Since it was first proposed by the Centers for Medicare & Medicaid Services, the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA, has generated much confusion and uncertainty.
This complicated piece of legislation, which modifies the physician reimbursement schedule issued by Medicare, aims to drive the healthcare industry toward better care, smarter spending, and healthier people with its key provisions. Ultimately, the goal of MACRA is to shift healthcare delivery in the United States from a fee-for-service model to one based on the concept of fee-for-value.
This legislation will fundamentally change the reimbursement model that currently covers healthcare providers serving nearly 90 million consumers. MACRA's Quality Payment Program establishes a two-track system for Medicare reimbursement: the Alternative Payment Model and the Merit-Based Incentive Payment System, or MIPS. Initially, the vast majority of providers who operate under the Medicare framework will fall under the MIPS payment program, with the use of Alternative Payment Model expected to grow over time.
The good news is that healthcare providers can benefit from MIPS by understanding the types of performance it seeks to measure. Providers that appropriate value-based healthcare measurement tools can position themselves now to optimize reimbursement opportunities later. By identifying and implementing measurement instruments that are consensus-recognized within a given specialty, healthcare organizations can gain a significant advantage before MIPS is finalized and the payment periods begin in 2019.
MIPS performance categories
MIPS establishes four performance categories, each focusing on a distinct area of a clinical practice: quality, advancing care information, clinical practice improvement, and resource use. Scored measurements from each of the four categories are then weighted and used to calculate each provider's composite performance score.
A provider's score will be used to determine whether any adjustments will be made to the reimbursement amount. If a provider's composite score falls below the performance threshold, a negative adjustment may be assessed. Providers that fall in the lowest quarter of the scale automatically receive a 4 percent reduction. Yet an upside exists, as providers can now earn positive adjustments for rising above the performance threshold.
• Quality: Providers will choose six measures to report, compared with the nine currently required under the sunsetting Physician Quality Reporting System. Among the six measures, providers will choose one cross-cutting measure and one outcome or other high-quality measure. It makes up 50 percent of the first-year composite performance score.
• Advancing care information: Formerly meaningful use, the advancing care information category requires providers to use certified electronic health record technology. Providers will choose a customizable set of measures to report their daily use of health record technology, emphasizing both interoperability and information exchange in particular. This makes up 25 percent of the first-year score.
• Clinical practice improvement activities: MIPS will reward providers who offer activities such as coordinating care, engaging with beneficiaries, and exercises in patient safety. Providers will be able to choose from more than 90 options on an approved activities list. This constitutes 15 percent of the first-year score.
• Resource use: MIPS will also calculate the composite performance score on the basis of Medicare claims, so there will be no additional cost reporting requirements. The category has anticipated variations between specialties by providing 40 episode-specific measures. This last category makes up the final 10 percent of the first-year score.
Anticipated delay adjustments
It is clear that the scope and complexity of recalibrating the Medicare payment schedule toward a value-based system is not going to be done overnight. Providers warrant extra time to identify relevant measures, focus on performance improvement, and figure out reporting mechanisms. In addition, technology vendors need time to develop, deploy, and integrate into clinical workflow.
Yet any delay might very well be short-lived, as MACRA identifies Jan. 1, 2019, as the release date of the first round of CPS and the start of payment adjustment on the basis of performance. The Centers for Medicare & Medicaid Services might choose to measure only the last six months of 2017 instead of measuring performance for the entire year.
As CMS Acting Administrator Andy Slavitt told the U.S. Senate Committee on Finance, such expansive new rules require adaptation by the healthcare industry, prompting the possibility of a delay in MACRA start dates. "We understand new rules require adjustment and preparation," he said.
Migrating to value-based healthcare
Early focus on incorporating the new metrics into the workflow will allow organizations to better enhance their performance scores from the beginning and better position themselves to benefit from incentives built into the payment structure. Under MACRA, providers can submit their performance outcome measurements through third-party intermediaries, such as qualified clinical data registries, that may optimize the reports.
Consider the following suggestions for healthcare providers:
1. Evaluate your electronic health records technology. If you already have an EHR system, make sure it relies on 2015 certified health information technology. The version will determine the measures on which you report in 2017.
2. Choose compatible IT vendors. Requirements are bound to continue evolving even after MACRA is in place, so be sure to identify and engage with IT vendors that are willing to keep up. Vendors should support new payment model adoption to ensure a stronger performance score for your organization.
3. Participate in a patient clinical data registry. MACRA will allow registries to submit data for performance categories on behalf of healthcare providers. The optimized reports can boost overall performance scores. If you aren't already participating, then find out how you can start by contacting your specialty society.
4. Understand your current quality measurements. Find out how you are currently scoring in quality across both Medicare's Physician Quality Reporting System and Private Payers. Identify areas you'll need to improve to meet the new performance categories' measurement requirements. Determine whether your specialty society offers consensus-recognized measurement recommendations.
Providers and healthcare organizations are legitimately concerned about how MIPS will affect their abilities to operate and prosper. The proposed delay gives a slight reprieve from the anxiety, but providers can and should begin preparing for the change as early as today, just in case.
Velyn Persaud is a doctor of medicine and a graduate of Columbia University in New York, with a master's degree in health administration. As the compliance analyst, Dr. Persaud ensures that Columbia, Missouri-based OBERD continues to play a major role in the nation's healthcare transition toward value-based care. Her expertise is in navigating compliance and identifying risks with new and existing laws, regulations, and requirements in the healthcare field.
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