More on Reimbursement

Here are the MACRA questions every healthcare provider must ask

The new rule hopes to drive the mass transition to value-based reimbursement.

Beth Jones Sanborn, Managing Editor

MACRA is the next generation of healthcare legislation, and it's sweeping. The new rule hopes to drive the mass transition to value-based reimbursement, with doctors getting paid based on the quality of their work and the steps they take to improve their practices.

The successor to the Sustainable Growth Rate rule, MACRA replaces the cuts with a 0.5 percent guaranteed increase in payments, followed a few years later by a freeze in payments. The law also takes the existing physician quality reporting system (pay-for-reporting), meaningful use of electronic health records, and the value-based payment modifier (pay-for-performance) and rolls them into one giant program called the Merit Based Incentive Payment System. MIPS has one scoring system and one set of dollars at risk.

"At first, it does actually lower the dollars at risk and then grows it back up," said Danielle Lloyd, Deputy Director of Premier Washington D.C. office and their VP for Policy and Advocacy. Premier Inc. helps healthcare entities improve performance. "Part of that is in recognition that in creating this program, it is going to take some time to understand it."

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[Also: Half of U.S. doctors in the dark when it come to MACRA, Deloitte says]

With MIPS, eligible clinicians will be measured and paid based on four primary metrics: quality, resource use, clinical practice improvement activities and meaningful use of EHR systems. Under a second path, if you also participate in alternative payment models at the same time, you get special preferential scoring under MIPS. Some of these APMs, like accountable care organizations, carry no direct risk and can provide a boost in MIPS performance, but this track has a time limit of six years before you either have to move up to risk or move down to MIPS alone, depending on how you fared, Lloyd said.

Advanced APMs represent a third path, and providers can get 5 percent bonuses on professional services and get out of MIPS if they participate. This most advanced path involves even higher levels of reimbursement but assumes the highest risk.

"The idea is to try to use a carrot to get organizations to move over to the more advanced payment models," Lloyd said. "The intent of the MACRA bill is absolutely consistent with the administration's goal of having 50 percent of traditional Medicare fee for service in APMs by 2018, but the Advanced APMs for which you get a bonus under MACRA is only a subset of the administration's definition." Depending on the final rule, CMS is shooting for only 10 to 15 percent of eligible clinicians getting the 5 bonus at first.

Lloyd said it's best to figure out your strategy now, as payments in 2019 are based on performance in 2017. Barring a delay that was hinted at as a possible option by CMS Acting Administrator Andy Slavitt at a July 13 Senate Finance Committee hearing, implementation could be just a few short months away. Lloyd said there are going to be questions you have to ask yourself to decide which strategy to take.

Who are your eligible clinicians and how are they structured?

This is not just about physicians. There are other professionals within your organization to whom MACRA applies and this question will determine how much revenue is at risk for MIPS. This question is also a necessary foundation for the other questions that follow, Lloyd said.

How do you optimize MIPS reporting and performance?

"Everyone is going to have to hedge their bets at first," Lloyd said.

The way the system is set up today, virtually everyone will have to start out under MIPS because even those seeking to become exempt won't know if they have succeeded until after the performance period for MIPS closes.

Lloyd said providers should be asking what reporting mechanism makes sense for their practice. For instance, small groups might find there are enough measures under the claims option to suffice and consider that the easiest path. Large groups might want to take advantage of the sampling methodology. It is important to note that neither of these give routine data or benchmarks so anyone looking for actionable information to improve might want to use qualified clinical data registries.

Consider what reporting mechanism makes sense, what measures you would perform best on, whether you feel confident in your ability to perform well under these measures, and ultimately if you want to stay under just MIPS, Lloyd said.

Should I participate in an APM, and do I want to do a MIPS APM or Advanced APM?

As described above, there are three paths a provider can follow under MACRA's payment program. Once you decide whether you can participate in an alternative payment model, then you need to decide which path is best. Look at what models are available in your area, as some are geographically based, and also what is available for application. There are application periods that need to be taken into account. For instance, you must be part of an ACO in 2016 if you want to report performance in 2017 for 2019 payment, Lloyd said. You also need to look at whether you meet eligibility requirements, think about market dynamics, as well as the financial implications of each model, and your appetite for risk. Some APM's carry more risk than others.

Lloyd also advised taking a look at how big your network is and whether you have the right composition. "In ACO's, primary care doctors really drive the attribution, so you have to consider whether you have a sufficient primary care network versus if you're going to oncology care model you need to be looking at those specialists," Lloyd said.

One thing to remember if you go with a MIPS APM, a one-sided model that carries no direct risk, you still have to be building your capacity to take on risk even while maximizing your time as a MIPS APM. "When you're in that middle bucket you can't wait til the end of the six years to think about taking on risk," Lloyd said.

If you take on an advanced APM model, how do you ensure success and maximize gains?

Lloyd said you need to have built up risk capacity, applied early enough, and need to be thinking about your private insurance contracts on several levels: whether they are up for renewal, whether private payers are offering models that meet the requirements and what kind of data can you get from those payers, like claims data for example.

You also need to think about state based issues: Are there medical home models in your state? What are the licensure requirements around risk? And is a separate legal entity required by your state for the advanced APM where you are seeking to participate?

How are you communicating your strategy to your organization, the clinicians you work with and to your community partners?

If your organization is to successfully navigate MACRA and flourish, then everyone needs to be on the same page, Lloyd said.

It's important to remember that MACRA isn't finalized yet. The official, finalized rules will be published for implementation in November, at which point providers will be expected to quickly prepare for reporting in 2017.

Those reports will determine reimbursement, and penalties and bonuses where applicable, in 2019.

However, CMS Acting Administrator Andy Slavitt on July 13 told the Senate Finance Committee that they were open to a delay in MACRA implementation, among other areas of flexibility, based on thousands of public comments. So it's anyone's guess as to whether the original proposed timetable will play out.

No matter when the rule takes effect, Lloyd stressed the importance of acting now and seeking help and/or funding for necessary upgrades if needed.

"No matter how this is finalized, it's very complex. It will be hard for smaller groups to grapple with the complexity, but that doesn't mean they have to seek employment or aggregate up. They can form virtual groups or can look to organizations to help them understand what the changes are and focus on quality reporting and improvement at a minimum," she said.

"As long as you have someone to work with in that area you can be successful. Understand what the rules of the road are, have a mechanism to understand where you need improvement, and find your opportunities."

Twitter: @BethJSanborn