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The New Era of Population Health: Key Trends for Physicians in 2017

Jas Grewal

While there are many definitions of population health or the “health outcomes of a group of people”, the terms place emphasis on the determinants of health and the interventions to elevate overall health status. Population health is often used interchangeably with public health to describe the activities conducted by governmental public health agencies, community and national organizations to improve the health of a community.

 

Promoting health and preventing disease are key components of population health, both at the societal level and within a primary care practice. And within that, there are three different levels of prevention:

1. Primary prevention – Prevention strategies that seek to prevent disease or injury, generally through reducing exposure or risk factor levels. These strategies can reduce or eliminate risk factors (risk reduction).

2. Secondary prevention – Prevention strategies that identify and control disease
processes in their early stages before signs and symptoms develop (screening and treatment).

3. Tertiary prevention – Prevention strategies that prevent disability by restoring individuals to their optimal level of functioning after a disease or injury is established and damage is done.

 

The goals of population health are to help physicians engage in preventive care, improve care quality, and ultimately, improve health outcomes. There are several benefits of applying a population focus to primary care. Population health tools—especially ones that leverage analytics—allow providers to track care across all of their patients, rather than limiting their attention to the patients who make appointments. One provider explained that “I thought I was doing a really good job” by discussing preventive care during annual physicals or acute visits. However, since adopting a more systematic method of monitoring all of her patients, she said, “now it seems that was not the case. We could not pull all the charts to see who needed [a preventive visit].”

 

Based on the 2017 healthcare reform landscape, there are six areas of initiatives that are currently shaping population health:

Wellness / Preventive health
The second most widely adopted initiative promotes workplace health, school health, weight loss and smoking cessation and are typically implemented to improve overall health and deter more serious conditions from occurring. This initiative category dropped from 79 percent in 2015 to 72 percent in 2016.

Clinically Integrated Network (CIN)
Another model of care, CIN, is a health network of providers/hospitals that use protocols to improve care, lower costs and increase value to a particular market. Roughly half of study organizations with initiatives in place in 2016 leverage this model of care for population health.

Patient-Centered Medical Home (PCMH)
Focuses on acute, chronic and preventative care that is coordinated and integrated across multiple sites with health quality and safety in mind. Care across the continuum could be proving to be difficult as approximately 50 percent of study organizations indicated they utilize this model of care in 2015 and 2016.

At-risk payment structures
At-risk payment structures include Accountable Care, Medicare Shared Savings Program, bundled payment, and employer contracts. An increase in this category since last year indicates the organizational shift to value-based payment but significant gains could take some time as organizations build out their population health programs.

At-risk cost structure
The least adopted program includes Medicare Advantage plans, Medicaid managed care, commercial plan, and self-insured employee plans. This particular initiative grew from roughly 17 percent in 2015 to 19 percent in 2016.

 

MACRA will certainly impact population health in 2017. MACRA was enacted in 2015 to replace the Sustainable Growth Rate (SGR) for physician payment. In 2016, new rules were issued for quality reporting and payment policies that will substantially change the status quo for Medicare’s physician reimbursement in 2017.

Get more in-depth information on the MACRA Quality Payment Program and learn more about Physician Focused Payment Models (PFPMs) Technical Committee.

 

As a physician, below are a few tips to get ready for the new MACRA:

  • Attend webinars.
  • Request a CMS speaker to give your group more details about the Quality Payment Program.

Although hospitals have been subject to the performance-based payment provisions of the Affordable Care Act (ACA), the concept is new to physicians, who need to understand how to improve performance and avoid payment penalties. In essence, this will entail developing more complex governance models, adjusting to more data sharing across the care continuum, and more performance measurement.

With a choice of payment models, physicians will need to conduct financial planning to determine which path presents the greatest benefit given current performance.

Once a payment model is selected, physicians must decide how to organize. Understanding that unprecedented levels of partner collaboration, testing, and co-innovation will be the keys to long-term success.

