MACRA Readiness for Healthcare Organizations

MACRA Readiness for Healthcare Organizations

Without even putting too much effort into listening to or reading the news, you understand that healthcare costs have steadily risen over the last couple decades, and yet we don’t really have any significant and correlating rise in outcomes to show for it.  CMS or the Centers for Medicare and Medicaid Services has also noticed this, and since they are a large payer to healthcare providers for healthcare services, they are shaking up the system and have mandated a change in the form of MACRA – Medicare Access and CHIP Reauthorization Act of 2015.

In very simplistic terms this says that providers will prove that they are providing better care, cutting costs and will either receive an increase to their reimbursements or will be penalized with a lower percentage reimbursement payment.  Because MACRA is now law, every healthcare and organization is required to participate, so preparing for MACRA readiness is vital to thriving in the healthcare industry going forward.

There are two different programs in which a healthcare organization can choose to participate.  Both choices should be looked at carefully by each organization to understand which one would be best for them.  It is assumed at this point that most institutes will end up going with MIPS – Merit-based Incentive Payment System, while the others will work under APM – Alternative Payment Method.

Merit-based Incentive Payment System

The Merit-based Incentive Payment System will take the three current quality-reporting programs and consolidate them into one.  The current programs are:

  • PQRS – Physician Quality Reporting System
  • VBPM – Value-based Payment Modifier
  • MU – Meaningful Use

In addition, a fourth category of clinical practice improvement activities (CPIA) will all go into creating a performance score on a scale of 0 to 100.  This score will be compared and measured against past performance within that specific organization as well as against other organizations of similar size, specialty department availability and patient populations.  As scores are assessed, and time goes by, each organization will be evaluated for progress towards patient outcomes and overall health costs.

Alternative Payment Method

To be a participant in the Alternative Payment Method, the organization must:

  • Have an original payment model expanded under the CMMI (Center for Medicare and Medicaid Innovation Participate in an MSSP (Medicare Shared Savings Program)
  • Participate in a Medicare healthcare quality demonstration program, Medicare acute care episode demonstration program or other demonstration program accepted by the federal government

The APM system requires that physicians see a certain number of CMS patients and have a certain percentage of billing that goes to CMS each year.  The threshold is a lot higher and all the main requirements for MIPS are still requisite as part of the APM program.

There are some that are worried about being compared with and measured against other organizations because some facilities are well-funded, have many specialists and physicians on staff and serve a big population base.  CMS understands that not everything is equal across the board and is prepared to balance the equation out by taking into consideration these and other factors when comparing organizations.

The reason that this is such a big concern is that CMS reimbursements and their percentages are dependent upon improved outcomes and cost cutting assessments going forward.  Smaller facilities have expressed further concerns that they have been working closer to real-cost pricing rather than the inflated rates that bigger or more populated organizations have, thus the ability to cut costs isn’t as significant percentage wise as their larger counterparts, and they will be penalized with lower reimbursement amount in the long run.

Due to the fact that MACRA is such a sweeping overhaul to the healthcare industry, and not all the data has been gathered or analyzed, there are going to be changes made to the program going forward.  Input from healthcare facilities with honest insights will help to reform parts of the program and reassess where further changes could be made.  Though this sort of concept that not everything is set in stone may bother some healthcare providers, this is an enormous ship being steered for the first time, and corrections will be made on the fly as needed.

Overall, MACRA readiness is going to help healthcare organizations to implement the necessary aspects of the program and to better their comprehensive care for all patients.  Patients may not see any specific change when they visit a doctor’s office or hospital, but hopefully they (or us, as it is) will experience the benefit of better outcomes and satisfaction in the experience.  Improvement to healthcare and control of healthcare costs are not small feats for those working in healthcare, but these are possible and now they are an expectation from more than just the patients.

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