The ABC of MACRA

Guest post by Abhinav Shashank, CEO and co-founder, Innovaccer.

Abhinav Shashank
Abhinav Shashank

Currently, one of the most discussed topics in the healthcare industry is MACRA; a complex 962-page document that is supposed to redesign the entire healthcare industry. Know all about MACRA in six questions.

What is MACRA?

MACRA stands for Medicare Access and CHIP Reauthorization Act. It’ll repeal the current Sustainable Growth Rate (SGR) Formula and extend CHIP for two more years. Extending CHIP for two more years (in total four years now) will help tens of millions of kids in retaining their insurance.

SGR was introduced in 1997, as a method to curb the Medicare expenditures. Under SGR the physician payments were cut if the overall expenditure was above the benchmark. This payment cut system turned out to be a major reason for significant losses incurred by physicians. Fearing payment cuts, many physicians started denying services to Medicare beneficiaries.

In 2015, “Doc Fix” or MACRA was proposed, which as the name suggests fixed the unprecedented payment cuts. If it weren’t for “Doc Fix,” physicians would have faced 21 percent payment cuts in 2015.

The Notice for Proposed Rulemaking (NPRM) was issued on Apr. 27, 2016, and the final rule will come in November. MACRA’s full implementation will begin from 1st January 2017.

What will MACRA change/replace?

The idea behind implementing MACRA is to create something that works and is enduring. MACRA would bring changes through its unified framework called “Quality Payment Program,” which has been further divided into Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Model (APMs).

All those who will be eligible for MIPS are called Eligible Clinicians. The term has expanded from “Eligible Provider” to “Eligible Clinicians.” It will include physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists and groups of such clinicians. This expansion has increased the number of people who will receive payments from Medicare. CMS might expand to Medicare part B after two years, which will include therapists, clinical social workers, clinical psychologists.

To keep health information flexible and user-centric, and bring all these changes with better care opportunities, MIPS will evaluate eligible clinicians on four measures namely: Quality Category to replace PQRS; resource use category to replace value-based modifier; Advanced Care Information (ACI) to replace meaningful use; Clinical Practice Improvement Activities (CPIA).

How will the four categories measure the performance?

Quality Category: Instead of reporting on nine measures, Clinicians will have the choice to pick speciality-specific measures. They can choose six measures to report to CMS that suits them the best reflecting their practice. But one of these measures must be an outcome measure or a high-priority measure and one must be a cross-cutting measure. Clinicians can also choose to report a specialty measure. Clinicians can report through Claims, Electronic Health Record (EHR), Clinical Registry, Qualified, Clinical Data Registry (QCDR) or Group practice reporting web portal.

For the year one, quality category will have 50 percent weight in the performance scoring procedure.

Resource Use: Clinicians are not required to report for this, CMS will calculate these measures based on claims and “availability of sufficient volume.” To account for the differences among specialties, CMS has proposed to add 41 episode-based measures. These episode groups have potential to provide more actionable insights on measure resource use than the various cost measures.

For the year one, resource use category will have 10 percent weight in the performance scoring procedure.

Advancing Care Information: Clinicians can report on the measures that suit their practices the best and reflect how the EHR technology is being used for daily needs, with particular emphasis on the interoperability and information exchange. The performance score does not use threshold and allows physicians to receive partial credits on measures.

For the year one, advancing care information category will have 25 percent weight in the performance scoring procedure.

Clinical Practice Improvement Activities: In this category, clinicians would be rewarded for activities that improves overall care delivery such as care coordination, beneficiary engagement, and patient safety. Clinicians can choose practices’ goal from a list of 90 plus activities. This category does not require a full year reporting. CPIA activities need to be performed for at least 90 days during the performance period.

For the year one, CPIA Category will have 15 percent weight in the performance scoring procedure.

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MACRA Anticipation: What a Delay Might Suggest

Guest post by Cheri Bankston, director of clinical advisory services, Curaspan.

