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A Day at the Office: The MACRA-sized Headache—Part 1

Lundy, Douglas W. MD, MBA

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Clinical Orthopaedics and Related Research: September 2018 - Volume 476 - Issue 9 - p 1713-1714
doi: 10.1097/CORR.0000000000000418
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The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repealed the Medicare Sustainable Growth Rate for the Medicare Physician Fee Schedule and replaced it with the Quality Payment Program (QPP), which pays providers based on the quality, value, and results of the care they deliver [3]. Congress also gave the Centers for Medicare & Medicaid Services (CMS) the authority to incentivize or penalize physicians based on whether they comply with MACRA requirements. Noncompliant physicians will be assessed a 4% penalty on their reimbursements from CMS starting in 2019. The penalty increases to 5% in 2020, 7% in 2021, and 9% in 2022 [6]. The penalties for noncompliance are steep, but high-performing physicians can be eligible for incentive payments of the same amounts.

Physicians are eligible to participate in the QPP through two pathways: The Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (AAPMs). Briefly, MIPS streamlined three previous Medicare programs into one payment program. Under MIPS, CMS measures and scores (0 to 100) eligible physicians (participating either as an individual or part of a group) under four categories: Quality of care, cost of care, the use of electronic health records, and improvements in clinical practice [2, 4]. These scores, known as the MIPS Final Score, are used to determine future Medicare Part B payment adjustments [4]. The second track, AAPM, offers eligible physicians maximum payment incentives to provide high-quality cost-effective care. But CMS set a high bar to gain eligibility, and few providers (perhaps as low as 5% [1]) will be eligible for the AAPM track in 2019. Most orthopaedic surgeons cannot participate in the AAPM track since there just aren’t programs available for us to engage with yet.

Private-practicing physicians may think that large academic and hospital-based health systems can simply absorb the 4% penalty for noncompliance, but there are many healthcare systems that could not take this financial hit. If this is the case for hospital-based systems, then what about the private-practice doctors or surgical groups? Although the American Academy of Orthopaedic Surgeons (AAOS) and other medical organizations maintained extensive communication with orthopaedic surgeons, many physicians have yet to implement plans to comply with MACRA, and in all likelihood, their penalty is coming. Medicare uses data from our 2017 activities to determine whether we are incentivized or penalized in 2019. In other words, if you haven’t paid attention to MACRA, there is nothing you can do at this point to avoid a 4% penalty on your CMS collections next year. I would recommend the CMS website to learn more about MACRA, MIPS, and AAPMs (

CMS has tried to ease the pressure on private practicing physicians and groups in a number of different ways including decreasing the burden on groups with less than 15 members, raising the “low-volume” threshold, allowing small practices to form “virtual” groups, and permitting eligible clinicians to submit a hardship exemption from reporting information for one of the performance categories under MIPS (Promoting Interoperability) [5]. Nonetheless, we in private practice must determine whether the cost of implementing these changes outweighs the penalties. Is it even possible for compliant private practicing orthopaedic surgeons or practice groups to qualify for incentives given all of MACRA’s quality initiatives or will we be stuck working harder just to avoid penalties?

In 2016, our physician group discussed whether we should participate in the QPP and concluded that it was worth complying under the MIPS pathway. We determined that the most reasonable method to stay in compliance was by switching electronic medical record (EMR) systems. We strongly considered other methods to comply with MACRA including employing outside MACRA-reporting vendors, developing our own program to report our performance measures, and negotiating with our previous EMR vendor. In the final analysis, we believed that implementing a new EMR system that collects performance data and reports this information to CMS will likely mitigate any penalties and possibly help physicians gain an incentive payment. But our group had grown accustomed to our current EMR system and had doubts about abandoning it after 10 years. Despite these concerns, the “sell” to the clinical staff actually was easy: “Change EMR systems to one that reports MIPS data to CMS or stay with the one that we have and complete stacks of performance measures.” With the clinical staff on board, the nonclinical staff went along with the decision since they knew it was good for the entire group.

While the staff understood and agreed to the switch, implementing the change was a painstaking process; the clinical staff did not anticipate learning entirely new clinical workflows. But the switch has proved beneficial—all of the physicians, advanced practitioners, and therapists met the criteria at least at the minimal level to be compliant with MACRA for 2019. Based on our current projections, we will be compliant in 2020 as well, and a number of our physicians may qualify for a bonus under MACRA.

But for the private-practicing surgeon or surgical group, a number of questions remain: Is the trouble of manually collecting and submitting performance measures tolerable, or will you have to adopt an EMR that can handle this task for you? Is the expense and hassle of adopting a new EMR worth the cost of the penalty? What if the private payers decide to adopt this new system? How far behind will you be if you weren’t in the game already?

I will answer these questions in part two of this series, as well as examine what our group did well in implementing a new EMR system and what, looking back, we should have done differently.


1. Aledade . MACRA Part 1: What are advanced alternative payment models? Available at: Accessed June 28, 2018.
2. American Medical Association. 2018 MIPS strategic scoring guide. Available at: Accessed June 29, 2018.
3. Centers for Medicare & Medicaid Services. What’s MACRA? Available at: Accessed June 28, 2018.
4. Practice Fusion. What is MIPS? Available at: Accessed June 28, 2018.
5. Quality Payment Program. About hardship exceptions. Available at: Accessed July 2, 2018.
6. SA Ignite. 10 FAQS about 2018 MIPS. Available at: Accessed June 29, 2018.
© 2018 by the Association of Bone and Joint Surgeons