposed rule comment period. They tweeted, blogged, hosted town hall sessions and webinars, appeared on radio shows and more. I appreciated these efforts throughout the process and I’m glad to see that they took action on a lot of what they heard. Throughout the executive summary, CMS repeatedly commits to keeping this dialogue open in the years to come. One can only hope that their aggressive pursuit of feedback will set a precedent that is followed by future administrations.

3: MACRA will be an iterative process

I’ve commented many times that CMS is acting like a trillion dollar startup. They continuously try new things and tweak models as they go through the Innovations Center and other initiatives. This can create big headaches for an industry used to moving very, very slowly. It can also make it difficult to know what’s really working and what’s not since these things take a long time to play out. That said, given the alternative of slow and methodical versus fast with some risk, I’ll take the latter every day of the week. This mentality is definitely visible in MACRA. For example:

Public commenters requested that the advancing care information performance category allow for reporting on “use cases” such as the use of CEHRT to manage referrals and consultations (“closing the referral loop”) and other practice-based activities for which CEHRT is used as part of the typical workflow. This is an area we intend to explore in future rulemaking, but we did not finalize any such policies in this rule. However, for the 2017 transition year, we will award bonus points for improvement activities that utilize CEHRT and for reporting to a public health or clinical data registry, reflecting the belief that the advancing care information performance category should align with the other performance categories to achieve the unified goal of quality improvement.

That’s a “Minimum Viable Product” or “MVP”-mentality. CMS likes the idea and plans to do something about it. Rather than wait and do something someday, they’re just taking a crack at it by granting bonus points. You know what happens next? Some innovative doctors will try some things out and report them for bonus consideration. Many won’t pan out, but a few will. Those successes give CMS real-world use cases to model future policy off of instead of just guessing (educated guesses are still guesses). There’s very little downside to trying this and no patients will be put at risk. This is a safe way to innovate and I hope we continue to see this tactic.

5: Go at your own pace, but… GO!

Many have applauded the “go at your own pace” flexibility that has been added to the final rule. I think it’s a great move, but it will spell trouble for those that think it’s ok to take their foot off the gas. If you’re a physician, then you should be aiming to participate as much as you possibly can in year 1 and use partial participation as a parachute. Your downside risk will only be protected for 1 or 2 years without full participation. IT projects and workflow changes will take a long time and 1-2 years will go by quickly.

Also, you should never aim for minimal compliance for 2 reasons:

  1. You don’t want to wait for CMS to tell you how you’re doing. If you’re underperforming on a measure in 2017, but don’t find out until Q2 2018 then you won’t have the problem fixed until 2019 at best. You want to know about the problem early in 2017 so that you can address it right away.  Take action now to ensure that you have constant visibility into the performance of your practice against your quality measures(and more).
  2. The market is shifting. It will be imperative for physicians to demonstrate the value they bring to their partners and communities. That means innovating in your workflows, collaborating with other providers and community-based organizations and showing them all that you’re the type of provider they want to work with. Don’t wait for anyone else to demonstrate your worth. They probably won’t and even if they do, you can do it better. The physicians who master this will drastically out-perform their peers in the coming years.

6: Go at your own pace may limit upside to full participants

MACRA must be revenue neutral. If doctors elect to just “try it out” they won’t be penalized in year 1. If way more doctors do this instead of not participating at all then there won’t be a ton of penalties to offset the bonuses for those that participate at the higher levels. Would that create a scenario where bonuses needed to be reduced?

7: That $100M in technical support may be more than it sounds like

At first, $100 Million over 5 years for technical support seemed like a drop in the bucket given the scope of MACRA. However, the new low volume threshold ($30,000 in Medicare Part B charges or 100 Medicare patients) immediately excludes about 1/3 of America’s clinicians from participating in MIPS (380,000 clinicians).  Then take away the 200,000 clinicians that are not one of the eligible types for the transition year and another 120,000 that might be in APMs.That leaves less than half of the U.S. clinicians to participate in MIPS. Out of those that remain, the $100 million in technical assistance will be available only to small practices, rural practices and practices in Health Professional Shortage areas (HPSAs). Now that $100 million is starting to sound like it could help a lot of the practices that need it most.

8: CMS has gone way out of their way to make MACRA consumable

I’ve focused on the executive summary here, but CMS really has gone out of their way to put together a bunch of useful resources for the industry. A few examples:

  1. The Quality Payment Program (QPP) Website – It’s nice to look at, flows well and conveys a ton of info in a clear way.
  2. The Quality Payment Program (QPP) Executive Summary – Most of us will never read or understand the full 2,205-page final rule (including comments and feedback) and that’s ok. You can read this slowly and digest it in an hour or so. I think everyone in the business should make that time investment.
  3. The Technical Support Fact Sheet – Lists several places small practices can go for assistance with MACRA
  4. Quality Payment Program (QPP) Webinar – October 26h at 2-3pm EST – Register here.

Join us for a conversation on the MACRA Final Rule

On Wednesday, October 19 we welcome CMS Spokesperson Aisling McDonough to the show. We’ll talk about the resources that CMS has made available to help clinicians understand and participate in MACRA, what we can expect down the road and where else you can go for help. We’ll also touch on the concept of Virtual Reporting Groups, ACO Tracck 1+ and more.

Livestream Video 12:00 – 12:30 PM EST

You can subscribe here, or watch the live stream below.

Tweetchat 12:30 – 1:00 PM EST

Immediately after the livestream we’ll jump into this week’s tweetchat. We’ll ask 3 questions in 30-minutes:

Q1: What were the best changes CMS made to #MACRA with the final rule?

Q2: What were CMS’ biggest misses in the #MACRA final rule? What should have been changed and wasn’t?

Q3: What would you like to see CMS do to support clinicians in #MACRA as we approach 1/1/2017 and beyond?

Follow the #hcbiz hashtag on Twitter or use an app like to join the conversation