Guest post by Abhinav Shashank, CEO and co-founder, Innovaccer.
A new complex rule is about to change the entire US healthcare industry. It will replace the Sustainable Growth Rate (SGR) and streamline the three programs. The NPRM for MACRA was passed in 2015 and after the comments and feedbacks from numerous healthcare experts, the final rule with comment period has been released by CMS.
In the final rule, CMS has responded to more than 4,000 comments in a document which is more than 2,300 pages long. Some of these comments have been implemented in the law. As a result of this feedback friendly approach, substantial changes have been made.
The New MACRA after changes
The law aims to bring in unified policies that will add greater value to the healthcare system through the new Quality Payment Program (QPP). The program rewards for value in two ways:
Merit-based Incentive Payment System (MIPS)
Advanced Alternate Payment Models (Advanced APMs)
Chance to adapt
To help the physicians get used to the program CMS has declared the first year — 2017 — as “transition” year. There will be four options available to physicians in the transition year:
Clinicians can choose to report one measure in the quality performance category; one activity in CPIA or report the measures in ACI to avoid the negative adjustments. Alternatively, if they choose to report none, they will receive negative adjustments of 4 percent.
Report for minimum 90 days more than one quality measure, more than one CPIA or more than the required ACI to avoid negative adjustments and qualify for possible MIPS positive adjustments.
Ideally, report for a year or more than 90 days and maximize the chances to receive higher positive adjustments.
Participate in the Advanced APMs program, and if can to see ‘sufficient’ portion of the Medicare Patients, they will be able to qualify for 5 percent bonus incentive payment to be paid out in the year 2019.
Merit-based Incentive Payment System
Under this program, eligible clinicians will get payment adjustments based on the quality, cost and other measures related to care. This program will see the “sunset” of three existing programs namely:
Guest post by Abhinav Shashank, CEO and co-founder, Innovaccer.
According to a survey almost 50 percent of the physicians do not understand MACRA. With less than five months to full implementation of MACRA, are we ready to embrace one of the most elaborate laws of US? And, most importantly, will it produce the needed positive outcomes? The program is expected to improve the current standards, sort the most persistent problems and create opportunities to rework and revise Medicare. How will all this happen?
With MACRA in place, there won’t be two digit payment cuts like in the current Sustainable Growth Rate (SGR) formula. Besides enhancing the use of electronic health records, MACRA is expected to increase the relevance of Medicare to the real world and reduce the administrative burden from physicians’ shoulders.
MIPS stands for Merit-Based Incentive Payment System. It will streamline the three independent programs Physician Quality Reporting System (PQRS), meaningful use, and value-based modifier to ease the burden on the clinicians. The three components in MIPS will replace these programs. Besides this, one more component will be there to bring improvements in practice. Namely following components will be there in MIPS:
1.) Quality: This component will replace the Physician Quality Reporting System (PQRS). Under MIPS the methods of reporting and the various quality measures have been adopted from the old programs PQRS and VBM. There are some changes in the reporting methods and for the registry, EHR, and Qualified Clinical Data Registry (QCDR) reporting methods, a clinician can select minimum six measures which could be a combination of any quality domain. If the clinician faces patients, then he has to select in such a way that one of these measures is cross-cutting measure (cross-domain-cutting), and one is outcome-based measure. If there is no outcome-based measure, then a high priority measure has to be selected.
Besides these six measures, CMS will calculate two or three more measures depending on the size of the group of physicians. For instance, if there is an individual physician or a group less than 10 then two measures and if more than that then three measures. Additionally, for QCDR and registry reporting methods, the “data completeness” standard has been changed. The number of patients to be reported within a measure denominator has been raised from 50 percent to 90 percent.
2.) Advancing Care Information: According to MIPS the meaningful use program will see a lot of changes. Currently, the meaningful use program is everything-or-nothing; i.e., if one clinician achieves a performance rate of 20 percent on meaningful use measures and another achieves 90 percent then they both get rewards in a similar fashion. However, under ACI the latter one gets 10 out of 10 points, and the former gets three points.
More than 100 ACI performance points have been defined out of which base 50 are base points given for reporting either “yes” or a non-zero numerator. The performance scores are up to 80 points based on the performance on eight measures. Rest bonus points are awarded for reporting any other public health registry.
Guest post by Abhinav Shashank, CEO and co-founder, Innovaccer.
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.
Guest post by Abhinav Shashank, CEO and c0-founder, Innovaccer.
Former US President Abraham Lincoln once said, “Give me six hours to chop down a tree and I’ll spend four hours sharpening the ax.” After having a look at the efficiency of the US healthcare system, one cannot help but notice the irony. A country spending $10,345 per person on healthcare shouldn’t be on the last spot of OECD rankings for life expectancy at birth!
A report from Commonwealth Fund points how massive is US healthcare budget. Various US governments have left no stone unturned in becoming the highest spender on healthcare, but have equally managed to see most of its money going down the drain!
Here are some highlights from the report:
The US is third when it comes to public spending on health care. The figure is $4,197 per capita, but it covers only 34 percent of its residents. On the other hand, the UK spends only $2,802 per capita and covers 100 percent of the population.
With $1,074, the US has the second highest private spending on healthcare.
In 2013, US allotted 17.1 percent of its GDP to healthcare, which was highest by any OECD country. In terms of money, this was almost 50 percent more than the country on the second spot.
In the year 2013, the number of practicing physicians in the US was 2.6 per 1000 persons, which is less than the OECD median (3.2).
The infant mortality rate in the US was also higher than other OECD nations.
Sixty-eight percent of the population above 65 in the US is suffering from two or more chronic conditions, which is again the highest among OECD nations.
The major cause of these problems is the lack of knowledge about the population trends. The strategies in place will vibrantly work with the law only if they are designed according to the needs of the people.
What is Population Health Management?
Population health management (PHM) might have been mentioned in ACA (2010), but the meaning of it is lost on many. I feel, the definition of population health, given by Richard J. Gilfillan, president and CEO of Trinity Health, is the most suitable one.
“Population health refers to addressing the health status of a defined population. A population can be defined in many different ways, including demographics, clinical diagnoses, geographic location, etc. Population health management is a clinical discipline that develops, implements and continually refines operational activities that improve the measures of health status for defined populations.”
The true realization of population health management (PHM) is to design a care delivery model that provides quality coordinated care in an efficient manner. Efforts in the right direction are being made, but the tools required for it are much more advanced and most providers lack the resources to own them.
If population health management is in place, technology can be leveraged to find out proactive solutions to acute episodes. Based on past episodes and outcomes, better decision could be made.
The concept of health coaches and care managers can actually be implemented. When a patient is being discharged, care managers can confirm the compliance of the health care plans. They can mitigate the possibility of readmission by keeping up with the needs and appointments of patients. Patients could be reminded about their medications. The linked health coaches could be intimated to further reduce the possibility of readmission.