Monthly MACRA - blueprint for 2019

Why do Macra monthly?

Because 2019 is different from prior years

MACRA Matters More Now - MACRA dollars are getting bigger each year.  In 2017, top-performing providers earned around 2.2% of Medicare payments.  For 2018, those numbers will be up a bit, as higher performance thresholds drive more providers into penalties - and each penalty in 2018 is worth 5%, rather than the 3% allowed in 2017.  For 2019, both performance thresholds, and penalty/reward percentages increase further.  

Getting into the habit of greater rigor prepares providers for 2020 and beyond, when CMS takes off the training wheels, and implements performance thresholds that will explicitly impose penalties on half of the providers in the country.  For good performers, this is very good news, as it creates a much larger pool of money to distribute.  

Monthly MACRA evaluates performance early enough to to remediate shortfalls and improve scores.  Better scores improve financial results, for sure.  But PI and CQM also drive clinical change.  And timely change shifts "box-checking" exercises at year end, to true improvement.  

2019 has distractions that require explicit programs that create focus.  During 2019 a lot of providers will switch to new, 2015 Certified EHR for Stage 3 requirements.  We all know that big conversions divert resources and consume corporate attention.   A formal MACRA Roadmap will reserve time for improving metrics. And of course, improving metrics is why we implement new systems, isn't it?  Monthly MACRA will enhance implementation, while optimizing Medicare revenues.  


Because past performance is no indication of future results ...

MACRA has been easier by design, so far

CMS created the first few seasons under "transitional rules", designed explicitly to assure high performance and high compliance.  Quite honestly, to this point very few providers have had to do much to "Optimize" MACRA, and performance exceeded CMS expectations.  

Groups of 16 or more providers knocked the ball out of the park in the first two years.  After all, MACRA is not new.  We already knew Meaningful Use and PQRS. As a result, 99% scored well enough to earn money, and 72% achieved “Exceptional Performance".    You can download CMS's report on results to check out your niche. 

But what if MACRA were not such a piece of cake?  How would you go about keeping ahead of the competition?   Transitional rules are being eased out - at the end of which everyone below average gets penalized (up to 9%), and those penalties are spread across those above average, based on their scores.  Once transitional rules are completely gone, top earners can get up to 19% of Medicare Billings.  

2019 emerges from transition to maturity

 2019 still falls under temporary rules, but 2019 is harder than prior years, for three reasons: 

  1. Everyone must follow Stage 3 EHR requirements;
  2. PI scoring rules eliminates the automatic 50 point “base” value (i.e., PI score of 98 in 2018 would translate to 48 for this reason alone); and
  3. Quality Measure scores get reduced to 7 points, on many popular measures marked  as "topped out".  

Bottom line is, in 2019, expect your 2019 MIPS scores to be lower than 2017 and 2018.  Sustaining prior year scores won’t happen without extra effort throughout all of 2019.  

But that's not all.  This year, MIPS is positioned to have a greater financial impact with higher thresholds that could drive more providers into paying penalties, that can be allocated to those with higher scores.  Then, in the second quarter,  MIPS scores will start to impact new patient flow, as well. Physician Compare content from MIPS will change the way patients seek doctors.  

Finally,  Turmoil among ACOs could change the MACRA landscape among providers.  At the end of 2018, 13% of Medicare ACOs departed the program.  In 2019, new regulations transition ACOs to higher levels of risk sharing. The National Association of ACOs (NAACOS) predicts that many more ACOs will elect to close their doors rather than accept this new risk. 


what is a high-performance monthly macra program?

For standalone groups of 100 or fewer providers, it should be enough to run reports from your EHR monthly, post them to a standalone MACRA database for performance analysis, and discuss shortfalls against targets. 

For complex multi-TIN organizations, including ACOs, Monthly MACRA needs a bit more:

  • Monthly MACRA Blueprint - that communicates an organizational vision for why MACRA is important, what activities drive success to what calendar events, and what resource exist. 
  • Monthly MACRA Program  - to lay out expected infrastructure of reporting, collaboration groups, benchmarks and targets.  
  • Physician Contracts with MACRA provisions - because the impact of today's MACRA activity does not translate into revenue (or penalty) until two years into the future, provider / TIN contracts may need to set expectations for current year behavior,  and identify consequences for non-compliance.  
  • Sophisticated Program Analytics  - raw MACRA scores don’t mean a lot to executive management or providers.  By adding financial impact, we create a clear frame of reference. Once CMS publishes Physician Compare content, the MACRA team should  study the impact of public scores on the flow of new patients.   
  • Dedicated MACRA Concierge staff - MACRA is a complicated beast, and it is not reasonable to expect that everyone stay up-to-speed.  Since failure to act on MACRA regulations can be costly, each organization needs at least one person with the expertise, time and resources (including access to external expertise) to sustain insights.  

Using these principles, we suggest the following set of Monthly MACRA activities.


Month-by-month macra activity



 Program kick off - set schedule, commit participants, clarify objectives  


All participants register for QPP ListServ 

Validate 2019 claims against 2017 reporting.