 

What To Look For In a Population Health Management Platform

Mark Aquino

Population health management platforms are a fundamental element of the healthcare IT stack. Along with EHRs, they’re a staple for organizations when it comes to improving and measuring the health of your patients. They enable doctors to engage at-risk patients, see data in aggregate, meet reporting efforts, and ultimately help improve the health of your patients. Navigating the vendor landscape can be a challenging task, so we’ve come up with things to keep an eye out for when looking into a population management platform:

 

1. Does it utilize predictive modeling with internal and external data?

Data in your EHR is undoubtedly critical, yet it’s not enough to get a 360-degree view of your patients. You need patient-specific information—both internal and external—from clinical, economic, and demographic, to geographic and economic data to give you this holistic view. With a complete picture of your patient population, you can predict risks and address their leading factors across the continuum of care. When looking into a population health management platform, look into whether a vendor has the ability to utilize any and all patient data—in and outside your clinic.

 

2. Does it support regulatory and performance reporting capabilities?

Reporting, whether it’s performance or regulatory, is vital. Providers must be able to report on measures like clinical improvement activities and care quality. Look for a platform that allows you to easily generate actionable reports, and enables you to address those measures—care programs and patient engagement for example—without having to leave the same system.

 

3. Does it interrupt existing workflows and processes?

Look for ways a population management platform can complement existing workflows and processes. Can the solution communicate with existing technologies in your organization? Are you able to implement the solution without complications? Being able to get up and running should not take months (or years).

 

4. Does it enable personalized and automated communication?

Personalized experiences—which is what patients want—are critical. The challenge is being able to do that without hindering other parts of your organization such as optimizing your staff. You need a solution that enables personalization and automation in tandem. One that is able to connect with patients 24/7 and knows how and how often to engage. To help you oversee patients throughout the care continuum, look for a vendor that enables bi-directional communication. Personalization and automation functionalities help you get what patients need, when they need it.

 

5. Does ease-of-use exist?

A population health management system—or any healthcare IT—shouldn’t create barriers between you and your patients. Whether it’s usability or accessibility, today’s healthcare IT should be able to help you continue providing and improving high-quality care to your patients. End-users, managers, administrators, and patients must be able to use the solution without difficulty.

 

6. Does it help me and my patients through and beyond the journey to value-based care?

MACRA is soon to be a reality and value-based care is a transition you’re likely to face. With changes to how providers go about their reimbursements and care quality measurements, you’ll need to have visibility into which patients fall under fee-for-service contracts and which fall under value-based care. Look for a vendor that is dedicated to helping you through and beyond the transition to value-based care, on providing the right solution.

 

Deciding on a population health management platform to go with isn’t a process that’s neither easy nor quick. It’s important to think about the functions and capabilities that matter and make sure the vendor aligns with your goals. With this checklist, we hope you can find the right solution for you and your patients.

 

Join Us at The Value Based Health Care Congress 2016

Mark Aquino

Untitled design

The Value-Based Health Care Congress is just a week away and we’re excited to announce we’ll be there, standing alongside industry veterans and learning more about the state of value-based care. Under The Value-Based Health Care Congress are 3 individual tracks for providers, each covering some of the key pillars of the landscape today:

  1. The MACRA Strategy Collaborative Summit
  1. Value-Based Network and Contract Management Summit
  1. ACO Strategy Summit

We went ahead and listed some of the conference sessions around care quality and health care IT that we’ll be looking forward to attending, and hopefully you will too. Be sure to stop by the CareSkore booth in the exhibit hall to see our Personalized Population Management™ platform, and learn how your healthcare organization can improve both clinical and financial outcomes. Without further ado, here are some of the sessions that we’re excited to see (exact times subject to change):

 

1. Measuring for Value – Panel Discussion

Track and Time: Main Summit, Day 1 @2:05pm

Core quality measure sets are in place and we’ve taken a significant leap forward in providing accurate, useful information on healthcare quality that can inform decisions. The next step in this transition to value-based care rests on our ability to integrate quality and resource use performance to ultimately drive better outcomes.

