Article Text


MACRA 2.5: the legislation moves forward
  1. Lauren Parks Golding1,
  2. Gregory N Nicola2,
  3. Sameer A Ansari3,
  4. Andrew B Rosenkrantz4,
  5. Ezequiel Silva III5,
  6. Laxmaiah Manchikanti6,7,
  7. Joshua A Hirsch8
  1. 1 Triad Radiology Associates PLLC, Winston-Salem, North Carolina, USA
  2. 2 Hackensack University Medical Center, Hackensack, New Jersey, USA
  3. 3 Radiology, Neurology, and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
  4. 4 Department of Radiology, New York University Langone Medical Center, New York, New York, USA
  5. 5 South Texas Radiology Group, San Antonio, Texas, USA
  6. 6 Pain Management Center of Paducah, Paducah, Kentucky, USA
  7. 7 Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, Kentucky, USA
  8. 8 NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
  1. Correspondence to Dr Joshua A Hirsch, NeuroEndovascular Program, Massachusetts General Hospital, Boston, MA 02114, USA; hirsch{at}


The Medicare and CHIP Reauthorization Act of 2015 remains the payment policy law of the land. 2017 was the first year in which performance reporting will tangibly impact future physician payments. The Centers for Medicare & Medicaid Services (CMS) considers 2017 and 2018 transitional years before full implementation in 2019. As such, 2018 increases the reporting requirements over 2017 in the form of a gradual phase-in while introducing several key changes and new elements. Indeed, it is the nature of the transition itself that led to the somewhat unique title of this manuscript, i.e., MACRA 2.5. Stakeholder feedback to the CMS regarding the program has ranged widely from the elimination of core components to expanding reporting to non-government payers. This article explores the potential impact on neurointerventional physicians.

  • economics
  • political

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In this article, we will briefly review the history of the legislation leading up to MACRA, then discuss in detail updates in the QPP most relevant to neurointerventional specialists. Our goal is to inform our readers about the myriad changes occurring in the sphere of payment policy, and to emphasize specific strategies that could be employed to optimize success in MIPS. The formal name for what is colloquially called Obamacare is the Patient Protection and Affordable Care Act (ACA).1 The name itself suggests two of the legislation’s core components: to increase quality and make care more affordable (ie, controlling healthcare costs).2 While people can debate the legislation’s effectiveness in improving quality and bending the cost curve, healthcare unquestionably continues to become more expensive in the United States.3–6

Specialty physicians including neurointerventionalists (NI) are most commonly paid through legacy Fee For Service (FFS) payment systems, such as the Resource Based Relative Value Scale (RBRVS). The currency of the RBRVS is the Relative Value Unit maintained by the AMA Multi-Specialty RVS Update Committee.7 8 NI physicians have thus played a part in determining appropriate compensation for the services they perform.9 10 Due to factors outside the control and influence of the neurointerventional specialty, the FFS environment is considered a root cause in the ongoing escalation of cost in US healthcare11 and thus a target in improving the economics of healthcare.

The ACA created the Center for Medicare and Medicaid Innovation (CMMI) to develop and test novel delivery system and payment models for improving healthcare quality while lowering costs.11 Among these models, NI were potentially most impacted by the Bundled Payment for Care Initiative and several Accountable Care Organization programs, both previously explored in JNIS.12 13 During this period of support for the transition of volume to value, the administration articulated its position through the Secretary of the Department of Health and Human Services that it anticipated significant changes to the traditional FFS system.14–16

Onto this backdrop, the Medicare Access and CHIP Reauthorization Act (MACRA) became law in April 2015.17 This bipartisan, bicameral legislation dramatically provided further steam for the effort to transform traditional FFS to a value-based agenda.18 19 MACRA defined two payment pathways; the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).20 21 In April 2016, CMS named the initiative the Quality Payment Program(QPP).22

The 2018 final rule

In November 2017, CMS released the 2018 Updates to the Quality Payment Programme Final Rule.23 Despite opposition from prominent organizations like the Medicare Payment Advisory Committee (MedPAC), the QPP continues to require that most Medicare payments to participants occur through one of two pathways: APM or MIPS.24 CMS expects the QPP to evolve over multiple years in order to achieve national goals of lowering cost and improving quality, and the 2018 rule is the next step in the staged approach implementing the program. Year 2 continues the gradual ramp-up of the QPP with policies aimed at encouraging successful participation in the program while reducing burden, reducing the number of clinicians required to participate, and preparing clinicians for the 2019 performance period. Per the abstract, given the plan for gradual transition, we have included the idea of a stutter step in the article’s title; MACRA 2.5.