 First data analysis for PI and CQM.  Establish targets, budgets and baseline performance 


Identify any targeted CQMs that are Topped Out for 2019, and find alternatives. 

Reconcile 12/31/2018 QPP checkpoint with EHR EC lists.  Correct  PECOS so that the August, 2019 checkpoint has enough claims to register. 



 Monthly measurement against baselines, and prior period  

 Finalize Directed Review requests of providers whose “finalized” CMS scores differ from internally projected scores.  



 Monthly measurement against baselines, and prior period  .



Monthly measurement against baselines, and prior period.    Kick off SRA

 Initial analysis of public data on Physician Compare.  Identify strengths and weaknesses and begin setting strategies to protect or enhance patient flow.  



 Monthly measurement against baselines, and prior period  

 Review draft of 2020 Proposed Rule for QPP (and ACO where necessary). 



 Monthly measurement against baselines, and prior period  

 Review second QPP snapshot of ECs.  Flag special cases (non-patient facing, Rural/HPSA, Partial QP) for scoring and financial projection. 



 Monthly measurement against baselines, and prior period.   Finalize SRA

Send  budget for  MACRA financial projections to CFO.

 Summarize findings from review of 2020 Proposed (or final, if available) Rule to identify any required internal action.  



 Monthly measurement against baselines, and prior period. 

 Verify with ACO that CQMs will be filed completely and timely.  

January - February 2020


 Data Submission.  Target of January 15.   No reason to miss early submission, if you've been doing Monthly MACRA all year long ! 

 Review QPP submission response. 

monthly macra tools and templates

Kick off the program!


 We have drafted a powerpoint deck as an outline for the initial meeting of the year.  The Concierge should use it for a 45 minute presentation on schedule, participants, activities and regulations.  At the end, participants should know why Monthly MACRA is important, and have a vision of what it entails 

Monthly Data Analytics


 In our MACRA Monitor subscriptions, the Concierge drives Monthly activity .  Our Concierge coordinates clinics analyzing each into monthly meeting powerpoint template. Clinic-level staff runs reports from EHR and issues an Action Item for the Concierge to load and analyze new data.  

Payment Validation Template


 With 2019 underway, the MACRA team should begin to analyze incoming claims payments.  Claims should be validated against each provider’s 2017 financial adjustment percentage. Report any discrepancies to CMS, and track recoupment of shortfalls that occurred prior to CMS correcting ongoing claims. Your MACRA database should help by maintaining a status log for each provider, to check that each gets reviewed. 

QPP / PECOS / EHR Reconciliation


 CMS refreshes data in the QPP Provider Eligibility system at  “snapshot” dates.  The dates of greatest interest will be September 30 of 2018, and September 30 of 2019. QPP Eligibility is based on claims history, so these snapshots are not available until 2-4 months, after the snapshot date. 

The bad news is that  each provider in your network needs reconciling.  CMS generates spreadsheets for some providers, but we have found the QPP Provider Eligibility tool to be the most current, and easiest to use. 

CQM Improvement Template


 We can’t optimize CQMs if we wait until year-end to analyze them.  A Monthly MACRA program will collect CQM data from each individual provider throughout the year.  Each month, provider results are rolled up to TIN-level scores, while allowing the MACRA team to analyze the best measures overall, and at the provider level. 

Using this monthly data will help analyze group-level targets, and for each measure, seek out those providers with “best practices” that result in highest scores, so that MACRA / Quality Leadership can share those practices across the rest of the provider team.  

Physician Compare Tools



By June of 2019, CMS is obligated by Congress to publish MIPS scores for individual and group providers, in a “patient-friendly” format.  You can get a preview of how this will look and work on an informative video on the CMS website.  The video is about 5 minutes long, explaining to Medicare patients how they can find new physicians.  At minute 2.00 in the video, CMS shows the role of Quality and other Performance data.  You will see where Medicare patients (or any other patients, for that matter), will be able to use quantitative MIPS scores to compare the “performance” of one physician against another. 

even ACO's need monthly macra

And there's no good reason why not ...

 Providers in ACOs need MACRA too.  Things break down differently between Advanced APMs (Level E, and Enhanced level), and MIPS APMs (Levels A,B, C, and D ).  CMS provides good descriptions of these  models on their website, and the National Association of ACOs (NAACOS) has organized a comprehensive guide for the overlap between ACO and MACRA.  Based on these regulations, ACOs can benefit provider groups with reduced data submission and aggregated group scores across a broad community of providers.  

There is no real reason to wait for year end to "do MACRA".  All it takes is some reporting from your EHR, presented and analyzed in a useful way.  Even in an  ACO, MACRA Revenues are as significant as are MSSP Shared Savings, so it just makes sense to incorporate MACRA into an overall  provider relations program, regardless of whether your clinic is standalone, part of a large IDN, or even part of an ACO.   

With a little creative thinking, ACOs can even measure MIPS CQMs monthly.  See our blog entry for more details.