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Understanding the MACRA Rollout

There has been much confusion and angst surrounding the regulation rollout of the Medicare Access and CHIP Reauthorization Act (MACRA). The rule is complex, requiring over 2,000 pages to outline its details. Moreover, MACRA carries significant reimbursement implications over the next several years, with possible penalties of up to nine percent of Medicare Part B revenue for non-participation or poor performance. The following four points may help you better understand the rule, gain clarity to what MACRA means to providers and determine appropriate next steps.

1. MACRA Is Here to Stay

First, MACRA has absolutely nothing to do with the Affordable Care Act and will not be held up in potential legislative gridlocks. The rule passed with strong bipartisan support, and it is already underway in 2017. In other words, MACRA is here to stay.

The Centers for Medicare & Medicaid Services (CMS) did listen to strong feedback from the medical community and relaxed the rules for 2017—a one-year grace period to prepare for the full transition in 2018—by allowing providers to submit a minimal amount of data to avoid a payment penalty. Providers now only need to report one quality measure or one improvement activity or the required Advancing Care Information (ACI) measures to avoid a penalty. In sum, practices that are ready for MACRA this year can potentially receive the positive payment incentive. Yet, providers who aren’t fully prepared for MACRA in 2017 can use the minimal data submission period to meet reporting requirements and continue to prepare for full engagement in 2018.

2. Most Nephrologists Will Participate in MIPS

Second, although MACRA contains two paths—the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs)—the vast majority of nephrologists only need to be concerned with MIPS. Although CMS intends to shift the majority of payments into APM models in future years, for now, due to the limited ability for nephrologist to participate in risk-based programs for the majority of their patients, the current reality is that almost all nephrologists will be participating in MIPS.

3. MIPS Really Isn’t New

Third, MIPS isn’t groundbreaking or new. The four categories of MIPS essentially take several existing programs, streamline their requirements and combine them into one umbrella program. The MIPS Cost Category, for example, reimagines the Value Based Modifier program, a category that won’t even count towards your score in 2017. The MIPS Quality Category simplifies the requirements of PQRS. The MIPS ACI Category modifies Meaningful Use (MU). And the MIPS Clinical Improvement Activities Category, while new, only requires attestation and allows providers to get credit for many of the quality-improvement activities they are doing anyway.

4. MIPS Is a Process

Lastly, MIPS really isn’t a thing; it’s a process. MIPS uses metrics and measures to allow providers to demonstrate quality clinical care. Therefore, seeking to understand every patient assignment algorithm or denominator criteria is not only futile, but also not necessary. Implement a good EHR partner and ask them tough questions about their readiness to help you succeed with MIPS. Empower your staff to understand the requirements of MIPS, and partner with your team to ensure you have the right processes in place to deliver the best clinical care possible. For instance, is your front desk staff registering patients for your patient portal as part of the new patient registration process? Is your staff requesting hemoglobin A1c and other necessary lab results from referring providers if those are necessary to meet the relevant quality metrics you have selected?

There are numerous resources available to help from organizations such as the Medical Group Management Association (MGMA) and the American Medical Association (AMA) an on the Quality Payment Program (QPP) website. Additionally, CMS will award $20 million each year for five years to fund training and education for Medicare clinicians in individual or small group practices of 15 clinicians or fewer and those working in underserved areas. Local, experienced organizations will use this funding to help small practices select appropriate quality measures and health IT to support their unique needs and train clinicians about the new improvement activities. Refer to the CMS website to find out what organizations have been selected to help in your area.


Take advantage of all these resources that are at your disposal. MACRA is here to stay, and it’s not as bad as you might think. Don’t let all of the acronyms scare you. Relax, practice great clinical care, leverage your resources to develop the right processes and begin to embrace the journey toward value-based reimbursement.


Some of this content has been repurposed, with permission, from Renal & Urology News.

Robert Provenzano, MD, FACP, FASN

Robert Provenzano, MD, FACP, FASN

In addition to his roles as chief medical officer at Nephrology Practice Solutions and vice president of medical affairs at DaVita Kidney Care, Robert Provenzano, MD, is a clinical professor of medicine at Wayne State University School of Medicine in Detroit, where he earned his medical degree. He completed his fellowship training at Henry Ford Hospital and served as the chief of the nephrology, hypertension & transplantation section and director of nephrology research at St. John Hospital and Medical Center in Detroit. Dr. Provenzano is former president of the Renal Physicians Association and chair of the National Kidney Foundation of Michigan. He is also former CEO of St. Clair Specialty Physicians, PC, a multistate nephrology practice. He has published extensively on kidney care business models and is the chief medical officer of Nephrology Practice Solutions (NPS), a national kidney care management company affiliated with DaVita that oversees owned and managed practices. Twitter: @DrBobPro