Many themes emphasized in Year 1 of the QPP are continued and expanded on in Year 2, including provisions aimed at encouraging successful participation in the program while reducing burden particularly for small and rural practices. To this end, CMS extends additional flexibilities in Year 2 including: increasing the low-volume threshold to less than or equal to $90 000 in Medicare part B allowed charges or less than or equal to 200 Medicare Part B patients; adding a significant hardship exemption from the Advancing Care Information (ACI) performance category for MIPS eligible clinicians in small practices; and providing bonus points that are added to the final score of MIPS eligible clinicians in small practices. Hardship exceptions are also granted for participants in areas affected by natural disasters, ensuring these clinicians will not receive a negative payment adjustment in 2017. CMS lowered the minimum score awarded for quality measures not meeting data completeness criteria from three points to one point for 2018, except for small practices which will be awarded a three-point minimum for any submitted quality measure. Small practices are defined as practices consisting of 15 or fewer eligible clinicians: neurointerventional groups meeting this definition should be aware of these scoring advantages when developing a strategy for participation in MIPS. For example, as interventional stroke care for emergent large vessel occlusion has become the standard of care,25–28 the number of mechanical thrombectomies is expected to increase.29 30 It is to some extent likely that care will become more geographically distributed and the number of NI physicians practicing in non-tertiary care settings will increase.31

Acknowledging a need to support clinicians caring for more challenging patient populations, CMS implements a complex patient bonus that will be available in 2018. This bonus utilizes CMS’s Hierarchical Condition Categories (HCC) risk adjustment payment methodology and a score based on the percentage of dual eligible beneficiaries to determine the complexity of a provider’s patient population and awards up to five bonus points to a clinician or group’s final score. As a specialty that often provides services for complex patients, neurointerventional physicians should be diligent in diagnosis coding of beneficiaries to maximize eligibility for this bonus.32

Continuing the gradual transition into MIPS, CMS has increased the threshold score, the level at which negative and positive income adjustments occur. In performance year 2018, clinicians must earn 15 points across the three performance categories in order to avoid a penalty in the payment year 2020, increased from the three-point threshold in Year 1. The MACRA statute mandated that the performance threshold be set at either the median or mean performance score in 2019, which would have been a significant increase from 15 points. However, the Bipartisan Budget Act33 passed on February 9 2018 includes a provision that allows CMS to gradually increase the performance threshold over the next 3 years, reaching the mean or median by 2021. While this will make it easier for clinicians to avoid a negative payment adjustment in the coming years, the consequence is a much more limited bonus pool available for high performers.

For the 2018 performance period, clinicians will be required to submit data in the quality performance category for a full calendar year rather than a 90-day performance period as specified in Year 1. For the improvement activities and advancing care information performance categories, the performance period is unchanged at a minimum of a continuous 90-day period within the 2018 calendar year.


The most significant change in MIPS scoring for 2018 is the increase in weight of the Cost performance category from 0% in Year 1% to 10% in Year 2. Consequently, the final weight of each MIPS performance categories changes in Year 2 with Quality comprising 50%, Advancing Care Information 25%, and Improvement Activities 15% of the final MIPS score for patient-facing clinicians. CMS initially proposed a 0% wt for the Cost category in 2018, however in the 2018 final rule CMS expressed concern that maintaining a 0% wt for Cost may not provide a smooth enough transition for integrating cost measures into MIPS and may not provide enough motivation for clinicians to prepare for the 30% weighting of the Cost category required statutorily by MACRA in 2019. Interestingly, the recently passed Bipartisan Budget Act33 allows CMS to keep Cost weighted at 10% for an additional 3 years, through 2021.

For the 2018 MIPS performance period, score in the Cost category will be determined by two measures: the Total Per Capita Costs for all attributed beneficiaries measure; and the Medicare Spending per Beneficiary (MSPB) measure.23 CMS chose not to include the 10 episode-based measures that were proposed for the 2017 MIPS performance period, but will instead focus efforts on developing new episode-based measures with more significant clinician input.34 NI are well represented in that effort with one co-chairing a subcommittee and three others participating as members of various subcommittees.

