Driving reimbursement success in MACRA: Five key trends

As organizations scramble to keep up with regulatory requirements, one that has been at the center of many Medicare providers’ conversations is the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

MACRA is an example of recent regulatory changes impacting the industry’s shift to improve health quality through value-based care. This is evident with the Centers for Medicare and Medicaid (CMS) most recently announcing updates to MACRA for physicians in 2018, aimed at easing their burdens in small and rural practices. To drive healthcare delivery, CMS has provided resources for providers to clarify these requirements and support providers’ efforts. However, the shift from the old to the new is posing a host of new challenges, which demand new approaches to care delivery, data collection and technology. Below are five trends providers should consider as they navigate the new MACRA requirements.

Interoperability: Organizations lacking integrated operations will face challenges that could lead to common care issues. For example, the inability to provide the full care continuum of services required to effectively service a patient, or the inability to execute effective decision making due to disparate financial and clinical operations. To tackle these challenges and enable better design of the end-to-end patient care experience, organizations must look to tools such as patient flow diagrams, and layer in financial and clinical data. This enables providers to drive decisions on the flow process and enhance care, both at the patient level, and at the population care level.
People Leadership & Accountability: keeping up with shifting regulatory requirements is often easier said than done, and is never a one-size-fits-all approach. A specific regulation can be implemented in various ways, which can create challenges within the organization, people and accountability during the change process. Since MACRA largely impacts providers and physicians, there may be challenges around measuring individual costs versus group costs, and difficulty getting buy-in from physicians. By identifying a physician champion, coupled with a strong change management plan, organizations can overcome this barrier and correctly identify high cost or high risk from variations in practice and treatment.

IT & Analytics: The most important puzzle piece in streamlining operations and efficiencies is ensuring data integrity. If healthcare organizations lack IT enablement, data integrity will be compromised. And lack of data integrity will compromise true interoperability. Providers that address these capabilities will drive long-term success with MACRA. This can be accomplished by implementing a strong analytics platform, coupled with excellent analytics capabilities. Furthermore, IT investments for these types of enablers must be met with a clear data management plan, a data warehouse investment or upgrade, as well as a data quality assessment. This will allow organizations to use an analytical tool to compare various treatment choices and costs associated with various health outcomes, which will be key to reducing costs, while increasing quality and patient-member experiences.

Patient Engagement: To effectively drive patient engagement, payers and providers must ensure that the patient population isn’t too large or too small, so that organizations can effectively manage upside/downside risk while meeting the needs of its patients. Another challenge includes low patient satisfaction and poor perception, which can be gauged through surveys or Consumer Assessment of Healthcare Providers & Systems (CAHPS) scores. As a result, organizations must refocus their strategies to appropriately steer and impact patient-member behaviors. Especially for MACRA measurement and reporting, gauging these behaviors is key to understanding and controlling patient population.

Clinical Improvement: Leveraging quality improvement efforts across MACRA and other Medicaid measures is crucial in ensuring that efforts are concentrated and organizations can drive success. A major challenge in clinical improvement is physician autonomy – often times, seasoned physicians may have a specific way of rendering care, that may not align with the majority of others in the practice. Physician autonomy can significantly impact data measurement for MACRA reporting, skewing the outcome, while affecting the patient’s health. Organizations looking to overcome this challenge should implement training, compliance auditing/monitoring and patient feedback/surveys to gain additional insight to drive standardization, produce consistent data and higher quality with MACRA reporting.

Decentralized supply chains also challenge the clinical improvement process, when areas that drive end-to-end clinical improvements are segregated and siloed. Supply chain management is key to breaking down these siloes. Strategies to address this include: long-term acute care contracts for high cost patients, standard care protocols, using a centralized formulary and having an identified leader for supply chain management.

Looking Ahead
As the healthcare industry navigates a major transformation towards MACRA implementation and value-based care, it’s imperative that stakeholders look to new strategies to improve healthcare delivery and reimbursement. By embracing these trends, payers and providers can drive success, incentivize population health and ultimately provide better outcomes.

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