By TKG’s Harshini Parvatha
Click here to read the original post on LinkedIn.
Recently, I had the pleasure of being a part of The Consortium for Southeastern Hypertension Control’s (COSEHC) annual board meeting and participated in an interactive discussion with Dr. Paul McGann, CMS Chief Medical Officer for Quality Improvement, Center for Clinical Standards and Quality. As most us are already aware of, he discussed the evolving state of the healthcare landscape, the involvement of commercial payers in the movement, and how CMS is starting to invest large money ($700 million) to improve the quality of care. As Dr. McGann asked the multiple providers in the audience the key factor needed for change, “incentives,” “value,” “collaboration” were terms tossed around the room. However, the key to facilitate change is really leadership. Under Secretary Sylvia Burwell’s vision and leadership, we need to learn our way into a better system, together by paying providers differently, delivering care efficiently, and distributing information as needed.
With the change in the delivery of care, a fundamental need arises to change culture and the way medicine is delivered. Typically, providers in the United States have been trained to over-test to ensure the protection of quality. As the healthcare landscape changes, providers need to re-train themselves to administer only necessary testing and to understand the new meaning of “value.”
In 2000, the CMS innovation center started with a clean slate, but by following the simple yet profound model of “identify, test, evaluate, scale,” multiple value-based initiatives and alternative payment models were introduced to the market. However, the multiple models and plans in the market have been acting in silos, creating an increasing burden on providers with mounting administrative paperwork and less time with their patients. CMS has been listening to these concerns, and introduced the Medicare Access and CHIP Re-authorization Act (MACRA). MACRA is a tremendous opportunity to break down the silos we see in the market between financial incentive plans and a chance to create a full population health approach by meaningfully tying together various value-based initiatives to support additional drivers down the road.
MACRA legislation has been signed into the law by Congress on April 16th, 2015 and CMS is currently translating the congress document to an implementable road map. MACRA repeals the Sustainable Growth Rate Physician Fee Schedule (PFS) from 1997 and defines two independent pathways to pay providers: The Merit-Based Incentive Payment System (MIPS) or Alternative Payment Models (APMs). Upon the implementation of MACRA, the separate application of payment adjustments for Physician Quality Reporting System (PQRS), Value-Based Payment Modifier (VM), and Meaningful Use of EHRs will sunset on December 31st, 2018.
Merit-Based Incentive Payment System:
Eligible professionals can participate in MIPs or meet the requirements to be a qualifying APM participant (the term “qualifying” is yet to be defined by CMS). As mentioned, MACRA streamlines the multiple individual quality and value programs for Medicare physicians into MIPS. The eligible providers for MIPs include physicians, physician assistants, nurse practitioners, clinical nurse specialists, and nurse anesthetists. Beginning January 1, 2019, CMS will assess the performance of eligible providers (EPs) during a performance period for measures and activities to determine a performance composite score in four weighted performance categories: quality (30%), resource use (30%), clinical practice improvement activities (15%), and meaningful use of certified EHR technology (25%). The Secretary is required to specify clinical practice improvement activities, some of which are expanded practice access, population management, care coordination, beneficiary engagement, patient safety, and alternative payment models. MACRA establishes a formula for calculating payment adjustment factors related to performance threshold and established “applicable percent” amounts and EPs receive a positive adjustment factor if their score is above the performance threshold and vice-versa.
Alternative Payment Models:
Beginning in 2019, for 6 years, 5% incentive payment will be provided to EPs who participate in certain types of APMs and who meet specified payment thresholds. It is important to note that the payment is made in a lump sum on an annual basis and EPs meeting certain criteria to receive APM incentive payment are excluded from the requirements of MIPS.
In addition, MIPS/APM provisions require the Secretary to engage the physician and eligible professional community to develop care episode groups, patient condition groups, and patient relationship categories, as well as provide technical assistance to small practices in rural areas, health professional shortage areas, and medically underserved areas with respect to the MIPS performance categories and to help practices transition to APMs.
In conclusion, it is worth mentioning that CMS recently announced that it has met the goal of “30% of providers’ payments in APMs by end of 2016” ten months early. MACRA will support this and will get us closer to HHS payment reform goals. The MACRA law has been determined but the regulations of it are yet to be developed.
The MACRA documents are available publicly and as a key member of the healthcare community. This is your chance to share your input with CMS to help shape the new future of healthcare.