The High Price of MACRA Mistakes
Help for physicians, physician assistants and others impacted by MACRA
July 07, 2016
Jay Bhatt, DO, Chief Health Officer, Illinois Health and Hospital Association and Heather Lavoie, Chief Strategy Officer, Geneia
MACRA (the Medicare Access and CHIP Reauthorization Act of 2015) aims to drive positive patient outcomes and reward physicians and clinicians who engage in the activities that support and further these goals. The core measures in MACRA dovetail into the population health work that clinicians do every day such as diabetic eye and foot exams, cancer screenings, tobacco screenings, immunizations, flu vaccines and more.
The release by the Centers for Medicare and Medicaid Services (CMS) of the proposed MACRA rule represents the next evolution in value-based healthcare. With 2017 rapidly approaching, clinicians need to understand how to prepare and how their current population health activities — or lack thereof — align with these new reimbursement structures.
Currently, reimbursement reporting, at best, is complicated. MACRA aims to provide a single framework to streamline and simplify the reporting process, one that aligns with commercial reporting and helps bring the joy back to the profession. Many measures in the new system will be familiar to those physicians participating in the Physician Quality Reporting System (PQRS) and the Value-Based Modifier Program (VBM). Physicians may also appreciate the reduction in EHR reporting as redundant — and frustrating — aspects of Meaningful Use 3 (MU3) are eliminated.
Ultimately, MACRA attempts to lift the heavy reporting burden that both impedes the delivery of high-quality, compassionate care and undermines the reasons for entering the field of medicine in the first place. For example, MACRA proposes to:
Two Tracks, One Funnel
MACRA lays out two tracks for clinician reimbursement — the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs). For the first measurement year only, all eligible physicians and clinicians will report through MIPS, with CMS determining who qualifies for the APM-specific bonuses, rewards and full APM track. (Clinicians will choose their own track in subsequent years.) This approach is designed for flexibility, allowing clinicians to move back and forth between the two tracks as is appropriate for their practice. Moving between tracks enables clinicians to receive credit for their APM activity, regardless of their ability to meet the threshold for the advanced APM track. For example, clinicians will move between tracks as they adopt new practices (e.g., coordinated bundles under an APM), assume different levels of risk or enter into an APM for the first time. The intent is a reporting structure that is tailored to individual practice needs.
Patients and Populations
MACRA works to establish a foundation that fosters the delivery of care and promotes, recognizes and rewards the health and well-being of individual patients and populations. To further reduce the reporting burden, CMS is collaborating with industry stakeholders on measures that apply to the MIPS and APM tracks for determining patient outcomes. The intent of this collaboration is to better align CMS reporting with accepted healthcare industry standards.
For those clinicians with patient registries and existing reporting mechanisms, the familiar measures should provide comfort and encouragement. However, it cannot be stressed enough that the timeline for MACRA requires that clinicians establish a strong baseline in 2017, which impacts reimbursement in 2019. Each clinician will be scored against measure baselines and payments will be adjusted up or down.
From Paper to Practice
Let’s meet three physicians and use their situations to help sort through these upcoming reimbursement changes. The track each physician ultimately selects will be highly dependent on his or her current setting — physician group, size of practice, populations served and local market structure.
Dr. Barlow works for a large physician group that assumes financial risk for patients in MACRA-approved APMs, such as the Bundled Payments for Care Improvement (BPCI) Initiative. A significant percentage of his patients are beneficiaries covered by these programs and, as a result, he is very familiar with the incentives of risk-based contracts. Even though Dr. Barlow will report via MIPS in the first measurement year, he is well-positioned to qualify for the advanced APM track and receive substantial bonuses.
Dr. Lin also works for a physician group, but unlike Dr. Barlow, she sees a variety of attributed and unattributed patients. Dr. Lin’s eligibility to participate in the advanced APM track depends on her ability to reach 20% of patients or 25% of payments through these advanced APMs. If there is a high percentage of Medicare ACOs, Medicaid and commercial payers who reimburse through shared-risk models, Dr. Lin might reach the APM threshold. Another option for Dr. Lin is an intermediate stage in which she can opt out of MIPS when she receives 20% of her payments or 10% of her patients through an advanced APM. Regardless of her ability to qualify for an advanced APM track, Dr. Lin will report via MIPS and receive credit for her APM participation.
Dr. Perez is part of a small practice and serves patients of varying insurance coverage, including Medicare Advantage. He believes he is close to falling below the low patient volume threshold of $10,000 in Medicare charges and having less than or equal to 100 Medicare patients, thus exempting him from MIPS. However, he will begin aligning with MIPS, aware that as his practice grows and his patients age, his patient mix will change.
Prepare Now for 2017
The pressure is on. Whether clinicians participate in MIPS or an APM track, they must begin developing strategies now that both improve their value-based benchmarks and address MACRA’s reporting requirements. Even if the 2017 start date is delayed, the effort to exceed current PQRS, MU3 and VBM benchmarks will be significant. Physicians and clinicians that employ efforts that raise their value-based performance now will be better positioned to excel under MIPS and APMs going forward.
Payers are also asking themselves – how will MACRA affect us? What, if anything, should we do to prepare?