On this episode of The #hcbiz Show! Don Lee and Shahid Shah interview CMS spokesperson Aisling McDonough. We discuss the MACRA final rule and the resources that CMS is making available to help clinicians transition to MACRA and MIPS.

The MACRA final rule has been released. This is real and it’s happening now. What should clinicians be thinking about? (1:08)

[Shahid Shah] Clinicians should think about what it would mean to their practice to lose 3-4% of their Medicare payments. If it’s not a big deal or they’re planning to retire soon then maybe it’s ok to sit on the sidelines. Otherwise, they should start looking at MIPS and the available Advanced Alternative Payment Models (APM) and see where they fit in.

What’s been the response to the MACRA Fina Rule? (4:00)

[McDonough] CMS is very happy with the response from the industry so far. They were able to listen to and incorporate feedback from stakeholders across the board from congress to clinicians.

CMS is  trying to do more in a broader, bigger movement within they’re organization. They’ve launched the Quality Payment Program (QPP) website, a call center and are accepting email questions. They are also conducting a social media blitz and Andy Slavitt appeared on the Politico’s Pulse Check podcast to discuss the MACRA final rule.

CMS also announced a new initiative to better connect with clinicians in the field. The initiative will be led by Dr. Shantanu Agrawal and intends to find out which regulations are holding up practices so that they can be streamlined. CMS wants to reduce the burden of their programs so that clinicians can get back to taking care of patients.

Medical Review Reduction (7:00)

[McDounough] CMS has launched an 18-month pilot program that will reduce medical review for certain physicians working in Advanced Alternative Payment Models (APMs). Medical review has been known to slow innovation attempts and getting it out of the way may lead to new opportunities for clinical transformation.

What are the major differences between the MACRA proposed rule and the final rule? 8:00

Specifically, what should small-to-medium sized practices care about?


  1. CMS raised the low volume threshold so that practices with fewer than 100 Medicare patients or that bill Medicare < $30K/year will be exempt from MIPS. They estimate that 50% of small practices and solo practitioners will be exempt from MIPS.
  2. CMS is providing $20 million/year for on the ground help to small practices. They will contract support organizations to put boots on the ground. The support organizations will visit practices and offer hands-on support for making the transition to MIPS.
  3. Pick your pace – This was announced early because CMS knew there was a lot of anxiety about 1/1/17 start date. Basically, if you’re ready to go on 1/1, then do it. Otherwise, you have until 10/2 to get started and can do a 90 day reporting period. Both ways make you eligible for the maximum MIPS bonus payment. If you’ve never done PQRS or MU and need some time to get ready, you can still avoid the penalty. Just pick a measure or improvement activity and report to CMS on it. You’ll only be penalized if you do nothing. McDonough added that, like with ICD-10, they’re telling people that it’s easier than you think. Also, they believe that gathering additional quality measure data will help inform clinical transformation going forward.

Will participating in MIPS actually improve clinical outcomes and patient satisfaction? (12:40)

[McDounough] MIPS pushes for and rewards Clinical Improvement Activities like Telehealth, keeping clinics open 24×7, providing 24×7 call lines, home visits, etc. Traditionally, these weren’t reimbursable under Fee-For-Service. Now you can get credit in MIPS and get paid for it. We’re paying for what people value: coordinated care, care that’s available, information exchange between patients and doctors and between doctors themslves..

McDonough also stressed that CMS went from 11 requirements to 5 for Advancing Care Information.

CMS is also rewarding clinicians for taking care of things that they should have already been doing like bolstering security in their EHRs. Data security is very important to patients.

CMS is trying to push for and reward clinicians for spending more time with patients and helping them get, share and understand their records and treatments.

3 really interesting things so far (16:15)

[Shahid Shah]

1. Not all activities will require medical review. This is a big deal.

2. There are some things that clinicians would like to do because they are the right things to do. Now there’s an opportunity to be paid for those activities.

3. You can get credit for doing things you’re already required to do (i.e. security) and that you could be fined for doing poorly by OCR.


Given these items, there may be opportunities worth exploring even if you are one of those clinicians who may be retiring, selling or merging.

More on improving clinical outcomes (18:00)

[McDonough] CMS doesn’t just make up quality measures. We work with specialty societies, individual physicians, the National Quality Forum (NQF), etc to build them with evidence behind them.

Also, she pointed out that the credits for telehealth, site visits, integrated behavioral health, etc were built based on feedback from actual clinicians about what they wanted for their practices. She encouraged clinicians to talk with CMS about what they need – get involved.

On getting involved (19:50)

[Shahid Shah] Sometimes clinicians feel like they don’t have a voice. CMS’ actions over the past several months show that they are actually listening. This is new and we need to take advantage of it. The industry must take the responsibility on its shoulders to get the right feedback to CMS. If we do that and they don’t take action, well, then we can complain. But until then, it’s on us. As a party looking at it from both sides, we strongly encourage clinicians to speak up.

Shahid also wondered how can the Health IT watch what’s going on in industry, roll it up and provide sentiment analysis back to governemnt.

User-driven policy (22:37)

[McDounough] CMS is working with US Digital Services (USDS) to generate user-driven policy. Yes, the final rule is over 2000 pages, but 70% of it are responses to the 4000+ comments CMS received.

How are Organizations being Selected for the $20M/year in MACRA technical support? (24:49)

[McDounough] CMS put out a Request for Proposal (RFP) for organizations to provide this support to practices. There were a huge number of applications and they are being reviewed. There should be an announcement on winners fairly soon.

The easiest way to get help is on the QPP site or email requests to qpp@cms.hhs.gov.  This support will be focused on rural practices, Healthworker Shortage Areas (HSAs) and on practices with < 16 clinicains.

What is the press missing about MACRA? (27:45)


  1. People think that MACRA is going to be some horrible, burdensome change. Compared to MU and PQRS, MACRA has half the requirements.
  2. People think positive payments have to come from somone else to keep MACRA budget neutral. This is a misnomer. CMS estimates $1 Billion in additional payments the first year with only $3oo Million in negative payments. The $1 billion comes from $500 million over 6 years from congress for exceptional performaers in MIPS, the 5% bonus to clinicians in APMs and the positive payment adjustmenst that clinicians will get from just being in MIPS.
  3. Lastly, CMS issued the MACRA final rule with a comment period. They’re looking for input. McDounough said, “We’re trying to get it right. Its a big change and we know it. We want to help people get there faster.”