  • Understand the quality-spending relationship and how it promotes provider buy-in and success in risk-based contracts
  • Learn how to incorporate the patient voice to develop meaningful measures
  • Align measures across the continuum of care to reduce burden and improve efficiency

Speakers:

David Introcaso (@HealthcareIssue)

Helen R. Burstin (@HelenBurstin) – Sr VP, Performance Measures at National Quality Forum

Kate Goodrich – Director, Center for Clinical Standards and Quality at CMS

John S. O’Shea – Sr Fellow, Center for Health Policy Studies at The Heritage Foundation

Stephen L. Ondra (@StephenOndra) – Chief Strategy Officer at Amida Technology Solutions

Linda Walker – VP, Health Security at AARP

 

2. Examine the Role of Health IT in Delivery System Transformation

Track and Time: MACRA Summit, Day 2 @10:45am

Healthcare IT is undoubtedly a critical piece to how we advance quality and value. ONC’s Elise Anthony gives us the catch-all on healthcare technologies—from flow of health info to patient data access, and care delivery—required for participating in CMS programs.

  • Understand how health IT is the foundation to better care, smarter, spending and healthier people
  • Learn about new health IT initiatives that can support practical needs of patients and providers

Speaker:

Elise Sweetney Anthony (@Policy2Progress) – Director, Office of Policy at ONC

 

3. Explore the Ingredients of a Health IT Value Strategy

Track and Time: MACRA Summit, Day 2 @11:30am

Implementing health IT does not guarantee success. These technologies—focused on improving care must allow stakeholders to be able to find usability and usefulness that also support processes—both business and clinical—of a value-based reimbursement system.

  • Review the HIMSS STEPS™ model and its five components
  • Identify areas where health IT has proven value and non-technical barriers to IT optimization
  • Explore potential new functions of health IT that should support value-based care

Speakers:

Peter Basch – Medical Director, Ambulatory EHR and Health IT Policy at MedStar Health

Patricia Wise – VP, Health Information Systems, HIMSS

 

4. Engage Physicians in ACO and Other Value-Based Models to improve Quality

Track and Time: ACO Summit, Day 2 @2:15pm

Successfully engaging physicians ensures that ACOs and other value-based endeavors reach potential, but that is easier said than done. It’s especially challenging when physicians continue to receive fee-for-service and value-based payments simultaneously.

  • Understand physicians’ risk-based payment and MACRA, and how to transition to a value-based mix
  • How to coordinate for optimal management of complex patients
  • Utilize integrated and actionable claims data, not multiple EHRs, and learn how to report data that demonstrates the impact of clinical decisions

Speaker:

Abigail Chen – Medical Director, Quality and Clinical Integration at Mount Sinai

 

5. Achieve Better Quality, Less Effort, and Greater Savings – How You Can Have All Three

Track and Time: ACO Summit, Day 2 @3:00pm

Through organizing information and communicating it with providers in addition to focusing on specific efforts such as cardiac and respiratory conditions, providers can improve cost and quality metrics in parallel and demonstrate the value throughout the health care community.

  • Explore feasibility of collecting and tracking patient data to understand quality performance
  • How cutting costs and increasing quality scores can earn shared savings
  • Illustrate examples of payer-provider engagement and alignment around shared objectives

Speaker:

John Haughton (@haughton_md) – CIO at Chautauqua AMP; CQO at Independent Health Plan

 

Beyond MIPS: A Look into the 90+ Clinical Improvement Activities

CareSkore

Header - Look into 90 activities

Under the MACRA, providers will be reimbursed according to a composite score that reflects how well you’re providing value-based care. This composite score comprises of four key categories: the quality of care you provide, the efficiency of your resource use, meaningful use of EHR, and last but certainly not least, clinical practice improvement activities (CPIA).

 

Image - 90 Clinical Improvement Activities

A rising tide lifts all boats, right? The great part about MIPS—one of the two payment programs as part of MACRA—is that all of these metrics tie-in to improve clinical outcomes and patient engagement. This leads to cost savings, efficient resource use, and improved adoption of your EHR. Maximizing your composite score will not only affect your payments positively, but it will help you provide efficient patient care.

