The Medicare Access and CHIP Reauthorization Act instituted major changes to providers' payment models and increased the need for strong coordination among healthcare organizations.
As providers take on more risk through MACRA's various alternative payment models, they must look to health plans with experience in managing risk, according to Karen Way, health plan analytics and consulting practice lead at Plano, Texas-based NTT DATA Services.
Ms. Way spoke with Becker's Hospital Review about MACRA's influence on payer-provider relationships and what further collaboration could look like for both parties.
Note: Responses have been lightly edited for clarity.
Question: What effect does MACRA have on payer and provider cooperation?
Karen Way: [MACRA's] measurement criteria are similar for health plans and providers, especially in regards to the clinical quality metrics. Health plans usually have more sophisticated systems and centralized data repositories, such as enterprise data warehouses. Smaller providers may not have this [and] may just have an EHR. Health plans can leverage their advanced analytics capabilities to help providers meet MACRA requirements. As health plans work to identify high-performing providers and health systems report under the Merit-Based Incentive Payment System and the Advanced Alternative Payment Model pathways, facilitating data sharing with each other should be part of a value-based care contract.
Health plans should also be able to help providers educate their patients on the costs of care and the treatment options. There continues to be an increasing need for open and effective communication between all parties in the healthcare lifecycle. In effect, collaboration between payers and providers is critical.
Q: How does MACRA affect risk-sharing relationships between payers and providers?
KW: Health plans could provide significant support for their provider networks. Health plans could help providers better understand the risks by providing insight via analytics and how to avoid taking on more risk than can be handled. There will likely be additional financial impacts (and therefore risk) due to MACRA as a result of continued provider consolidation and attempts to shift costs to other payers. Both of these factors will make contract negotiations more difficult and increase both cost and risk. Because MACRA is about managing risk in populations and financial risk through the reimbursement process, health plans need to remain flexible and willing to support providers on their network.
Q: How does MACRA encourage data exchange between payers and providers?
KW: Data exchange and the need for interoperability is going to become more important under MACRA. This legislation has been a big factor in a lot of joint ventures between payers and providers. I'm not sure I've seen enough outcomes of the JVs to say whether it is positive or negative, but it's one way we could solve the [interoperability] issue.
Provider-owned health plans, ACO markets and integrated health systems are exchanging data as well. Those are also great opportunities to bring the information together to benefit both health plans and providers. As was mentioned earlier, because there are similarities in the quality reporting requirements for health plans and providers, both are beginning to see the value in sharing data. With this understanding, the need to resolve interoperability issues is now a priority.