MACRA: The Road Map to the Future of Healthcare

One date marked on the calendar of many individuals at the management level of health organizations is January 1, 2017. To some 2017 is being viewed as a “year of reckoning“.  Although this sounds ominous, most negative effects on health organizations can be easily avoided as long as providers are prepared for MACRA. Since 2015, MACRA has been slowly integrated into the operations of medial organizations across the country. In 2017, the performance of medical organizations that qualify as MIPS will be tracked and these results will determine how providers are paid in 2019.

This may sound a bit confusing. It sounds like money’s on the line. It sounds like big changes are coming. But what exactly does MACRA mean and what exactly is a MIPS? To answer these questions I’ve put together a brief starter guide to MACRA and what it means for the healthcare industry.

What is MACRA?

In a nutshell, MACRA is new set of rules and regulations that will reshape the way that medical organizations receive government funding, handle Medicare, and ultimately function. The government MACRA with bi-partisan support back in 2015. Given that MACRA is such a large overhaul of the healthcare system, adoption to the rules and regulations of MACRA has been generously spaced out over a timeline of many years.


MACRA Timeline

MACRA Timeline from

In brief, MACRA will change how Medicare pays medical providers.

Yes, but what does MACRA stand for?

MACRA stands for Medicare Acccess and CHIP Reauthorization Act of 2015.

And what does CHIP stand for?

Children’s Health Insurance Program. Basically the program that provides states with matching federal health insurance funds for families with children.

OK, so getting back to MACRA…

Yes, getting back to MACRA…

How will performance be tracked?

That depends. There are three different classifications of medical payment models: MIPS, APMs, and e-APMs.

More acronyms?

You bet. MIPS (or Merit Based Incentive Payment Systems) will effect the majority of providers. APMs (or Alternative Payment Models) are a bit trickier to qualify for. E-APMs (eligible alternative payment models) are basically a subset of APMs. APMs are still subject to MIPS, but will receive favorable scoring, with reimbursement rates that reflect accordingly.

Wait, Scoring?

Just like a building might need to reach certain benchmarks in order to be certified as LEED or an Olympic diver has to be mindful of technique and style in order to win a higher score from the judges, so will medical organizations need to meet certain benchmarks in order to receive more favorable payment rates.

That means that medical organizations will need to make sure they are reaching to achieve a slew of metrics pulled from PQRS (Physician Quality Reporting System), EHR (Electronic Health Record), and the VM (Value-Based Payment Modifier) outlined in MACRA’s performance measures.

MIPs from

MIPS model from

So what happens once all of these measures are taken into account?

Based on how an organization meets these metrics, they will be given a MIPS composite score that is either positive, negative or neutral. Each of these will adjust the base rate of a provider’s Medicare Part B Payment, which is money that an organization qualifies to receive from the government when a patient uses Medicare for services covered under Part B. And these incentives really do add up. Larger medical organizations stand to lose or gain 15 to 20 million bucks depending on whether or not they receive favorable scores.

So if hypothetically a lot of identical organizations are performing well, will they all get the same amount of money?

Not exactly. This system will be budget neutral.


That there’s a fixed pool of money available for medical organizations. Those with higher scores will in effect take away money from medical organizations that perform more poorly.

Sounds kind of harsh.

Admittedly, MACRA does pose some big challenges for the healthcare industry, but the overall goal is something that we could all agree on: better value and better outcomes for patients. The thing is, the healthcare industry is heading in that direction anyway. There are so many medical organizations out there right now that it’s less a matter of if someone can get to a healthcare provider, it’s which one should they go to. In order to stay in business, providers need to step up their game and really show patients that they value them.

So why is MACRA being introduced if we’re already seeing better patient-centered care?

At the moment government money is provided to healthcare organizations with much more lenient standards on the efficacy of care given. Basically, organizations that are continually doing a poor job of putting patient’s first are still being kept afloat by government money. MACRA will push these organizations to either improve or yield to nearby healthcare all-stars.

Sounds great, but I’m not interested.

Like it or not, MACRA is coming and all providers will need to adapt in order to stay afloat.

OK. So what should I do?

Learn all you can! One thing that is recommended is to see if your organization can qualify as a PCMH (Patient Care Medical Home). This will help getting qualified as APM a lot easier and also carries some rewards of its own. Renown Health was the 1st provider in Nevada and the 4th in the country to adopt the PCMH model.


Good luck!


Mark Behl

A Population Health Crash Course

The field of “population health” is one of the most exciting developments in healthcare in the last last 15 odd years. However, actually describing what population health is can be a little tricky. Although I’ve broken it down before in other blog posts, I thought I’d compile some videos that make the meaning of population health a bit more accessible:

For starters, here’s a general overview:

So, you might be thinking, “That sounds a lot like public health.” Here’s the difference:


A great video that looks at the social determinants that are so critical to consider in the population health paradigm:

Thanks for viewing.