 

Not all activities are created equal

Certain categories are worth more than others due to their impact on patient care. High-weighted activities are worth 20 points, whereas medium-weighted activities value at 10 points. While these CPIAs only account for 15% of your total score, leveraging the highest-weighted tactics can be easy wins for your practice. Planning, completing and reporting 3 activities is much easier to pull off than 6 different initiatives. During your 90-reporting period (here’s a plan for when should start thinking about it), you must achieve 60 points by completing these clinical practice improvement activities in which there are over 90 tactics across 8 categories, in the combination of your choice.

 

Here’s a look at some of the types of activities in each category per ASCRS:

Expanded Practice Access: expanded practice hours, telehealth services, and improving access to services

Population Management: chronic care management programs, community and rural healthcare programs

Care coordination: health information sharing, timely communication and follow-up, care coordination training to handle transitions of care, and active referral management

Beneficiary Engagement: EHR to document patient-reported outcome,enhanced patient portals

Patient Safety and Practice Assessment: ongoing practice assessments and patient safety improvements, and use of tools such as the Surgical Risk Calculator

Achieving Health Equity: seeing new and follow-up Medicaid patients in a timely manner, and use of QCDR for demonstrating performance of processes for screening for social determinants

Emergency Response and Preparedness: participate in disaster medical teams or participation in domestic or international humanitarian volunteer work

Integrated Behavioral and Mental Health: tobacco intervention and smoking cessation, and integration with mental health services.

 

Choosing your activities

With several ways to maximize points in these categories, many activities may overlap and will have a bigger benefit for your patients.

Let’s take the Beneficiary Engagement and Population Management categories for example. You can implement specific programs and protocols to help patients with chronic illness like heart disease and diabetes. Helping patients manage their care at home with blood pressure testing and glucose measurements will help keep them on track and reduce the risk of readmission.

Bonus: Have a tool where patients can electronically share data and communicate with providers.

 

Convenience is king

Anything you can do to make life easier for your patients will most likely be a highly weighted CPIA. Expanding access to care with extended hours or e-visits can significantly decrease appointment cancellations or no-shows. Also, providing 24/7 real-time communication with care teams and reminders will greatly improve patient engagement and overall outcomes.

Another highly weighted activity is participation in CMS’s Transforming Clinical Practice Initiative which aims to help:

  • Exchange patient data information for the best continuity of care
  • Track patients through the entire process and integrate information from specialists to make sure care is documented
  • Coordinate phone calls, communication, navigation post-discharge
  • Communicate timely results for follow-up
  • Create individualized care plans for high-risk patients to share with other providers

 

Attaining Full Credit with Reporting

Given that the entire healthcare industry is shifting towards value-based care, reporting will be one of the most critical components within the continuum of care. If you haven’t already, begin to determine what measures you will report on and evaluate your strengths. Identify what gaps can be filled and put in the necessary plans to improve those gaps. Here at CareSkore, we envision providers getting the credit they deserve.

Through CareSkore, providers can:

  • Generate reports for measures including MACRA, PQRS, and HEDIS
  • Manage your patient population with real-time assessments
  • Understand patient data and quality metrics in order to improve outcomes

Whether it’s reporting for Clinical Improvement Activities or any of the mentioned categories, understanding your patient population through reporting is the first step to cultivating the provider-to-patient relationship.

 

Sources:

MIPS, MACRA & MU - The Next Evolution of Healthcare Payment Reform

MIPS: Clinical Practice Improvement Activities Category

MIPS Program: 2017 Clinical Practice Improvement Category Proposed Rule Guide

Federal Register - Subcategories

Medicare Program; MIPS and APM Incentive Under the Physician Fee Schedule

Transforming Clinical Practice Incentives

 

Preparing Your Practice for MACRA: A Plan for 2016 and Beyond

CareSkore

Header - Preparing for MACRA

Significant changes are coming to the way physicians are reimbursed through the Medicare Access and CHIP Reauthorization Act (MACRA). As part of a larger initiative to transition from fee-for-service towards value-based care, one of MACRA’s proposed payment programs, the merit-based incentive payment system (MIPS) will help providers focus on improving clinical outcomes by reducing administrative burdens. In the long run, this will offer more financial certainty and a greater potential for bonus payments. As a healthcare organization, there are action items you must take in order to receive credit for the high-quality care you’re providing.

