Guest post by Cheri Bankston, director of clinical advisory services, Curaspan.
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.
Guest post by Emily Tyson, director of emerging markets, Curaspan.
Emily Tyson
On the cusp of many important changes currently impacting major healthcare policies, Andy Slavitt, acting administrator at the Centers for Medicare & Medicaid Services (CMS), made a striking statement to the audience at the J.P. Morgan Health Care Conference earlier this year: “The meaningful use program as it has existed will now be effectively over and replaced with something better.” This remark created a stir within the healthcare community, which has long lamented the burdensome documentation and lackluster results most often associated with the Meaningful Use (MU) program, and left many providers and healthcare organizations wondering what that really meant for the future of reimbursement, along with healthcare technology and EHR regulation.
What do we know today?
Slavitt’s comments reference a transition – not a replacement – to a new payment program. The government is making a concerted effort to lessen the burden associated with its programs and push the industry toward value-based care. Last year Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA). The Act made three notable, high impact changes to Medicare reimbursement:
It ended the Sustainable Growth Rate (SGR) formula for physician reimbursement;
It created a new framework to compensate healthcare providers for better, higher quality care (rather than higher volumes of services); and
It streamlined the process by combining existing quality reporting programs into one new system.
With the recent release of the proposed MACRA ruling, the Act and associated rules may take effect on January 1, 2017 and will offer healthcare providers two options for participating in quality programs: (1) Fee-for-service (FFS) combined with greater incentives through a new Merit-Based Incentive Payment System (MIPS), or (2) Alternative Payment Models (APMs). The current payment adjustments associated with the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier (VBPM), and MU will be phased out and replaced with a consolidated approach. MIPS will provide payment adjustments based on four weighted performance categories: Quality (30 percent), Resource Use (30 percent), Meaningful Use of Certified EHR Technology (25 percent), and Clinical Practice Improvement Activities (15 percent). APMs include reimbursement models, such as ACOs, patient centered medical homes, and bundled payments.