For more population health updates, follow me on Twitter @MarkBehl.

How IBM Watson is Revolutionizing Healthcare

If you’ve been following big data the past several years, chances are you’ve heard of IBM’s Watson. To recap, Watson is IBM’s revolutionary commercial computing capability that utilizes the cloud in order to process high volumes of data and then turns this data into evidence-based answers when presented with questions in natural language. Put simply, Watson is a cloud-based supercomputer that companies can make use of. Watson’s ability to comb the cloud for data makes it a catalyst for great change in the healthcare industry. In fact, in 2015 IBM launched IBM Watson Health and the Watson Health Cloud platform specifically designed to assist physicians, researchers, and insurers in harnessing the great amount of personal health data being circulated around the cloud.

ibm watson logo

IBM Watson is revolutionizing how the world analyzes health data.

IBM’s recent collaboration with Welltok and and Pathway Genomics illustrate two ways that Watson is revolutionizing population health management.

Welltok and Improving Heart Health

In line with a number of other initiatives this National Heart Month, IBM has revealed plans to team up with the social health management company Welltok and the American Heart Association (AHA) in order to develop workplace technology that improves heart health. The unnamed app will make use of AHA’s Workplace Health Achievement Index, which uses best practices “to measure and rank corporate health initiatives” and give an overall assessment on workplace health culture.

welltok logo

Welltok’s most recent project comes on the heels of a similar workplace health platform developed specifically for IBM offices.

Employees could take advantage of Welltok’s platform by filling out the AHA’s My Life Questionnaire, at the core of which is the AHA’s Simple 7 key cardiovascular health indicators: not smoking, eating healthy, being physically active, achieving and maintaing a healthy weight, managing blood pressure, controlling cholesterol, and reducing blood sugar. Using the data from this questionnaire, as well as that from other of IoT devices–from wearable fitness trackers to wifi-connected scales–Welltok would be able to tailor health recommendations to the individual needs of each employee.

Optimal population health management is all about pooling resources. It’s about pooling data.  In this case, we see how IBM’s computing capability, Welltok’s health platform, and AHA’s metrics would all work together for better healthcare outcomes.

Pathway Genomics

In January, IBM teamed up with Pathway Genomics teamed up to create another personalized healthcare app. Instead of targeting workplace heart health, Pathway’s OME makes use of information from Pathway’s “FIT” Test, which takes a look at a number of metrics including exercise and genetic predisposition, and pulls metrics from a number of IoT sources, such as wearable health monitors and Apple HealthKit.

ipad with OME app on screen

Pathway Genomics’ OME delivers health recommendations based on your genetic traits.

Critical to this platform is the analysis of genetic traits and their effects on health. After receiving approval from a licensed physician, participants receive a saliva DNA collection kit. Pathway uses this to conduct their FIT test, which looks at 75 genes that deal with a number of health factors. The insights gained from the FIT test are then incorporated into personal wellness plans.

More to Come

Both the Welltock and Pathway Genomics collaborations with IBM Watson illustrate the boon of integrated systems in population health. But we’re just scratching the surface. Welltok’s platform focuses on workplace health and Pathway Genomics’ OME focuses on genetic predisposition, but what if the two technologies could work together instead of separately? What if both genetic predisposition and genetics were compared in one’s personalized healthcare recommendations? We’re well on our way to finding out.

5 Hurdles in Population Health

The health industry has yet to define the true meaning of population health. According to, population health is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group. Before population health becomes common practice, there will be some hurdles that need to be addressed. Let’s take a look at some of these hurdles according to

1. Lack of compliance by clinicians

Many health networks have applied evidence based pathways, protocols and decision trees outlining how they want patients treated by doctors and nurses. However, getting clinicians to comply as well is another hurdle in itself.

2. Too little clinical care coordination for patients

Poor adherence continues and it leads to massive over-utilization of the system due in part to a number of different technologies coming to market. Patients and health insurance companies are changing the way they pay for health insurance.

3. Population health “hotspotting” not yet widespread

The practice of population health involves providers taking a look at data analytics to find patient populations that consume large portions of cost care and identity the ways to bring and impact and change to those population subsets. However, because it’s still an emerging practice, the data is not quite there yet to be scrubbed.

4. Abundance of data

Sometimes when you’re trying to solve or find a problem, data can help. Problem is when you have too much data to analyze, it could make it overwhelming and hard to find a place to start. Everyday, patients are constantly generating new data and it’s hard to account for every piece of data.

5. The need to activate more patients

Providers need to better figure out how to incorporate their patients, whether that’s as simple as taking medications regularly or actually changing long-standing lifestyle habits, to drive adherence because it’s the key to better outcomes, reducing overutilization and ultimately slashing costs.

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