 

Preparing for MACRA in 2016

In 2015, about 56% of physicians said they were unsure whether or not they were ready to participate in MACRA. Ready or not, the following are things you can start doing today to prepare for the newly proposed payment programs.

  • Understand the impact: Review the proposed changes and explore their implications.
  • Know yourself: There is no one-size-fits-all approach given that each and every provider is unique in their own way, so only you—alongside your administrative team—can complete an accurate self-assessment.
  • Develop a success plan: Outline your strategy with target dates to keep you on track.
  • Educate your team: Get in touch with providers and internal stakeholders to make sure everyone is on the same page.

 

What You Can Do Today

Start thinking about which payment track is most fitting for your practice. Unless you’re part of an accountable care organization (ACO), you will most likely begin with MIPS. You’ll need to review your Quality Resource and Use Report (QRUR) to get a baseline of where you can improve.

 

1. Meet Meaningful Use

If you aren’t already using an EHR or electronic health record system, now is the time. It should allow patients to access and exchange their information across the coordination of their care. Find a solution that enables you to connect with patients and will be easy to adopt.

 

2. Start Reporting

Determine which quality measures you plan to report on. Since this could differ based on specialty, you’ll want to carefully evaluate your strengths. If you’re part of a physician practice, decide whether you want to report as a group or as an individual.

 

3. Understand Resource Use

Once you dig into your data and evaluate your benchmarks, you’ll be able to understand how you’re spending your resources. Knowing which of your patient populations are keeping costs up is critical to developing a plan to improve care. Often, these groups include patients with chronic illness that require frequent visits and engagement. Strategize how your practice can deliver care more effectively to these patients.

 

4. Identify High-Performance Areas

Your practice is probably already performing well in some quality areas. Use this as an opportunity to get credit for the things you do best. Then you can develop a plan and fill in the gaps where you need to improve.

 

5. Evaluate Your Readiness for MACRA

Whether you follow a MACRA checklist or create your own success plan, gauge your progress and understand the timeline in order to set your practice up for success.

 

What You Need To Do in 2017

In January 2017, CMS (The Center for Medicare and Medicaid Services) will begin collecting data to get a baseline for the rest of your performance metrics. You’ll receive your first feedback report in July of 2017, giving you a better idea of your current quality measures. It’s also a chance to quickly adjust any measures during Q3 and Q4.

In 2017, you should decide on your 90-day reporting period. Many factors can influence your choice such as the timing of major holidays or when providers will be on vacation. Choose a time that will provide the complete, most accurate picture of your practice. Your practice will also need to decide which Clinical Practice Improvement Activities to begin. Getting a jump-start on these can help your overall composite score, and improve the patient experience. Talk with your team about which activities will be the most impactful and cost-effective to facilitate and make both short-term and long-term plans.

Make sure it’s meaningful: it won’t be enough just to meet meaningful use. Your EHR technology will be evaluated for efficacy by CMS and will want to know it’s adding value to the patient experience, not just checking off a box. The following are things to look for when evaluating an EHR:

  • Make sure it is secure
  • Make sure patients are actually using it
  • Make sure patients are using it to access health information and receive secure messages

 

Thinking About 2018

By 2018, the CMS’s goal is to have 90% of Medicare payments shifted to quality or value-based care. When you receive your second feedback report in July of 2018, you can compare your progress and understand where you can improve. From creating improvement action plans you’re positioning yourself to maximize payments.

Understanding how all practice operations work together is great if you can easily synthesize all the data and see trends. That’s where CareSkore comes in, giving healthcare providers the ability to:

  • Get a 360-degree view on patients and patient populations by accurately assessing both patient risks and needs, and improve outcomes.
  • Coordinate and manage the most appropriate and timely care through personalized follow-up with high-risk patients and understanding data that will improve quality measures.
  • Improve patient engagement by connecting with patients even after they have left the premises to reduce both no-shows and cancellation rates.

These simple, yet impactful tactics can enhance the patient experience, improve outcomes and reduce administrative and operational challenges that keep your practice from providing the best possible care to every single patient—which is ultimately what MACRA will be evaluating.

