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MACRA – What You Don’t Know Can Hurt You

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Earlier this year, the Deloitte Center for Health Solutions 2016 survey of U.S. physicians queried a subsample of 523 physicians (non-pediatric specialties) about the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The initial findings presented some interesting surprises to various stakeholders across the entire healthcare industry.

In a nutshell, MACRA is the new Medicare payment law driving the healthcare industry toward the path of value-based care and away from fee-for-service models. By aligning payment with quality and outcomes, MACRA offers financial incentives to healthcare providers who take part in risk-bearing, coordinated care models. The initial law was passed in 2015 and the first set of proposed rules were published in May 2016. The final rule was published by the US Centers for Medicare and Medicaid Services (CMS) in October 2016, with the law taking effect Jan. 1, 2017.

What MACRA Entails 

Physicians (and other clinicians paid under the Medicare fee schedule) who bill more than $30,000 a year and provide care for more than 100 Medicare patients a year will be required to follow MACRA and will generally choose between participating in Alternative Payment Models (APMs) or receiving payment based on individual or group performance under the Merit-based Incentive Payment System (MIPS) for reimbursement.

In that Deloitte survey, about half of physicians with more than 30 percent of Medicare share in their practices said they had never heard of MACRA. Despite recent news media reports of that number falling to about 25-30 percent, that’s still a huge chunk of healthcare providers who are unaware of an industry shift that promises to change how they deliver healthcare and how they are reimbursed for their work.

As a practicing physician, I’ve talked with many of my peers during the past year – very few have any real understanding of MACRA. Putting one’s head in the sand simply is not an option because this new law will impact physicians whether they’re prepared or not.

What Providers Should Understand 

The first thing that providers need to understand is that MACRA replaces and consolidates current programs, such as PQRS, Meaningful Use, and the Value-Based Modifier (VBM), into a single program. That said, it does not abandon the focus on increasing the quality, reducing costs, and doing that in an environment of enhanced EHR use by innovative care models that were already an initiative through these earlier programs.

To become better versed in MACRA and the different payment models available, CMS built a website, Quality Payment Program, aimed at educating healthcare providers who are subject to the new MACRA law. The website guides users through MACRA, with particular emphasis on the first year of the program beginning on Jan. 1, 2017.

Recognizing that any new law with this significant of a shift in reimbursement models requires some flexibility, CMS developed a “pick your pace” program with options providers can take to begin their transition to MACRA for data that will need to be submitted by March 31, 2018.

Providers and practices that have a strong focus on quality and cost and are familiar with reporting against quality measures and how to interpret their data relative to cost, can begin to fully participate in the new program beginning Jan. 1, 2017. By doing so, they will have the opportunity to enjoy the full financial upside of positive performances.

Practices that aren’t quite ready to take the full leap on Day 1 have other options:

  • Report only for a 90-day period in 2017. This allows providers to report against the full number of quality measures that only report for 90-day period versus the entire year so that they can start later in the year. If they are not ready on Jan. 1, 2017, they have until Oct. 2, 2017, to begin collecting that data. By doing this, they can enjoy the possibility of a reduced bonus/upside.
  • The other option, especially for practices that feel unprepared, is to submit a minimum amount of 2017 data to CMS, thereby avoiding penalties. For example, if a physician or practice can provide data that shows one quality measure or one improvement activity for any point in 2017, that will suffice for this first year of MACRA reporting.

Doing nothing will have some significant consequences. Physicians and practices that fail to send any 2017 data whatsoever, will receive a negative 4 percent payment adjustment. No provider wants to be in that position, so taking the time to understand what is required to comply with MACRA is critical.

Additional MACRA Resources 

The CMS Quality Payment Program website has educational guides and fact sheets providers can review to learn what payment program will be best for them, which makes this “pick your pace” idea a good starting point for everyone impacted by MACRA.

I’ll blog again soon about the nuances of MACRA, because there’s very little chance of this program going away, and almost no chance of the industry shifting away from value-based payment models. It will take time and effort to fully indoctrinate performance reporting protocols into our industry, but it can and will happen, with everyone’s eyes on the common goal of delivering high-quality care, reducing costs, and improving the health, lives and well-being of everyone in our community.

Dr. Locklear - Healthcare Analytics for Population Health Management - About Our Healthcare Analytics Company, Lightbeam Health Solutions

Dr. Kent Locklear, Lightbeam’s Chief Medical Officer

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