Guest post by Abhinav Shashank, CEO and co-founder, Innovaccer.
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.
Guest post by Justin Sotomayor, pharmacy informatics director, CompleteRx.
Justin Sotomayor, PharmD
The field of health informatics has grown exponentially over the past 50 years. From Robert Ledley’s work paving the way for the use of electronic digital computers in biology and medicine in the 1950s, to the founding of the American Medical Informatics Association in the 1990s, to the launch of the Medicare/Medicaid Electronic Health Record Incentive Program in the 2000s, it continues to mark new milestones at an astounding pace, presenting both challenges and opportunities for the healthcare industry.
Three trends – in particular – will have a marked impact on patients and practitioners, and are certain to define health informatics in the near future, if not for years to come.
The end of Meaningful Use
In 2009, with the passing of the Health Information Technology for Economic and Clinical Health (HITECH) Act, came the launch of the Meaningful Use program – and the related requirement that healthcare providers show “meaningful use” of a certified EHR to qualify for incentive payments. With both Stage 1 (adoption) and Stage 2 (coordination of care and exchange of information) behind them, hospitals are fully responsible for Stage 3 (improved outcomes) by 2018. While, undoubtedly, the program has improved EHR adoption – in many cases, streamlining and enhancing patient care – it has been widely criticized. In a 2015 news release, the American Medical Association regarded Stage 2 as a “widespread failure,” suggesting it monopolized staff attention without commensurate benefit to patients, and hampered innovation.
Most recently, following highly-publicized remarks in January by CMS Acting Administrator Andy Slavitt that Meaningful Use would be replaced, the U.S. Department of Health and Human Services has proposed transitioning Meaningful Use for Medicare physicians to the “Advancing Care Information (ACI)” program under the Medicare Access and CHIP Reauthorization Act (MACRA). According to Mr. Slavitt, this program is designed to be “far simpler, less burdensome, and more flexible,” primarily by loosening the requirements to qualify for extra payments, and incentivizing providers based on treatment merit, known as Merit-based Incentive Payment System (MIPS). While this update doesn’t yet affect hospitals or Medicaid providers, and these groups should continue to prepare for full Meaningful Use implementation, it’s an indication that industry concerns over meaningful use are being heard and responded to, and that additional changes may be forthcoming.
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.
