Health Plans: Prepare Clinicians for Success with MACRA to Avoid Expensive Cost-Shifting Measures

September 15, 2016
Heather Lavoie, Chief Strategy Officer, Geneia


Clinicians are the front lines of every healthcare system. Whatever impacts them will impact others, including health plans.

When clinicians and the health systems and practices that employ them pay penalties and lose money on their Medicare patients, they frequently offset those losses by increasing rates on commercial health plans. This process is known as cost-shifting and it happens to a greater degree than most realize.  For example, recent research in southeastern Wisconsin reveals, “cost-shifting is responsible for 35 percent of the overall commercial rates paid.” To reduce the need for cost-shifting, health plans can take steps to ensure their providers receive appropriate reimbursement for Medicare patients.

The Composite Performance Score

Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), most physicians clinicians will be reimbursed via the merit-based incentive payment system (MIPS). The composite performance score (CPS) is the scoring mechanism for eligible clinicians.

The CPS contains four main categories to measure and score eligible clinician performance:

  • Quality
  • Resource Use
  • Clinical Practice Improvement Activity
  • Advancing Care Information
Quality, resource use and advancing care information categories are complex entities containing multiple measurement variables. Thankfully, they are similar to previous programs such as the MIPSblogTestPhoto1Physician Quality Reporting System and Meaningful Use. New to the mix is the clinical practice improvement activity category. The Centers for Medicare and Medicaid Services (CMS) states the overarching goal of this new category is to promote activities that drive innovative care delivery methods and ultimately enhance patient outcomes.

Clinical Practice Improvement Activity (CPIA)

Because the CPIA category is heavily weighted, it is a valuable piece of the overall composite performance score. At first glance, the CPIA category appears straightforward in nature. For example, clinicians only have to report on one of approximately 90 options and reporting improvement beyond one option earns a prized bonus point for each successful improvement. The challenge is twofold – the penalty for not reporting improvement in an accurate and timely fashion and the focus on population health techniques, such as:

  • Leveraging telehealth
  • Employing longitudinal care plans
  • Improving care coordination through regular training
  • Using evidence-based medicine
  • Applying patient engagement techniquesEnhancing patient health literacy

Challenges of Improving Population Health Techniques

Population health techniques have tremendous potential to improve patient outcomes. However, to succeed within this measurement category, eligible clinicians need education to improve existing skills and to establish baseline skills where none exist.

Barriers to education include the motivation for clinicians to seek out training on their own and for provider practices to implement change. Because nearly half of physicians with 30 percent or more of Medicare patients are unaware of MACRA, there is little likelihood of change.

MACRA reimbursement changes begin in 2019, based on performance in 2017. Clinicians will not be prepared for a measurement year they are unaware of.

Another significant barrier to clinician education and training is their time-constrained schedules. Dealing with the challenges of the rapidly changing care delivery environment has already restricted the flexibility of a clinician’s schedule, and taking the time to attend traditional educational programs is not always feasible.

Role of Health Plans

Health plans can help improve awareness of MACRA requirements and provide meaningful training that fits into clinicians’ busy schedules to help them succeed in the CPIA reporting category.

One option is making The Geneia Institute (TGI) available to a health plan’s network clinicians. TGI offers dynamic eLearning modules that provide clinicians with the skills needed to succeed within the CPIA category. These modules are:

  • Self-paced
  • Autonomous
  • Time conscious
  • Available anytime and anywhere with an Internet connection

TGIselfPacedTrainingTextInsertThe Geneia Institute’s online programs also satisfy certain training requirements found within the clinical practice improvement activity category. For example, we offer multiple ‘micro’ courses that satisfy the requirements for:

  • Beneficiary Engagement (sub-category of CPIA):
    • Engage patients and families to guide improvement in the system of care
    • Provide self-management materials at an appropriate literacy level and in an appropriate language

A micro course is 15 minutes – or less – in length and can be repeated multiple times for maximum impact. Micro courses that satisfy the category mentioned above include:

  • Health Literacy
  • Teach-Back Method
  • Cultural Competency

These engaging courses educate eligible clinicians on useful techniques to fulfill the required reporting options.

MACRA is full-steam ahead and eligible clinicians must be prepared to thrive within its measurement categories and report on performance in 2017, whether for the full or partial calendar year. With the right educational tools in place, eligible clinicians will succeed in improving the outcomes of patients through new population health techniques.

The clinical practice improvement activities (CPIA) category of MACRA is just one aspect of Medicare reimbursement. But, health plans must help wherever they can to ensure clinician success with MACRA and Medicare reimbursement to alleviate the need for expensive cost-shifting measures.


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