Cheri Bankston
Cheri Bankston

As physicians across large and small practices struggle to prepare for the many payment reforms under the Medicare Access and CHIP Reauthorization Act (MACRA), Centers for Medicare and Medicaid Services’ (CMS) Acting Administrator Andy Slavitt recently suggested that MACRA could be delayed from its intended Jan. 1, 2017, start date. He also proposed that reporting requirements may be adjusted to ease the burdens on physicians. For example, data and measurements could be potentially submitted through an automated method.

MACRA is expected to greatly transform how Medicare pays for physicians and other clinicians who participate in the fee-for-service program. Under MACRA, payment changes will be split into a two-track system for Medicare reimbursement:

Merit-based Incentive Payment System (MIPS) is for providers who operate using fee-for-service reimbursements. This new program combines parts of the Physician Quality Reporting System (PQRS), the Value Modifier (VM), and the Medicare Electronic Health Record (EHR) incentive program into one single program for participants.

Alternate Payment Model (APM) is for physicians who take on a significant caseload of patients. New payment models enable health care providers to be paid by Medicare. From 2019 to 2024, CMS may pay some participating health care providers a lump sum incentive payment.

How This May Impact You

Working with physicians and understanding their business model is the core of transition management, especially for physicians who are providing care to patients in the Fee-for-Service program. With a deeper understanding, it is easier to foster a more collaborative and effective relationship. Hospitals have been paid a lump sum since the early ‘80s, but it is important to recognize that some physicians and physician groups do have patients enrolled in bundled payment models and others who are not. So how important is it for case managers to know how a physician is paid?  For a case manager to properly perform their job, they must know how the business of health care functions.

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5 Themes I Tracked at HIMSS 2016 in Las Vegas

Guest post by Tom S. Lee, Ph.D., CEO and founder, SA Ignite.

Tom S. Lee
Tom Lee

Those making the long trek to and through the annual, arduous health IT connection-fest known as HIMSS are undeniable siblings-in-arms. Each has their own list of “must learns” by which they measure the return on the foot blisters and hurried lunches.

This year, I brought my particular list of themes to track. Although the odds are great that I missed relevant crevices of the show, I believe I gathered a decent quorum of items to share here.  You be the judge.

Theme 1: More Regulatory Guidance from CMS and HHS

The HHS, ONC and CMS brain trust spoke to packed rooms in an illuminating 24-hour span, which crossed multiple themes on my list. On the regulatory front, HHS Secretary Burwell, National Coordinator for HIT DeSalvo, and CMS Acting Administrator Slavitt, all made direct or indirect mention of the MACRA legislation and its constituent parts, the Merit-based Incentive Payment System (MIPS) and alternative payment models (APMs; e.g. Medicare accountable care organizations). MIPS and APMs together redefine how $250 billion per year in Medicare Part B payments will be paid to physicians in value-based, rather than fee-for-service-based, manners. The hub-bub around MIPS, in particular, stems from the fact that it can reward high-performing providers with incentives up to and even beyond 27 percent of Part B payments and penalize low-performing providers up to 9 percent, while also reporting their MIPS performance scores to consumers.

Although CMS was unable to confirm or deny many aspects of the CY2017 MIPS rule currently being drafted, I heard strong clues from CMS and its contractors confirming a Jan. 1, 2017, start of the first MIPS performance year. In addition, CMS officials publicly stated across multiple sessions that the draft CY2017 MIPS rule would be released “within a few months,” “in the spring,” and perhaps as soon as April.

Theme 2: The Rising Importance of the Back-Office Impacts of Value-Based Programs

Over the last nine months, it wasn’t clear how Medicare’s Chronic Care Management (CCM) program was playing out in the field.  CCM rewards primary care providers with a monthly per patient fee for delivering a set of high-quality, chronic care services to patients both within and outside the clinic.  The dollars netted by a practice can be substantial, even eclipsing the incentives earned from complying with meaningful use over the last several years. However, the front-office and back-office tasks needed to support a successful CCM program can be substantial. Whereas after walking 80 percent of the main exhibit hall floor I saw no CCM vendors, I saw in the first-time-exhibitor hall several companies out of ~40 exhibiting focused exclusively on offering outsourced CCM program delivery services. Maybe the CCM model and market are starting to take root.

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