Of the cost measures included in the 2018 MIPS score, MSPB is the most likely to be applicable to NI. An MSPB episode will be attributed to the clinician who provides the plurality of Medicare Part B services to a beneficiary during an index admission. For example, a patient treated for stroke or aneurysm could be attributed to the NI if the claims billed by that physician exceed those billed by other clinicians providing services for the patient during the admission period. Neurointerventional radiologists who also read diagnostic imaging studies could be attributed patients under MSPB, particularly in the emergency department setting.35 For example, multiple advanced imaging studies performed in a trauma or suspected stroke patient who is subsequently discharged may represent a plurality of billed services and result in attribution of this patient to the interpreting radiologist. MSPB will be applied to clinicians or groups who meet a threshold of 35 attributed beneficiaries. The number of attributed beneficiaries and performance on the measure in prior years under the Value Modifier program can be found on a group’s Quality and Resource Use Report (QRUR), and similar semiannual feedback reports will be provided for MIPS.

Benefits of using MSPB and TPCC to calculate a clinician’s score in the Cost category include their familiarity from the Value Modifier programand their broad, system-wide nature that encourages collaborative accountability for the cost of care. However, these measures have several shortcomings. The attribution methodology is complex. Critics assert that these measures do not differentiate between costs that clinicians can control from those that they cannot. In contrast, episode-based measures hold promise in promoting accountability for cost in a more reliable and impactful manner. Episode groups and measures that are directly relevant to NI are likely going to be developed going forward.

Benchmarks for cost measures are based on the concurrent performance year, which further hinders a clinician’s ability to predict performance in this category. While favorable performance on cost measures could positively impact a clinician’s MIPS score, familiarity with the measures, their applicability, and limitations will be important in optimizing performance in the QPP. These factors will be of increasing relevance as the contribution of Cost escalates from 10% to 30% in 2021.

Quality performance category

Policies for the Quality performance category remain similar for Year 2 of the program, other than an increase in the data completeness criteria from 50% to 60% for 2018 and 2019 performance years. This means that for 2018, groups reporting via qualified clinical data registry, qualified registry, or EHR must submit data on at least 60% of all patients that meet the measure’s denominator criteria, regardless of payer. Groups reporting via claims must submit data on at least 60% of their applicable Medicare Part B patients. CMS intends to increase this threshold progressively in future years, citing the importance of incorporating higher thresholds to ensure a more accurate assessment of clinician’s performance on the quality measures and to mitigate selection bias.

The 2018 rule also delineates a systematic approach to address topped-out quality measures, defined as measures on which a high percentage of clinicians submitting the specific measure performs at or very near the top of the distribution. Measures identified as topped-out will be subject to an achievement point cap of 7, though bonus points will still be available for topped-out measures that are high priority or reported using end-to-end electronic reporting. CMS established a 3- year timeline for identifying and removing persistently topped-out measures.23

Six highly topped-out measures were selected for 2018. Clinicians reporting these measures will receive a maximum of 7 achievement points for performing in the top decile. These include at least three measures that may apply to NI:

  • Perioperative Care: Selection of Prophylactic Antibiotic-First- or Second-generation cephalosporin (Quality Measure ID: 21).

  • Perioperative Care: Venous Thromboembolism Prophylaxis (Quality Measure ID: 23).

  • Optimizing Patient Exposure to Radiation: Utilization of a Standardized Nomenclature for CT Imaging Description (Measure ID: 359).

Improvement activities

Twenty-one new Improvement Activities were approved; otherwise no significant changes were finalized in this performance category for 2018. While the 2018 Medicare Physician Fee Schedule rule delayed the mandate to implement appropriate use criteria (AUC) until 2019, early adopters of AUC through a qualified clinical decision support mechanism will receive credit for a new improvement activity for the 2018 MIPs performance period. Of note, only ordering providers are eligible for this improvement activity.

Advancing care information

CMS allows a greater number of clinicians to gain exemption from the ACI category for the 2018 performance year.23 As mentioned above, small practices can claim a significant hardship exemption for the ACI category. Additionally, clinicians who furnish 75% or more of covered professional services in an ambulatory surgery center may choose to reweight the ACI category to 0%. Non-patient-facing clinicians will continue to be exempt from ACI as in 2018, and more radiologists will meet this definition since thoracentesis, paracentesis, myelogram, lumbar puncture, and joint injection codes were added to the list of patient-facing encounter codes for 2018. CMS expands the definition of the ACI-exempt hospital-based clinician to include services furnished in an off-campus outpatient hospital (Place of Service 19).

Also of relevance to the ACI category, clinicians will be allowed to continue the use of 2014 Edition Certified Electronic Health Record Technology (CEHRT) rather than be required to upgrade to 2015 Edition technology.36 A group or clinicians who do use 2015 edition technology will earn a one-time bonus of 10 percentage points in the ACI category for the 2018 performance period.

