MACRA's Biggest Hurdles

MIPS or Advanced APMs?

CMS has given practices an option of doing very minimal levels of reporting to avoid a penalty for 2017. Martie Ross, a principal in the Kansas City office of consulting firm, Pershing Yoakley & Associates (PYA), says that by far the easiest way to check the box for 2017 is to report one clinical practice improvement activity. "You should fire your practice manager if he or she can't figure out how to get you full points on Advancing Care Information and Clinical Quality Improvement Activity," she says.

But Ross added that practices should ask themselves the following question: Does it make sense for us to simply check the box in 2017, then focus our energies on more long-term strategies? For example, CMS promises to open up enrollment in Advanced APMs significantly for 2018 reporting. "You could develop lots of infrastructure to do quality reporting for MIPS or you could spend time evaluating Advanced APM options for your practice," she says. "If you think you are in a position to do well by these MIPS metrics, and you can identify the right measures and earn a bonus, then it is definitely worth the effort. But if it is a matter of positioning your organization more broadly for value-based reimbursement, I don't know that just dotting the i’s and crossing the t's on MIPS is going to get you there."

By: David Raths

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PQRS to MIPS Quality Metric Mapping

The 2,171-page final rule contains several differences that crosswalk existing PQRS measures to new finalized metrics. The simplest way to ensure your PQRS-to-MIPS transition goes smoothly is to search each quality metric and data submission method here.

Several important tables for your reference in the final rule:

·        Table A (Page 1,902) outlines each of the available MIPS Quality measures.

·        Table D (Page 2,019) explains each of the brand-new MIPS Quality measures.

·        Table F (Page 2,114) contains each of the PQRS measures that are no longer available in the MIPS Quality Program.

·        Table G (Page 2,126) identifies PQRS that were subjected to “substantial changes,” for the MIPS Quality Program.

Keep in mind, to submit enough data for a “moderate positive adjustment,” in the 2017 Performance Year, you need to submit 6 measures, including one outcome measure, or one high-priority measure for a minimum of a continuous 90-day period. Specialists can also report specialty-specific sets, some of which contain fewer than 6 measures but many include 10+ measures. 

Risk Stratification for Better Population Health Management

At a time when managing patients with chronic conditions has become increasingly vital, organizations can take various approaches to better understand their patient populations and manage their resources more effectively.

In 1996, when Montefiore Health System first began stratifying patients according to risk of utilization, the approach was fairly simple.

"We used very basic stratification models based on claims data that we received from payers," says Urvashi Patel, PhD, senior director and chief data scientist with Montefiore's care management organization.

That process in fact predated Patel's tenure at the New York City-based health system, which comprises 11 hospitals, a medical school, a school of nursing, and various primary and specialty care clinics.

That initial approach involved aggregating patient data from a variety of sources into several databases, then stratifying those patients into different categories based on their use of services and calculating a risk score, Patel says. For example, a patient visiting the emergency department (ED) multiple times for chronic conditions would be given a higher risk score than someone visiting the ED for appropriate care, such as a sprained ankle.

Today the health system takes a multipronged approach to risk stratification that includes rigorous analysis using statistical modeling, Patel says. But that basic method still plays a role.

"As we gained more experience, we started to bring in additional data elements, such as electronic medical record (EMR) data, when they became available," she says. The organization also takes into account nonclinical data, including health risk assessment information gathered internally, such as demographic data on financial and housing status, Patel says.

Managing patients with chronic conditions has become a central strategy in population health endeavors and other efforts to optimize the quality of care. Risk stratification enables providers to better understand their patient populations and manage their resources more effectively.

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By: Karen Wagner

Building the Foundation for Value-Based Care

Retooling the Core

Success in a value-based contract depends on three elements that are at the core of any healthcare operation: people, processes, and technology.

People. Value-based care requires teamwork from clinicians both inside and outside the primary care practice. Prevention, early intervention, wellness, and post-discharge care are provided by integrated care teams that include physicians, care coordinators, disease educators, pharmacists, and behavioral health specialists. In a high-performing model, hospitals, skilled nursing facilities, and other ancillary providers all understand and support the primary care clinical model and the goals of improved quality and efficiency, and network partners understand the need to use data to drive continuous improvement and commit to timely communication and data sharing. Transition of care management is most effective with timely notification of admissions and discharges. Hospitals and specialists unwilling to help primary care physicians manage their patients to the best clinical result will be excluded from primary care physicians’ networks. And hospitals that own primary care practices will obtain marginal benefits from such ownership if they do not provide such essential support to the physicians.

