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.
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.
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.
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.
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.