Sue Ducat
Director of Communications
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Melissa Blair
Robert Wood Johnson Foundation
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Implementing MACRA

A new policy brief from Health Affairs and the Robert Wood Johnson Foundation addresses the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), signed into law by President Obama in April 2015, with the initial phase of the law having begun on January 1, 2017. The new law, the focus of an earlier Health Policy Brief, transforms the government’s approach to paying physicians from fee-for-service, regardless of clinical need, to one based on the quality, value, and results of the of the care they deliver. As of this writing, the new Trump administration has not indicated whether it plans changes to the MACRA rules, a program referred to by the Centers for Medicare and Medicaid Services (CMS) as the “Quality Improvement Program.” This policy brief focuses primarily on the context in which MACRA’s implementation is taking place, implementation challenges, and the debate over the law and the concepts that underlie it.

Topics covered by this policy brief include:

  • What’s the background? This section of the brief traces the history of government payments to physicians since the inception of Medicare in 1965. Since that time, physicians have worked to ensure that they would be paid the same fees that they received from private insurers — and Congress has continually examined whether providers were overbilling the government on services provided to Medicare patients. The brief relays the 1997 creation, and 2015 demise, of the Medicare Sustainable Growth Rate (SGR). Changes in the past decade, most notably including the passage of the Affordable Care Act (ACA), have focused on improving the quality of care and promoting transparency and accountability as well as payment reform. The Obama administration’s goal was for half of physicians’ Medicare payments to be made through value-linked payment by 2018. However it is not clear whether the Trump administration will retain that goal.

  • What’s in the rules, and what’s the debate? This section of the brief explains the procedure for physicians billing Medicare more than $30,000 per year and/or providing care annual care for more than 100 patients to participate in the program (about 70 percent of US practitioners), offering them the option of enrolling in either the Merit-Based Incentive Payment System (MIPS) or the Alternative Payment Model (APM). The brief details both options. The debate section examines the issues raised by key stakeholders as a result of this substantial change in the way Medicaid pays physicians.

  • What’s next? Years of complex rulemaking lie ahead, amid a still-entrenched fee-for-service system, the fate of the ACA, and changes in both the administration and Congress. As the brief concludes, in the context of Medicare’s long history, MACRA is but its latest experiment and will be closely monitored. The final rules will create a formal pathway for continued stakeholder and public comment in coming years.

ABOUT HEALTH POLICY BRIEFS: Health Policy Briefs are aimed at policy makers, congressional staffers, and others needing short, jargon-free explanations of health policy basics. The briefs, which are reviewed by experts in the field, include competing arguments on policy proposals and the relevant research supporting each perspective.

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About Health Affairs

Health Affairs is the leading journal at the intersection of health, health care, and policy. Published by Project HOPE, the peer-reviewed journal appears each month in print and online, with additional Web First papers and health policy briefs published regularly at Read daily perspectives on Health Affairs Blog and customize the content you want to see in Health Affairs Alerts.

About the Robert Wood Johnson Foundation

For more than 40 years the Robert Wood Johnson Foundation has worked to improve health and health care. We are striving to build a national Culture of Health that will enable all to live longer, healthier lives now and for generations to come. For more information, visit Follow the Foundation on Twitter at or on Facebook at