The recent presidential election and impending change in administration and policy has, understandably, caused uncertainty about the Affordable Care Act (ACA) and future CMS reimbursement policies. Many healthcare provider organizations have begun preparing, or are at least planning to prepare, for MACRA and some are questioning whether they should proceed. My opinion is yes, not only because there is no telling if or when the ACA will be repealed or what will replace it, but also because the steps needed to prepare for MACRA will pay off, whatever the future brings.
Brief MACRA Overview
The Medicare Access and CHIP Reauthorization Act (MACRA) is a value-based payment program which, according to CMS, is designed to “reward healthcare providers with incentive payments for the quality of care they give to people with Medicare.” MACRA introduces a new framework to reward providers for quality care, ends the sustainable growth rate (SRG) formula, and combines existing care quality reporting mechanism.
We are currently in the second year of 0.5% annual Medicare payment increases to physicians, which will continue until 2018. In 2019, two new payment tracks become available under MACRA: the merit-based incentive payments system (MIPS) and the alternative payment model (APM).
MIPS combines PQRM, VBM, and meaningful use into one program that gives physicians a quality score, which is used to determine their fee-for-service payment, subtracting a percentage for below-average scores and adding a percentage for above-average scores. Amounts to be subtracted or added range from up to 4% in 2017, 7% in 2018, and 9% in 2019.
The APM track requires a group of physicians to collectively accept a lump sum payment from CMS to cover services for a defined group of patients. ACO’s, patient-centered medical homes, and bundled payments are all examples of APM’s. APM participants are eligible for a 5% bonus each year from 2019 to 2024, in addition to regular Medicare payments.
CMS anticipates that the majority of physicians, approximately 600,000, will go into the MIPS track, with only 120,000 expected to take advantage of APM incentives. In both cases, there are eligibility requirements, quality measures, and timelines, which are too lengthy to cover here (CTI will happily provide informative summary documents for readers who request them), but which must be clearly understood and meticulously planned for by administrators and clinicians.
Leading the Change
As with all important initiatives, success depends on good leadership and careful planning. We recommend the following:
Engage stakeholders at all levels: Whether MIPS or AMP, reimbursement under MACRA depends on quality of care and positive outcomes and there are no team members who do not affect the patient experience. A good first step is to create a steering committee with representatives from various departments and levels within the organization. Be sure to consider all perspectives and account for impact that might not be obvious.
Learn Requirements: Both MIPS and AMP have very specific requirements for eligibility and quality measures. Leadership must, of course, review these requirements and determine the correct option for the practice or institutions. When you know which path you will take, waste no time educating your entire team about the requirements and their role in ensuring high quality scores. Complete understanding of the rules and the impact on your organization is the best way for team members to put their own role in context and greatly increases the chances that they will not only cooperate, but also collaborate to come up with innovative solutions for a successful transition.
Share the Vision: Share your plan with all stakeholders, including the goals, new policies and processes, compliance regulations, and performance measures. Be sure to consistently communicate the connection between reimbursement rates and the actual quality of care, emphasizing that patient experience and outcomes are shared goals of CMS and healthcare providers and top priority for your organization.
Test, Tweak, Commit: Even with excellent preparation, implementation plans for large-scale change rarely go completely smoothly. Minimize unforeseen obstacles and side effects by testing your implementation plan, tracking results, soliciting feedback, and adjusting as needed. In addition to increasing the likelihood of success for the live implementation, a thorough test will instill confidence and commitment in team members.
Sustain Meaningful Change: The point of value-based reimbursement is to reward a high level of quality in patient care. As noted earlier, this is a goal that all dedicated healthcare professionals share. It is important to keep this objective front and center by tracking and sharing meaningful performance measures that demonstrate value to patients. And it is crucial to keep the dialogue open by welcoming and taking seriously feedback from all stakeholders. Often seemingly unrelated and minor changes can cause big disruptions and suddenly what worked smoothly yesterday has stopped working today. Good leaders always keep an open mind and stay focused on the big picture.
By taking the approach that the ultimate goal is to improve the patient experience and increase the quality of care by engaging and respecting team members, preparation for MACRA will be beneficial, regardless of any future changes in CMS policy. The uncertainty only expands the opportunity for leaders to move their organizations in the right direction.