MACRA is coming—Are you ready???

Posted by: Ryan Graver, Cathie Biga, and Kelsey Reichert on Thursday, November 19, 2015

MACRA advances the movement away from payment for volume and replaces it with a system that ties payment to mandates for quality, outcomes, and efficient care; it achieves this with the introduction of the merit-based incentive payment system (MIPS) and the alternative payment models (APMs).

Figure 1. The reimbursement decision for providers.One of the latest examples of the ever-changing health care landscape is MACRA, the Medicare Access and CHIP Reauthorization Act of 2015, which was signed into law on April 16th as the fix for the sustainable growth rate (SGR). The real impact of MACRA will be its role as the road map for the implementation of a value agenda. Although many details about MACRA are yet to be determined, it will (in absolute terms) force a migration away from fee-for-service reimbursement and push health care toward its goal of achieving the triple aim of high-quality, low-cost care with an exceptional patient experience. MACRA advances the movement away from payment for volume and replaces it with a system that ties payment to mandates for quality, outcomes, and efficient care; it achieves this with the introduction of the merit-based incentive payment system (MIPS) and the alternative payment models (APMs) (Figure 1).

THE VALUE AGENDA

MACRA is largely focused on furthering the value agenda under the Affordable Care Act. The initiatives that were created by the current value-based modifier program (also known as physician value-based purchasing program), along with the physician quality reporting system (PQRS) and Meaningful Use, will sunset on December 31, 2018. After that, physicians will be faced with deciding between following the guidelines for participating in MIPS or choosing to be in an APM. Both options pose financial risk to reimbursement if preset quality measures and savings goals are not met. Regardless of which program a physician chooses, MACRA is pushing physicians to focus on delivering value, not just providing services for patients.

MIPS

Although many unknowns continue to persist, MACRA does outline that MIPS will be one of two pathways that physicians may choose in terms of how they will be paid. It is believed that MIPS will embrace many of the current quality elements, while develop­ing a new methodology to assess performance in order to create a performance score to use for calculating payment incentives and penalties.

APM

On January 26, 2015, Health & Human Services announced measurable goals and a timeline for shifting Medicare from the traditional fee-for-service system to one that pays on the basis of quality of care and out­comes, or a “value-based” payment system. The Centers for Medicare & Medicaid Services (CMS) pandor called for a specific, year-by-year increase in the percentage of Medicare payments that are value based. According to the schedule, by the end of 2016 at least 30% of tra­ditional, or fee-for-service, Medicare payments will be tied to quality or value through alternative payment models, such as accountable care organizations (ACOs) or bundled payment arrangements. By the end of 2018, that value will be 50%. The goals also include tying 85% of all traditional Medicare payments to quality or value by 2016 (and 90% by the end of 2018) through pro­grams such as the hospital value-based purchase and hospital readmissions reduction programs.

Physicians will be faced with deciding between following the guidelines for participating in MIPS or choosing to be in an APM; both options pose financial risk to reimbursement.

The big question for physicians: how do you want to be paid? What are the pros and cons of penalty-based payment versus population risk-based payment? How will physicians be measured and benchmarked? Are your practices and service lines ready for what comes with each track? What will the impact be—for health care systems and the communities they serve? What is the best way to achieve high-quality health care at lower costs? As providers, are you leading the transformation of your care delivery to be successful in this new normal of health care?

Success in the evolving value-based world requires understanding of the nuances of programs like MACRA that are pushing the industry forward. Being involved with the process, networking with peers, talking with experts, and having a voice in how MACRA develops will help each physician make smarter and more sustainable choices.

The above is excerpted from an article in the September/October issue of Cardiac Interventions Today magazine by Ryan Graver, Cathie Biga and Kelsey Reichert. To read the complete article, go to http://citoday.com/pdfs/cit0915_Coding_Graver.pdf

Ryan Graver is President of MedAxiom Ventures and has more than 2 decades of diverse health care experi­ence spanning multiple dimensions of care delivery, research, business development, and med tech-related strategy includ­ing global health economic leadership and payment policy. He may be reached at rgraver@medaxiom.com.

Cathie Biga is President of Cardiology Advocacy Alliance and President & CEO of Cardiovascular Management of Illinois. She has over 30 years’ experience in health care and has been active in practice management for the last 15 years. Ms. Biga may be reached at cbiga@cardiacmgmt.com.

Kelsey Reichert is Executive Director of Cardiology Advocacy Alliance and may be reached at kreichert@medaxiom.com.

How can you become MACRA ready?

Watch this video presentation by Suzette Jaskie, President & CEO of MedAxiom Consulting, that details what programs should be doing now to prepare for MACRA's implementation and provides information sources to help you stay abreast of this important development. Learn how cardiovascular programs and providers can be proactive in shaping the future of health care delivery and reimbursement.

tags: APM, MACRA, MIPS

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