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MACRA: The Tidal Wave That Hit The Healthcare Industry
  • Tina Colangelo
  • Apr 09 2017

MACRA is the tidal wave that has hit the medical community. Yet many physicians and healthcare clinicians don't understand how beneficial or how devastating this can be for their business. Physicans need to find the balance between patient care and their bottom lines. The new MACRA system is shrouded in secrecy, mainly because providers don't know what to expect. It has proven to be both complicated and overwhelming to most people in the healthcare industry. But covering your eyes and ears in fear will not make MACRA disappear. It's understanding the reasons for the shift from fee for service to value-based care and the requirements for MACRA that will help the medical community adapt to this change and not be so fearful. 

The reason for this change is that the traditional fee for service model (volume) no longer works. It does not reduce costs or patients symptoms. The Centers for Medicare and Medicaid (CMS) are requiring providers to take on some percentage of risk for patient outcomes. Providers who deliver high quality care and lower costs will be rewarded. However, providers who deliver low quality care and increase costs will be penalized. 

Here is what expected from providers under MACRA. There are two different reimbursement tracks that physicians will fall under: Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (AAPMs). In MIPS, providers are required to pick their participation pace, identify measures that apply to their practices and decide how to report the measures to CMS. In 2017, providers can pick their participation pace. 

Option 1- Submit something, one quality measure on one patient and one imporvement activity to avoid the four percent penalty in payment year 2019

Option 2- Submit data for partial year, report measures for a minimum of 90 days for a small payment adjustment in 2019

Option 3- Submit data for a full year, starting January 1, 2017 through December 31, 2017 for a moderate payment adjustment in 2019

Option 4- Participate in an Advanced APM

Providers will need to report measures across four performance categories in MIPS. The categories are Quality, Advancing Care Information (ACI), Improvement Activities (IA) and Cost. Each provider will earn a composite perfromance score (CPS) based on their performance in each of the categories. Each of the four categories are weighed differently. With each performance year the weights of the categories shift. In 2017, the weights in MIPS are Quality (60%), ACI (25%), IA (15%) and Cost (0%). There are four ways that providers can report data to CMS in MIPS. Data can be reported by used a qualified data registry, qualified clinical data registry (QCDR), electronic health record or CMS Web Interface for groups 25 or more. Groups who would like to use CMS Web Interface need to register by June 30, 2017.

A second path affecting how providers are paid under MACRA is advanced APMs. Apms are innovative payment models that are geared towards reducing costs and imporving quality. They can be episode-based or condition-based. MACRA offers a 5% lump sum payment to providers who participate in APMs. The eligibility requirements are:

1. Use quality measures comparable to measures under MIPS

2. Use certified electronic health record (EHR) technology

3. Assume a financial risk or is a medical home expanded under the CMMI

The most important thing to remember is to be prepared. MACRA is something to hit the ground and run with instead of trying to wait out the changes. Waiting out the changes will make it difficult and your practice will be trying to play catch up while the other practices have been reporting to CMS. 

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