The American College of Surgeons (ACS) submitted a comment letter June 27 on the Centers for Medicare & Medicaid Services (CMS) proposed rule on implementation of certain provisions of MACRA. Specifically, the CMS set forth proposals on the two pathways by which MACRA replaces the sustainable growth rate (SGR) formula: the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). Among other issues, the ACS comments address the four components of MIPS: 1. quality, 2. resource use, 3. advancing care information, and 4. clinical practice improvement activities. The comments also address the criteria necessary for an APM model to be considered an “Advanced” APM, specifically: 1. use of certified electronic health records technology, 2. inclusion of quality measures comparable to MIPS, and 3. taking on more than nominal financial risk. Participation in an Advanced APM would exclude the clinician from participation in MIPS. For more information on the proposed rule or the comment letter, contact regulatory@facs.org.