Why would an ACO care about MACRA?

An ACO Has one job. Make money for its providers.

That job involves two pots of money

The pot of money you signed up for is MSSP Shared Savings.  

The pot of money you inherited without being asked is MACRA Earnings - and it can be as great as, or even greater than, your MSSP savings.  Every year.   Even in years that MSSP shares losses.

Getting MACRA money is not automatic - it must be earned, consistently, across a broad population of disparate providers.  

Your ACO is the only entity with the relationships, influence and data to optimize the scores that put this money in your providers coffers.  

It is not good enough to hope that everyone does what they should. You need a program to optimize MACRA.   We have a comprehensive program that optimizes ACO's MACRA, so your providers prosper.  


your ACO is the steward over huge MACRA Dollars


You didn't ask for it. You didn't even agree to it. But you are fiscally responsible

MACRA came into law after ACOs came into existence.  Then, the MACRA regulations put ACOs explicitly in charge of Quality.  That was what you were already doing.  But PI is another large portion, and although each clinic is "responsible" for their own results, the ACO is where results are aggregated, and everyone shares in the same aggregation.   Member clinics look to the ACO  for a good overall PI / MIPS score, whether you asked for it or now.  

The dollars are as great as MSSP Shared Savings (or Losses)

Some years, ACOs don't have shared savings to distribute, but every year MACRA imposes penalty or reward.  And once MACRA hits full swing, the potential positive adjustments are +19% of Medicare receipts, and penalties -9%.  When you consider overall Part B Billings, MACRA can be bigger then Shared Savings or Losses, even in a good year for the ACO.  

No one other than you can manage it

Every clinic in the ACO is individually responsible for their own MIPS PI submissions.  But here's the thing.  Those submissions all roll up to an ACO score, and every clinic inherits the rolled up aggregate.  So a clinic that performs well can be dragged to a lower level by other ACO member clinics over which they have no control ... and with which they may not have any relationship at all.  

The ACO is the only entity with relationships across all clinics.  In fact, the clinics often expect that the ACO will help them out with MACRA (whether you have every promised to do so).  

You are tempted to (erroneously) claim that you don't have the ability to know

Because you don't create or submit MIPS PI data for your clinics, you have to ask for visibility.  But you might be surprised how willing providers are to share their data, if you are willing to help.  Especially once you explain that your influence with everyone else can make money for each of them.  

Providers don't hold you accountable (yet). But they will, eventually

MIPS scores have been an abstract concept, until this year.  But now, 2019 Medicare Payments start to reflect the results of MACRA work you did in 2017.  Envision, for a moment ... a cardiology group, billing $10M in Medicare.  Further envision that cardiology group as an excellent user of EHR technology, and having wonderful quality scores.  Finally, imagine that the overall ACO aggregate scores are less than what the cardiology group could have earned on its own.  Ato some point, those providers will look to the ACO for an explaination of why they earn less than they would have earned without you.  

You can turn it all to a huge provider relations (and financial) bonanza

A High-Performance Monthly MACRA program can show providers your level of compassion for their Medicare Revenues.  

If you dedicate the right resources, tools, and people to MACRA, you will earn provider gratitude, and assure that you don't lose providers, for reasons completely apart from your core mission.  You never asked to be responsible for MACRA, but your providers won't necessarily see it that way if things go wrong.  

ACO and MACRA in 2019

2019 will be different for ACO providers. What should we do ab out that?

2019 is harder for everyone under MACRA 

The basic relationship between MACRA / QPP and ACO has not changed as a result of 2019 regulations, but the relationship between ACOs and their clinics bears review.  Every provider needs to be on the newest version of their EHR, for "Stage 3" requirements.   2019 is more difficult because of tougher PI Scoring rules,  topped out Quality Measures, higher MIPS  thresholds, and the requirement for new EHR upgrades to Stage 3 measures.  

PI Scores reduced by 50 points across the board 

Changes in the PI scoring system means that providers who "maxed out" 2017 and 2018 with PI scores of 100 will only score 50 points.  Bringing those providers back up to snuff will require attention throughout 2019.  

Because the biggest MACRA impact on ACOs is for Promoting Interoperability (PI), and because PI scores will be cut in half compared to prior years, ACOs will need better tracking tools, more frequent interaction on PI (we like monthly), and an ability to understand MACRA's financial impacts in addition to tracking Shared Savings / Loss risk. 

ACO and MIPS Quality Measures

Everybody knows that ACOs follow a unique, CMS-defined process for calculating quality measures.  But we believe ACOs truly can measure Quality outside the CMS process, and do it often enough (even monthly), and with physician-level granularity to improve scores.  Take a look at our ACO CQM Improvement blog article for details. 

Two-sided Risk Arrangements don't eliminate MACRA

Over the next couple years, all ACOs will glide into two-sided risk arrangements as Advanced APMs, or be forced to unwind their overall operations.  Either scenario creates new MACRA challenges.  For example, even Advanced APMs are likely to have some providers "fall out" of the ACO as Partial Qualifying Participants (Partial QPs).  These Partial QPs are not required to file MIPS content, but in many cases will actually receive more MACRA reimbursement than the standard 5% earned by their Qualifying Provider (QP) colleagues.  

MIPS Data goes public for Physician Comparisons

The big hidden topic this  year will be the publication of MIPS performance scores on the Medicare Physician Compare site.  CMS has done a really incredible job with creating a tool that patients of all types (not just Medicare) can use to select a new provider.    For now, this is the only location where patients will use MIPS content (particularly CQM scores), but very soon MIPS scores will be published in a downloadable database.  Once that happens, we should expect most physician comparison  tools to incorporate the same content.  The upshot will be that a provider with a higher "performance" or "quality" score will appear more desirable, and may pick up patient flow from those providers with lower scores.

QPP Eligibillity Inquiry Site

ACOs register their TINs and providers  through mechanisms separate from QPP / MACRA reporting, and in some cases, not all providers registered to an ACO end up being eligible as MIPS APM (ACO) participants.  The workaround for ACO MACRA is to periodically check the QPP Eligibility Inquiry site to see how CMS sees your providers for MACRA purposes, and treat them accordingly.   Remember, this site is only refreshed by CMS for specific snapshot dates (generally August 31 and December 31).  The data is generally quite good, although we have found occasional errors, and keep track of site accuracy in a blog entry we update regularly. 

Also, since QPP inquiries tend to be one-at-a-time, we have built into MACRA Monitor the ability to conduct those inquiries efficiently, and automatically embed the results into MACRA Monitor so you can treat "exception" providers appropriately.  


ACO MACRA Success tied to regular monthly Activity


You can't optimize MACRA at Year End

Improving MACRA Metrics comes from a regular program, throughout the year.  We get started as soon as a full month's data is available, and follow a regimen of extract, report, analyze and plan and act for every month thereafter.