Caradigm Solutions for MACRA

Tailored Solutions for Medicare Access and CHIP Reauthorization Act of 2015

What is MACRA?

On April 16, 2015, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law changing the healthcare financing system in the most significant way since Medicare’s inception in 1965. MACRA determines reimbursement for physicians receiving Medicare Part B payments.

MACRA goes into effect January 1, 2017 impacting clinicians and hospital networks.

  • Repeals the Sustainable Growth Rate (SGR)
  • Replaces Meaningful Use (MU), Physician Quality Reporting System (PQRS), and value-based payment modifier reporting with Merit-Based Incentive Payment System (MIPS) reporting
  • Rewards participation in advanced Alternative Payment Models (APMs) and attainment of quality and performance metrics.



Medicare Part B clinicians

affected by Medicare


MACRA has two major pathways

CMS’ Quality Payment Program has two pathways: 1) Merit-Based Incentive Payment System (MIPS), which represents the majority of providers for performance year (PY) 2017, and 2) the advanced Alternative Payment Model (APM) path. All providers should prepare to submit MIPS reporting because they won’t find out if they qualify for the advanced APM exemption until after PY2017.

The MIPS track replaces the reporting required under the Physician Quality Reporting System (PQRS), the value-based modifier (VM), and Meaningful Use. It includes activities from CMS Innovation Models as a new reporting category.

MIPS relies on a composite score composed of four categories:

  • Quality – An adaptation of the PQRS model, this category forms the bulk of the MIPS score in PY2017: 60%. Providers report on six measures, from a set of roughly 200, one of which must be an outcomes measure.
  • Improvement Activities – CMS incentivizes activities related to CMS Innovation Models, non-eligible Alternative Payment Models, population health, and beneficiary engagement. Providers must attest to engaging in these activities for at least 90 days to qualify for this category. It comprises 15% of the PY2017 score.
  • Advancing Care Information – Formerly Meaningful Use, this category mandates the use of health IT products certified to at least the 2015 criteria. It holds constant over the MACRA performance years at 25% of the MIPS score.
  • Cost – An adaptation of the value-based modifier, CMS will compute Cost from adjudicated claims beginning in PY2018. There is no data submission requirement.

Providers can pick the pace of participation in 2017 (According to CMS)

A Holistic Approach to MACRA

MACRA should be viewed holistically as part of your organization’s overall value-based strategy because it’s closely linked to your participation in other value-based initiatives. You will need to succeed not only with the Quality Payment Program, but also as an ACO, in bundled payments, with patient centered medical homes, etc. As participation in advanced APMs—taking on two-sided risk—becomes inevitable you will need tools to operationalize population health and maximize financial performance in the short-term (e.g. earn MIPS bonuses) while keeping an eye on the future. In the long term, you will likely be managing much larger patient populations and could have the majority of your revenue tied to value-based reimbursements.

Some key questions to think about are:

  1. Where are there synergies between requirements in MACRA and your current value-based programs? (e.g. MSSP ACO, bundled payments, CPC+)?
  2. How will you establish an efficient data collection process in 2017 that can scale as you manage larger populations in the future?
  3. How can you create a flexible analytics infrastructure that can deliver fast time to value and pivot with future regulatory changes?
  4. How can you more efficiently manage patient populations so you can earn bonuses and shared savings today while ensuring success with two-sided risk and larger populations in the future?

How can Caradigm help me achieve my MACRA goals?


Start with data collection in 2017

2017 is a transition year for the MACRA program. Individual physicians and groups have the opportunity to submit partial data in order to avoid a negative adjustment or to obtain a small positive adjustment. This is the opportunity to enhance your organization’s data collection and reporting practices that can serve you in all of your value-based activities going forward. In more complex environments with a high volume of disparate data sources, this step is vital for your ability to report efficiently when you are ready to attest for MIPS.

If choosing a faster pace

If your organization chooses a faster pace by submitting either partial data (i.e. 90 days of 2017 data) or a full year of data, you will need more advanced measurement capabilities. If your 2017 goal is to test a few quality measures to evaluate where you will do well, Caradigm has a large library of MIPS measures as well as measures from other sets (ACO, HEDIS, STARs) that you can choose to measure your performance. If your organization is interested in the advanced APM track, Caradigm can support computation of advanced APM measures, such as those required for Comprehensive Primary Care+, the Oncology Care Model, and ACO Tracks 2-3.

Begin improving the management of patient populations

Improving the management of patient populations is a central part of all value-based initiatives, including MIPS, where Improvement Activities is a category for which providers will have to attest. This requirement will grow over time as organizations scale their programs and manage larger and larger patient populations. Building capabilities in areas such as care coordination, risk stratification, and patient engagement is a strategic investment because these capabilities will not only help you attest for MIPS, they can help you improve outcomes, lower costs and deliver ROI in all of your managed patient populations (e.g. Medicare, Medicaid, self-insured, commercial).

Caradigm’s enterprise solution suite can help you build a powerful and flexible population health infrastructure to meet your MACRA needs as well as the broader needs of a value-based strategy. Your organization can begin with the solutions that make sense for you today and add integrated applications as requirements increase and evolve over time.