Processes. Processes that promote greater coordination of care should be explicitly defined and implemented. Delivering comprehensive, coordinated care requires the use of guidelines and best practices aimed at reducing variation and promoting clinical excellence. Clinical standardization applies not only to physicians, but also to any point of contact within the care delivery system for patients, whether it be a provider, a facility, a support staff member, something less tangible. The way phones are answered, patients are scheduled, and nurses are used to help complete quality metrics each presents an opportunity for reducing variability and improving outcomes.

Technology. Technology can be a lifejacket or an anchor. Technology that integrates data from diverse sources, assists in risk stratification, or improves patient outreach and education is critical for success in a value-based contract. The key for primary care physicians is to use technology that helps drive their clinical models rather than attempt to change their clinical models to fit the capabilities of the technology. Technology should help primary care physicians execute their strategies, not define them. Technology that puts data in the hands of physicians at the point of patient care will create the greatest impact. For example, all clinical notes from the physician, care manager, diabetic educator, and pharmacist are loaded into the electronic health record (EHR) and accessible to all members of the care team at the point of care. Outside claims data also are integrated into the EHR so it can generate alerts to gaps in care, which can be addressed while the patient is present in the office.

Executing the Value: Village Family Practice

Understanding the components of a value-based contract and the work necessary for success is step one; next comes the hard work. Many physician practices struggle to implement the programs, processes, and outreach that truly provide benefits for patients. Identifying high-risk patients does not reduce risk. Hiring a care management nurse does not reduce readmissions. Providing a patient a handout on a chronic disease is not the end of patient education.

By: Healthcare Financial Management Association

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Mixed reactions to CMS tool predicting impact of MACRA on providers' bottom line

The CMS is considering unveiling a new web tool that helps clinicians assess the potential impact of merit-based incentive payment systems (MIPS) on their reimbursement. It will also help them evaluate their performance under the system and provide tips to improve scores. The tool could help ease concerns about the risk undertaken in the new payment models.

Under MIPS, which were mandated under the Medicare Access and CHIP Reauthorization Act, physician payments will be based on a compilation of quality measures and the use of electronic health records. 

By Virgil Dickson 

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AGA Advocates to CMS for GI APMs

AGA leaders Larry Kosinski, MD, MBA, AGAF, clinical councillor, AGA Institute, and Joel V. Brill, MD, AGAF, AGA CPT advisor, met with high ranking officials from CMS and the Center for Medicare and Medicaid Innovation to advocate for the inclusion of specialty alternative payment models (APMs) in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). AGA asked CMS that GI payment models that demonstrate positive clinical and fiscal results, such as Project Sonar, be recognized as a Clinical Practice Improvement Activity (CPIA) and represent a path to qualify as an APM in 2018.

By: American Gastroenterological Association

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CMS will give providers flexibility on MACRA requirements

The CMS on Thursday announced it will allow providers to choose the level and pace at which they comply with the new payment reform model aimed at emphasizing quality patient care over volume.

The announcement comes after intense pressure from industry stakeholders and policymakers to ease implementation of the Medicare Access and CHIP Reauthorization Act, which is set to start Jan. 1, 2017. Two months ago, CMS Acting Administrator Andy Slavitt said the agency was considering delaying the start date.

Next year, eligible physicians and other clinicians will be given four options to comply with new payment schemes such as the Merit-based Incentive Payment System (MIPS) or an alternative payment model such as accountable care organizations.

By Virgil Dickson

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3 Steps to get ready for MACRA

Many practices are not sure how best to approach and prepare for compliance with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) payment reforms. Here are some short-term changes practices can implement to prepare.

Start small with a focus on quality

Due to the size and scope of MACRA, it’s wise for practices to start small with a targeted strategy when approaching compliance. Since quality accounts for 50% of the total Merit-based Incentive Payment System (MIPS) score in the first year—and most commercial payers are also moving towards linking fee-for-service payments to quality measures—this is a good area on which to focus initially. 

To comply with the regulation’s quality requirements, providers will need to report six measures from a list of nearly 300. Scores will be linked to performance on these measures (in the style of the Value-based Modifier), rather than the simple reporting of measures (as in the Physician Quality Reporting System).

By Chris Emper

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MACRA doesn't spell the end of Independent Medical Practices

While the Medicare payment reform law Congress passed last year poses numerous challenges for independent medical practices, it will not doom them. In fact, practices that understand how they will be evaluated under the law may be able to improve their bottom lines when the law takes effect.

That was the consensus of participants in the Medical Economics roundtable discussion of the issues medical practices confront today, held during the National Society of Certified Healthcare Business Consultants’ 2016 annual conference in Palm Springs, California.