Alternative payment models

CMS estimates Advanced APM participants to double from 70 000 to 1 20 000 clinicians in Year 1 to 1 80 000 to 245,000 clinicians in Year 2, largely secondary to inclusion of the new Medicare Track 1+program as a qualifying APM and the reopening of applications for the Next Generation ACO program and Comprehensive Primary Care Plus (CPC+) program. Nonetheless, opportunities remain limited for specialists, including NI, to participate in Advanced APMs.37 The 2018-updated rule extends existing APM qualification criteria through the 2019 and 2020 performance years. Risk-based programs eligible for the APM track will still require a revenue-based nominal amount standard at 8% of the estimated average total Parts A and B revenue of eligible clinicians.23

The MACRA statute created two pathways to allow eligible clinicians to become qualified participants (QPs) in Advanced APMs. In the Medicare Option, available for all performance years, eligible clinicians achieve QP status exclusively based on participation in Advanced APMs within Medicare. The All-Payer Combination Option allows eligible clinicians to achieve QP status based on a combination of participation in Advanced APMs within Medicare and Other Payer Advanced APMs offered by other payers. The 2018 QPP rule establishes criteria for determining whether a payment arrangement qualifies as an Other Payer Advanced APM: however this option will not be available until the 2019 performance year.23

In January 2018, CMS announced Bundled Payments for Care Improvement Advanced (BPCI Advanced), a new voluntary episode payment model that utilizes retrospective bundled payments for 29 inpatient and three outpatient clinical episodes.37 BPCI Advanced will qualify as an Advanced APM and as such participants are expected to bear financial risk, utilize CEHRT, and perform well on quality measures. Of particular relevance to NI, stroke is one of the clinical episodes in BPCI Advanced.38 Neurointerventional physicians who predominantly treat stroke patients could achieve QP status through this APM, and others with more clinically diverse patient populations could combine BPCI participation with other APMs to cumulatively reach the QP threshold. Achieving QP status results in an automatic 5% bonus on all Medicare payments and exempts a clinician from MIPS. Ideally, the development of episode-based measures within the Cost category of MIPS will be aligned with the clinical episodes of BPCI Advanced, enabling NI and other clinicians to more accurately predict their performance in the APM.38

New areas

The 2018 rule addresses two important avenues for participation in MIPS that were not included in the first year of the program: the virtual group participation option and the option for facility-based reporting. MACRA establishes three general ways to participate in MIPS: as an individual; as a group; and as a virtual group. In the 2018 rule, CMS finalizes requirements for MIPS participation at the virtual group level. CMS defines a virtual group as a combination of MIPS-eligible solo practitioners and/or groups with 10 or fewer eligible clinicians. In the virtual group option, two or more of either of these types of practices can voluntarily come together as a group to participate in MIPS for a performance period. The 2018 rule does not specify any restrictions in terms of geography, specialty of the practices, or number of practices that can form a virtual group.23 Practices must elect to participate as a virtual group by December of the year prior to the performance year. Details of the virtual group participation option have been described in an earlier publication.39 Virtual group participants collectively measure performance and report in aggregate into the four performance categories of MIPS. The ability to coordinate resources and share responsibility across diverse groups could be advantageous for highly specialized clinicians such as NI. However, groups that choose to report within a virtual group will forfeit their small practice bonus if the virtual group exceeds 15 clinicians. Additionally, a NI that is a member of a radiology practice that is not accountable for Cost at the group level will become accountable for Cost by joining a virtual group if the combined attributed beneficiaries for the virtual group exceed 35. This particular circumstance would not likely occur for endovascular neurosurgeons or neurologists functioning within a group of their broader domain.

A second new reporting option discussed in the proposed rule for Year 2 of the QPP allows facility-based MIPS eligible clinicians to elect to use their institution’s performance rates as a proxy for the MIPS eligible clinician’s performance in the quality and cost performance categories. In the final rule, CMS were elected to delay implementation of the facility-based measurement option until 2019.23 Clinicians whose primary professional responsibilities are in a healthcare facility can elect to participate based on the performance of their associated hospital in the Hospital Value Based Purchasing Program (VBP). The VBP is an existing program under Medicare that provides adjustments to bundled payments based on facility-wide quality measures. There are currently 13 quality and efficiency measures defined under VBP. Under the facility-based measurement option, a facility’s scores in the VBP will be converted into MIPS Quality and Cost performance category scores based on percentile performance. MIPS eligible clinicians who elect facility-based measurement are not scored on other cost measures specified for the Cost performance category, even if they meet the case minimum for a cost measure. Facility-based clinicians may be eligible for a zero percent weighting for the ACI category according to the same exemptions available for non-facility clinicians. Improvement activity requirements and scoring likewise remain the same.

