Even midway through last year, the Quality Payment Program (QPP) within the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, was still a source of mystery to healthcare professionals.
While the vast majority of healthcare professionals who participated in a MACRA QPP survey in 2017 say they were prepared for the requirements of the MACRA’s Merit-based Incentive Payment System (MIPS), more than half were unaware of the 26 percent difference in payment between top and bottom performers.
One factor that is certain about MACRA’s QPP, or any value-based care payment program, is that commercial and government payers are incentivizing better population health management (PHM) of patients with chronic conditions. As such, healthcare providers need to explore methods to eliminate manual data searching and reporting to monitor those patients and begin to automate intervention processes.
Integrating automation where it is safe and effective enables healthcare organizations to devote their limited care-management resources to the most challenging, high-risk patients, leading to greater care quality and financial returns regardless of the value-based care payment program.
Peer performance affects MIPS payment
In our recent MACRA MIPS survey, 800 healthcare professionals from around the country were polled. The results found that 90 percent of those surveyed believe they are up-to-date on all MIPS and MACRA legislation as it pertains to them and nearly 90 percent believe they can meet MIPS requirements.
Even though these professionals felt prepared, 40 percent reported they did not understand or were unsure about payment adjustments that will be made by the Centers for Medicare and Medicaid Services (CMS) in 2019 based on providers’ performance last year. What’s more is half of respondents were not aware that the payment difference between maximum negative and exceptional performance is 26 percent.
This payment difference is due to the peer-based performance incentives included in MIPS for providers who report the highest quality metrics. For 2017, the top performing quartile could receive as much as a 22 percent payment bonus, while the lowest performing would receive a 4 percent penalty. By 2022, the difference could reach 46 percent due to increased bonuses for top performers and penalties for poorer performance. Considering the large portion of revenue most healthcare organizations receive from Medicare, this payment swing could have a massive impact on sustainability.
Staying ahead with advanced information technology
If MIPS were providers’ only pay-for-performance program, it would be challenging enough. Yet CMS has 74 programs and initiatives surrounding value-based care payment. Meanwhile, major commercial payers, including, Aetna, Anthem, Cigna, Humana and United Health Group, are all transitioning to value-based care compensation models.
Providers may only participate in a handful of value-based care payment programs, but monitoring performance and delivering care to maximize those incentives is still a labor-intensive proposition.
Utilizing sophisticated PHM technology can help providers stay ahead. Such advanced platforms not only make monitoring patient populations more efficient, but can also automate patient interventions based on timely and reliable data integrated from multiple sources.
Data sources such as claims and clinical data are the foundation to these technologies. From this baseline, providers can incorporate other crucial information into their PHM analysis. These include social determinants of health data points, including:
• Physical environment. Air and water quality; housing type, access to transportation and proximity to grocery stores.
• Behavioral. Diet, exercise, tobacco- and drug-use; stress, adherence history information, and even metrics on estimated likelihood to modify behavior.
• Social. Education level, literacy, employment, income, financial history, neighborhood, and highly granular data such as the distance away from the closest relatives.
Diverse and deep datasets that are aggregated and normalized for constant analysis present a much clearer and more accurate picture of the patient compared to claims and clinical data alone.
Targeted outreach that changes behaviors
With rich datasets that include information on social determinants of health, providers can begin to group patients according to care quality goals, such as those associated with MIPS. For example, a population can be created based on patients with diabetes and hypertension, that are older than 65 and who have HbA1c test scores within a certain threshold.
Once these rules are in place, care managers can create campaigns to automatically notify patients either through two-way email, text messages, interactive voice response phone calls, postal mail and other methods to help them adhere to their care plan. Care managers can tailor campaigns based on what would most likely elicit a response and modify behaviors. This communication insight could also come from a diverse and broad set of social determinants of health data.
Advanced PHM technology enables patients to move in and out of these at-risk groups based on timely test results, such as if the patient maintains a lower HbA1c score, controls their hypertension or loses weight. More accurate and reliable analysis allows care managers to focus attention on higher-risk patients who are less responsive to outreach.
More touch points, better outcomes
As a result of the automated interventions, patients are contacted using their preferred communication methods seven to 10 additional times in a month without giving more work to already overburdened care managers.
Technology-assisted interventions have already demonstrated efficacy. For example, a 2016 study of text message medication reminders found it doubled the likelihood of adherence to regimens.
Through analyzing and targeting patient populations, aligning population health initiatives with value-based care goals, and combining with other outreach methods and reliable PHM insight, organizations can position themselves for success in MIPS or any other value-based care payment program.
About the author:
Gary Hamilton is chief executive officer of InteliChart