 

Sources

 

MACRA Basics: MIPS vs APM - What You Need to Know About the New Rules

CareSkore

Header - MACRA MIPS vs APM (1)

What is MACRA?

The MACRA (Medicare Access and CHIP Reauthorization Act) is the new healthcare reform poised to replace all of the different “patchwork programs” for physicians who receive Medicare payments. As part of the shift towards value-based programs proposed by CMS (Centers for Medicare & Medicaid Services), it’s purpose is to set up a new framework that rewards physicians, not on the amount, but the quality of care they provide. As a provider, you have two different options for how you want to get reimbursed: MIPS (Merit-based Incentive Payment System) and APMs (Advanced Payment Model).

 

What is MIPS?

MIPS determines your reimbursement rates by the quality of care. Payment adjustments under MIPS are based on the MIPS Composite Score, which comprises of 4 key areas:

  • Quality (Formerly Physician Quality Reporting System or PQRS)
  • Advancing Care Information (Meaningful Use)
  • Clinical Practice Improvement Activities
  • Resource Use

If your score is above the threshold, you’ll receive a positive payment adjustment. But if you’re below, you’ll have a negative payment adjustment for the following year. Scores will be compared to both year-over-year improvements and other providers.

 

Benefits of Merit-Based Payments

High performers under MIPS receive a positive payment adjustment for up to 3x the adjustment factor, but physicians still have to report on quality measures to make sure standards are being upheld. Providers can maintain a higher score by simply improving patients’ outcomes through care coordination and ensuring patients have easy electronic access to their health information. Many are already using technology to increase patient engagement. By communicating with their patients in real-time, providers can better serve patients who have a higher risks of complication and readmission to the hospital. Through patient engagement and communications, providers receive credit for helping patients through personalized reminders to take their medicines, monitor their performance, and keeping them healthy throughout the continuum of care. Tying clinical practice improvement activities such as improving patient safety, population health, and long-term outcomes together, ultimately makes your practice much more efficient.

 

What is APM?

Aside from MIPS, the other payment track is an Advanced Payment Model or APM. Currently, patient-centered medical homes (PCMHs) and accountable care organizations (ACOs) use this model. CMS, however, anticipates that more individual providers will qualify for this option. APMs will provide a 5% lump sum bonus based on the prior year’s payment beginning in 2019 over a 6 year time period.

To be eligible for APM, participants must:

  • Have serious quality measures comparable to MIPS
  • Use EHR (Electronic Health Record) technology
  • Bear “more than a nominal financial risk” similar to an ACO or PCMH

Physicians who choose an APM have an opportunity to earn more, but run the risk of paying Medicare back if they don’t meet savings goals. Understanding these risks and determining if they outweigh the potential benefits is a decision that providers will have to make individually or with their practice management team.

 

How to Choose the Best Payment Model

Which path do you take? You and your partners can weighout both payment models under the MACRA, but first, you’ll want to get the facts to make an informed decision.

Know yourself - Dig through the quality data. Are you a high performer? Find out why or why not. Know your current quality metrics and create a plan to improve.

Know your patient population - Do you know you take on patients that have multiple health problems or things you can’t control? That could be a factor in your reimbursement rates.

Under MIPS, there are over 90 activities you can choose from to demonstrate how you’re improving your clinical practice. These tactics can give you credit for helping patients overcome challenges like making sure they’re taking their medicine or adhering to a rehab program.

 

How Meaningful is Meaningful Use Technology

Another thing to consider is your meaningful use technology. Now, you’ll be measured on how well patients are making use of their electronic health information. Is it actually providing value? The intent is that providers and patients are actually sharing information and making prevention and high-quality care more accessible to patients.

 

Start Planning Now

The good news is that the current payment programs requiring reporting on quality metrics will be absorbed into the MACRA. Physician practices have until 2019 to choose their payment track, however, it’s never too early to understand your options and have a general idea of what makes the most sense for your practice. In the meantime, you should honestly evaluate your quality metrics and how you’re meeting meaningful use. Take the time to look for ways to improve and implement tactics that can help your patients now.