"There are opportunities to do better under this model if you've got your act together and you understand the opportunities to increase [revenues] really are there," said panelist Max Reiboldt, CPA, president, and chief executive officer of Coker Group, a healthcare consultancy. "It's going to be different, though,, and change is hard to adjust to."

His observations were echoed by Dave Zetter, CHBC, founder of Zetter HealthCare, a medical practice management consulting group. “Those that understand what they’re doing and know how to manage the process, especially in the first couple of years, are the ones that are going to be making the bucks,” he said.

By Jeff Bendix

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Small Practices Forging Ahead in Value-Based Care

There is a lot of skepticism in the physician world on whether or not "value-based care" — where providers are reimbursed based on quality measures, rather than quantity — can work.

In an upcoming, yet-to-be-released survey from Physicians Practice, more than 50 percent of physicians (1,314 were surveyed) said value-based care was a good idea in theory, but difficult in practice. A smaller group, approximately 20 percent, went so far to say that it was a bad idea that would never succeed. Only 6 percent of respondents said it was a good idea and good for patients.

Yet despite the fact that value-based care may not be winning the hearts and minds of physicians across the country, CMS is attempting to do just that before those doctors have to get on board. The agency recently proposed a rule to implement the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), mandating two tracks for physician reimbursement — the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).

Most physicians will fall under the former, where they'll be scored on quality measures, usage of technology, clinical improvement, and cost utilization. APMs require participation in Medicare-based payment models such as accountable care organizations (ACOs) and Patient-Centered Medical Homes (PCMHs). In the past few months, CMS has spent a copious amount of time to get physicians on board, through webinars, speeches from officials at professional meetings, and more.

By Gabriel Perna

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Physicians: MACRA Threatens Small Independent Practices

Nine out of ten solo practices plan to minimize Medicare volume to avoid filing quality and clinical practice improvement reports or cost performance reports to CMS, survey data finds.

Federal legislation that aims to improve healthcare quality and reward those improvements with incentives tied to reporting bodes ill for the dwindling supply of small physicians practices that accept Medicare.

The culprit is the Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA), which passed in 2015.

A BlackBook Research survey of 1,300 physician groups of five or fewer clinicians found 67% of such physician practices believe their independence will end with MACRA.

By HealthLeaders Media

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Which MACRA Track Makes Sense?

At the heart of the new Medicare physician payment plan, outlined in an April 27 proposed rule, is a key question for hospitals and physicians: “Which of the participation tracks makes the most strategic sense?” says AHA’s Akin Demehin, senior associate director of policy.

The two Medicare Access & CHIP Reauthorization Act tracks introduce new acronyms: the Merit-based Incentive Payment System, or MIPS, and the advanced Alternative Payment program (APM).

MIPS is the default track that the Centers for Medicare & Medicaid Services culled from the current physician quality reporting and meaningful use programs. Under MIPS, a pay-for-performance approach, physicians receive annual bonuses or penalties — beginning at 4 percent in 2019, the first payment year — based on their performance in four categories: quality, resource use, health information and clinical practice improvement.

By Maggie Van Dyke

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Population Health's Impact on the Private Practice

As the push to implement population health initiatives gets underway, Lonnie Joe, MD, is still mulling over whether his private practice can survive the changes he’ll have to make to participate in this emerging model of care.

Like many private practice physicians, Joe, an internist who has been practicing for almost three decades, is trying to tailor his four-year-old group practice in Detroit, Michigan, to meet the defined goals of population health: identifying groups of patients with specific medical conditions such as diabetes, hypertension, or cancer, and implementing a variety of health management approaches to improve these patients’ outcomes.

With a population that is aging rapidly (the number of people aged 65 and older is projected to be 83.7 million by 2050, compared with 43.1 million in 2012), the urgency to build a smarter healthcare system that targets older patients, patients with chronic illnesses and others who are more susceptible to worsening health conditions requires a fundamental transformation in how care is delivered and paid for.  

Population health is one of many health reform initiatives that stakeholders claim will slow the rise in healthcare costs and improve patient outcomes. However, for small-to-medium size physician practices, implementing this model often will require redesigning their practices as they adopt new incentive payment models that involve taking additional steps to closely monitor patients so as to improve their health. 

Such an endeavor requires additional staff, better patient engagement and more technology to support population health initiatives. 

“Implementing a long-term population health strategy at private practice physicians’ offices requires a team-based model of care with skilled personnel and infrastructure, all of which requires adequate financial support,” says Nitin Damle, MD, FACP, president-elect of the American College of Physicians.  

By Nicole Lewis

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