Facility-based measurement cannot be combined with other submission mechanisms, however CMS intends to allow a facility-based clinician to compare their expected MIPS performance category scores under the facility-based measurement option with their expected scores under the options available to all MIPS eligible clinicians and pick the higher of the two. Since higher performance category scores may result in a higher final score and a higher MIPS payment adjustment, this could provide a competitive advantage for facility-based clinicians relative to their non-facility based MIPS eligible peers.

Because there are no data submission requirements for the facility-based measures used to assess Quality and Cost performance categories, this option could reduce the reporting burden on facility-based MIPS eligible clinicians by leveraging existing quality data sources and value-based purchasing experiences. In addition, facility-based measurement may more closely align incentives between facilities and the MIPS eligible clinicians who provide services there. Allowing clinicians to choose the higher of their facility-based and MIPS scores offers more flexibility and potentially results in a higher MIPS score, but removes the advantage of the reduced reporting burden.

CMS defines a facility-based clinician as one who furnishes 75% or more of their services in either an inpatient hospital or emergency room, not inclusive of hospital outpatient centers. A facility-based group is defined as a group in which 75% or more of the MIPS eligible clinician NPIs billing under the group’s TIN are eligible for facility-based measurement as individuals. A subset of neurointerventional physicians will likely have the option to participate in facility-based measurement according to these criteria. While this reporting option will not be available until the 2019 performance year, NI should consider the potential advantages and prepare accordingly by continuing to collaborate with healthcare systems in reducing costs for conditions commonly managed by their expertise.

The neurovascular quality initiative

From the outset, the MACRA has allowed Qualified Clinical Data Registries (QCDR) to satisfy all the four elements in the Final Score except for cost.40 41 The Neurovascular Quality Initiative (NVQI) has been a focused effort that is under the auspices of the SNIS Patient Safety Organization. There are currently modules for intracranial aneurysms, AVMs, and acute ischemic stroke intervention with over 2700 cases thus far submitted. The NVQI is merging with the Neurosurgery Quality Outcomes Database which will greatly expand the scope by doubling the existing number of sites. In 2018, once that merger is complete, metrics will be submitted to CMS to obtain QCDR status. This affords NI specialists a good opportunity to score well on the quality portion of MIPS.


Year 2 of the QPP continues and expands on many of the flexibilities finalized in the 2017 ‘pick your pace’ year, in keeping with the goal of promoting high-value care and patient outcomes while minimizing the burden on eligible clinicians. Many of the policies in Year 2 represent expected gradual phase-in of program requirements, supporting clinicians’ transition to full implementation of the program. Key changes relevant to specialists who provide high-cost services in predominantly high-risk patients include the availability of a complex patient bonus and decision to assess performance in the Cost category. The most significant change in Year 2 for many clinicians is the inclusion of Cost as 10% of the MIPS final score in 2018. Uncertainties inherent to the existing cost measures and benchmark methodology warrant close attention as groups prepare to be scored in this category. Two new reporting options may provide opportunities for NI to optimize their performance in MIPS, the virtual group reporting option available in 2018 and the facility-based measurement option available in 2019. The inclusion of stroke as a clinical episode in BPCI Advanced is the first significant opportunity for many NI to participate and achieve QP status within an Advanced APM. Provisions of the Bipartisan Budget Act will make it easier to avoid a negative payment adjustment in MIPS at least for the next 3 years, but the lower performance threshold will result in limited bonus money available for high performers.

In order to maximize performance in MIPS and lay the groundwork for success in value-based care models, there are a few key take-aways for neurointerventional specialists based on 2018 updates to the QPP. First, all clinicians should be aware of the special considerations available in MIPS and take advantage of the exemptions and/or bonus points associated with these special considerations. NI specialists can check their participation status (including any special considerations such as non-patient facing, hospital-based, small or rural practice, etc.) on the CMS QPP website: NI specialists should study their group’s QRUR and soon-to-be-released feedback reports from CMS to determine whether they will be held accountable for cost, and start looking for ways to manage costs in their health systems and networks. Finally, NI specialists whose practices are ready to transition to risk-based payments should seek opportunities to participate in advanced APMs such as BPCI Advanced. By learning how to maximize reimbursement under MIPS while preparing for APM participation, NI should be well positioned for success in the future of value-based care.


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  • Contributors LPG and JAH wrote the original draft. All authors were given an opportunity to review and provide meaningful feedback in the creation of the final draft. All authors approved the final draft.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

  • Competing interests ABR and JAH are supported by Research Grants from the Harvey L Neiman Health Policy Institute.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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