Mastering MACRA: What My Pain Management Practice Should Know

By: Mitch Evans

Reading Time: 4 minutes

Last Friday, CMS released the final rules for MACRA, a program that represents a fundamental shift to the way providers are reimbursed by Medicare.  The rule is designed to give physicians more flexibility to provide high quality, safe, and effective care.  But, it’s important to know that the rule can impact your income both positively or negatively.

You’ve got just over 2 months before it goes into effect (January 1, 2017), and if you’re anything like 82% of physicians who responded to a recent Deloitte survey, you have either never heard of it or only recognize its name.

It’s important to understand that MACRA has 2 tracks:

  • Advanced Alternative Payment Models (APMs)
  • Merit-Based Incentive Payment Systems (MIPS)

The vast majority of physician practices will start in the MIPS track since APMs require certain pre-conditions that you may not be ready for. If you’re considering MACRA for the first time, we’ll assume you’re in this group. Fortunately, there’s some flexibility built into the MIPS track for 2017.

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For 2017 MIPS participants can take one of several paths:

  • Don’t Participate (don’t send any 2017 data), and receive a -4% payment adjustment
  • Test (send a minimal amount of 2017 data), and avoid a negative payment adjustment
  • Partial (send 90 days of 2017 data), and receive a small positive payment or no adjustment
  • Full (send a full year of 2017 data), and receive up to a 4% payment adjustment

Regardless of the MIPS path, 2017 performance data is due March 31, 2018 and payment adjustments will go into effect January 1, 2019.



Payment adjustments expand from +4% of Medicare payments in 2019 to +9% in 2022 and beyond.  As you can see, the rule has the potential to greatly increase your reimbursement assuming you implement certain measures.



Your MIPS score is based on 4 categories:

  • Cost/Resource Use (not applicable for 2017 performance year): Scores based total per capita costs per beneficiary via Medicare claims; no additional reporting required
  • Quality: Report 6 measures from over 200 listed in the existing Physician Quality Reporting System (PQRS)
  • Advancing Care Information: Replaces Meaningful Use and incorporates many of the same requirements (Security Risk Analysis, ePrescribing, Summary of Care, etc.)
  • Clinical Practice Improvement Activities: Identify, perform, and attest to completion of activities from a list of over 90 for a maximum score of 60 points (40 points for some small or rural practices)

You may have noticed that for 2017, MIPS simply combines 2 existing standalone programs, PQRS and Meaningful Use with a new 3rd category. Let’s take a look at some of the most popular Clinical Practice Improvement Activities for Pain Management practices--some may cover activities your practice is already undertaking:




Patient Safety and Practice Assessment

Consultation of prescription drug monitoring program prior to the issuance of a Controlled Substance Schedule II opioid prescription that lasts for longer than 3 days (60% in first year and 75% in second year).

High: 20 points

Patient Safety and Practice Assessment

Annual registration in the prescription drug monitoring program of the state where they practice.

Medium: 10 points

Patient Safety and Practice Assessment

Completion of training and obtaining an approved waiver for provision of medication -assisted treatment of opioid use disorders using buprenorphine.

Medium: 10 points

Patient Safety and Practice Assessment

Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs.

Medium: 10 points

Integrated Behavioral and Mental Health

Depression screening and follow-up plan: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including depression screening and follow-up plan for patients with co-occurring conditions of behavioral or mental health conditions.

Medium: 10 points


Yes, MACRA represents a significant shift in Medicare payments, and yes, it’s approaching sooner than many realize.  If you take the time to prepare now, you will be best positioned to provide the best patient care possible and to positively impact your reimbursement rates.

Practices participating in MIPS have the opportunity to stay ahead of the curve in the initial performance year of 2017 by streamlining Quality (replacing standalone PQRS) and Advancing Care Information (replacing Meaningful Use) and adding Improvement Activities, by documenting existing eligible activities or selectively adding high impact activities to enhance.

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