 

Sources:

NPRM - Quality Payment Program Fact Sheet

CMS Quality Reporting Programs

Medicare Access and CHIP Reauthorization Act (MACRA) Preview Module

Quality Payment Program - CMS

Quality Payment Program - MIPS and APM

MIPS or APM: Which is better for your practice?

Moving toward improved care through information

MACRA Payment: APM vs MIPS

 

MACRA is a Reality Sooner Than You Think – A Law Paved with Good Intentions and Steep Implementation challenges: Face it with the right partner

Aditya Mangal

macra header

 

“For a small practice, it is more critical to embrace MACRA sooner, to avoid the negative impact on your income.”

- Jas Grewal, CEO at CareSkore

 

We took the pain of reading through the 962 page MACRA NPRM document to understand the intricacies of the law.

The good news: MACRA will pay physicians for doing what they already want to do: provide the best possible care for their patients. Hence when a provider does the best thing in the interest of the patient — doing good — they’ll also do financially well.

The bad news: MACRA is soon to be a reality. Experts are calling it the most significant change to clinician reimbursement in more than two decades. And that means you have to be ready.

 

Fast and Furious

The MACRA timeline is aggressive—performance measures go into effect in 2017—and you need to get up to speed on how this complex program will impact your organization.

You have to start now, to ensure implementation of tools needed to baseline your performance and jumpstart the MACRA journey. MIPS payments start in 2019, based on the quality of care starting with 2017. Hence, 2016 an important year for you to understand and strengthen quality benchmarks.

So what should a clinician do as far as technology is concerned?

By 2017, the clinicians should

  1. Use a 2014 or 2015 Edition Certified HER
  2. Decide which track they should choose when reporting to CMS
  3. Report on stage 2 or stage 3 care information objectives and measures
  4. Allow ONC to review of their EHR; provide support for HIE

And, when they get spare time after that, continue to take care of their patients

 

MACRA Implementation Timeline

macra timeline q

 

Financial Impact & Incentives

A major question is how aggressively the MIPS program would redistribute payments from low performers to high performers.

As we combed through the enormous document, we found that CMS’s analysis estimates the impact on providers by practice size in Table 64 (Page 676 of 962), suggesting that 87% of eligible clinicians in solo practices and 70% of practices with two to nine clinicians will have a negative adjustment due to a below average score.

These estimates suggest that in the first year, the average MIPS adjustment (positive or negative) would be several thousand dollars per clinician.

Clinicians working for a practice with 100 or more eligible clinicians, 81.3% will have a positive adjustment, only 18.3% are estimated to receive a negative adjustment.

In total, the solo physician practices with a negative payment adjustment would collectively be getting $300 million less than they would without MIPS. This number is only $57 million for practices with 100 or more eligible physicians.

 

Small Providers

If you are a clinician or group that fall under the low volume threshold that CMS defines as clinicians or groups with $10,000 or less in Medicare charges AND 100 or fewer Medicare patients or in first year billing Medicare, you are excluded from MACRA.

That is only a tiny fraction of the providers.

Smaller providers face steep challenges complying with MACRA metrics, in particular, the EHR and technology-based requirements or some of the qualifying APMs that require greater capital or a patient population.

MACRA will enable provider affiliations will be characterized by tight partnerships through which the entities can share capabilities.

Smaller, independent practices may actually have more agility as the sole authority in crafting their MACRA strategy. Independent medical groups have will have more flexibility in what they do to respond to MACRA that medical groups associated with hospitals or health systems won’t have.

 

Looking Forward

Final MACRA rules are still a couple of months away, and there could be some change in the ruling. However, the proposal gives insights on CMS’s thought process and what to expect with final ruling later this year. Not only the regulatory reporting is going to be substantial, but also the financial incentives are significant. Hence, the clinical and financial outcomes of your practice are very co-related as MACRA gets into effect.

As provider’s address MACRA, they need to address not only MIPS/APMs, but also Medicare Advantage, Medicaid incentives, and commercial insurances. Stay tuned for future posts as we address these concerns.

 

References

  1. The MACRA proposed rule is at: https://www.gpo.gov/fdsys/pkg/FR-2016-05-09/pdf/2016-10032.pdf.
  2. The CMS “Measure Development Plan” is at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Final-MDP.pdf.