Physician Practice

The MACRA minute: Executive brief for MD payment reform

Physician Practice Insider, June 28, 2016

by Debi Primeau, MA, RHIA, FAHIMA

After 16 years of annual fixes to the sustainable growth rate (SGR) formula, the Medicare Access and CHIP Reauthorization Act (MACRA) is poised to become the permanent price fix for physician services.

On April 27, CMS released a proposed rule titled “Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models.” The proposed rule provides detailed information on how Medicare plans to oversee and manage MIPS and APMs, two payment models created by MACRA.

MACRA permanently eliminates the SGR formula and its annual threat of physician payment cuts. Instead, it provides positive annual payment updates lasting through 2019 and minimizes confusion caused by the various physician payment models currently in place. Revenue cycle leaders need to know the essential high-level information on MIPS and APM to prepare for the transition.

MACRA replaces multiplicity

Right now, Medicare measures the value and quality of care through a combination of programs. Some doctors and clinicians are part of APMs such as accountable care organizations, the Comprehensive Primary Care Initiative, and the Medicare Shared Savings Program. Others participate in programs such as the Physician Quality Reporting System (PQRS), the Value Modifier Program, and the Medicare Electronic Health Records (EHR)Incentive Program.

According to HHS, MACRA’s primary goal is to structure this mishmash of value-based payment models via a new framework called the Quality Payment Program. Doctors can choose from two paths:

  • MIPS scores clinicians on four performance categories based on flexible measures and activities chosen by physicians based upon their specialty
  • Advanced APMs, including the comprehensive primary care plus and next generation ACO models

Whichever path physicians choose, big changes are coming for them and for the way they’re paid. Payments through either path will be based on quality of care, rather than the number of services provided.

Quality payment program requirements

MACRA will have a significant impact on the finances of physician practices and the way they deliver care. Eligible clinicians impacted include physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists. There are two primary requirements to succeed under MACRA.

1. Doctors need to have interoperable EHRs and options for treating patients. MACRA regulations should be flexible as practices figure out what works best for them. Practices will also need skilled resources to make changes while continuing to serve patients, as it may be difficult for solo or small group practices to stay on top of the technical aspects of data reporting through EHRs. Practices will want to achieve high measure capture rates in EHR platforms. Larger organizations may be better able to support skilled labor with expertise in quality reporting, while smaller practices might be at a disadvantage.

To counter this, CMS has proposed funding to assist small practices (defined as 15 or fewer physicians), particularly in rural and disadvantaged areas, through regional extension centers and other third parties. However, training might not be adequate for some smaller practices that may require ongoing support from knowledgeable professionals to achieve high levels of performance.
2. A higher focus on quality will challenge organizations to track and manage patient information in a new way. Instead of simply charging a set fee for each service, they’ll need to systemize care and share information. Users must report on a minimum of six MIPS quality measures, many of which are identical or nearly identical to PQRS measures. At least one of the measures must be considered cross-cutting. Cross-cutting measures are defined by CMS as any measures that are broadly applicable across multiple clinical settings and eligible professionals or group practices within a variety of specialties. One of the most significant changes to quality reporting associated with MIPS is that the program no longer has an all-or-nothing reporting requirement, as it was under the PQRS and Meaningful Use programs.

Big changes will not happen overnight and it will take some time to adjust to MACRA’s Quality Payment framework. However, permanency and simplification surely beat annual doc fixes and ongoing payment uncertainty. These are exciting and challenging times for us all.

About the author
As president of Primeau Consulting Group, Debra (Debi) Primeau, MA, RHIA, FAHIMA, has over 35 years of experience in health information management and health information technology as an executive consultant, IS director, and HIM director. Debi leads Primeau Consulting Group as HIM and HIT practice leader working with other HIM and HIT professionals in the industry to bring superior consulting services to the healthcare industry. Previously, Debi has worked with various HIM consulting companies as the VP of HIM services, compliance of privacy and security, as well as being responsible for developing and implementing clinical documentation improvement programs and developing and providing education and training programs.

This article originally appeared in the Revenue Cycle Daily Advisor.

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