More MACRA to understand!
Don’t worry, I’m still just as confused but hopefully the rest of this MACRA series will not only help you understand this colossal change to our healthcare system, but also help me get a better grasp at it. I’ve always been one to learn and reinforce my understanding by teaching others! But I get it, we’re all still confused. Overall, today’s post will probably be a rehash of the basic MACRA information and the two payment tracks that physicians are allowed to follow but other than that, I’ll do my best to keep it light and interesting. I can’t tell you how many times I’ve fallen asleep just reading the “primers” about MACRA which are only a couple of pages… imagine how the healthcare economists and policymakers feel when they had to draft that 900+ page bill!
Once again, the Medicare Access and CHIP Reauthorization Act was successfully passed during 2015/2016 and it took a couple of months to finalize all of the final details and release the information to the healthcare organizations that had to follow it. It outlined the details of the plan to transition healthcare from a payment system that relied on volume and quantity to one that rewards value in treatments. This is the next step in efforts to drive healthcare organizations from the “fee-for-service” model that promoted excessive tests and diagnostics to a value-based care reimbursement model, which helps to maximize care. As expected of a federal bill and true to its name, one of the biggest changse will be to Medicare and how its reimbursements will work for the healthcare providers.
- Who is affected by MACRA? In essence, any medical clinician that has to deal with billing for professional services that fall under Medicare. As a result, more of the highbrow and “boujee” healthcare organizations will probably not be as affected by MACRA since they will typically only be taking private insurances. However, more federally or state funded healthcare organizations and hospitals will undoubtedly be affected as they will not only have to bill for Medicare, but also most likely be required to bill for Medicare. Additionally, MACRA expands its umbrella to not only include providers but also to dentises, chripracters, nurse practitioners and the other roles that fall under a healthcare clinician title. Of course there are exceptions for clinicians that are new to Medicare. Individuals aside, MACRA also affects hospitals and clinics in a few area related to technology (EHR-specific) regarding the surveillance and oversight of their EHR systems and ensures that there is the proper flow of data sent to those that require it.
- What does it mean for meaningful use and other programs? As I mentioned before, MACRA will consolidate and replace a couple of existing programs that exist and stemmed from the ACA (but it is led by the CMS, not part of the ACA). One that was repealed is the Medicare Sustainable Growth Rate (SGR). And then there are three programs that have been rolled up into MACRA, which are the Physician Quality Reporting System (PQRS), Value-Based Payment Modifier (VM), and Meaningful Use. The PQRS was fortunately revamped because it was simply arbitrary metrics that really provided no insight to quality of care, VM was incorporated into the two payment tracks of MACRA, and MU was expanded into the incentive-based portion of MACRA. With MACRA, the eligible clinicians (stated above) can choose between one of two major tracks of MACRA, the incentive-based program MIPS, and the alternative payment model (APM). The payment tracks are part of the Quality Payment Program, whic streamlines quality reporting programs together as a way to implement and emphasize value-based care.
- Merit-Based Incentive Payment System (MIPS) – Comprised of four components that are weighted differently as the years go by, this is to ensure that those who transition the fastest are able to receive a financial incentive that reflects their ability to “tear down, build up”. The weighted score will then be used to determine the reimbursement which comes as a positive or negative payment adjustment percentage. The four areas are: Quality, which replaces PQRS, Resource Use/Cost, which replaces the cost component, Clinical Practice Improvement Activities (CPIA) which helps to ensure that different areas are being satisfactorily met, and Advancing Care Information (ACI), which incorporates EHR incentive elements based off of how the patient information data is managed. ACI specifically works to emphasize data being interoperable as well as makes an emphasis on the health information exchange that was started in stage 2 of Meaningful Use. Before, MU essentially asked for a “one-size’fits-all” and “all-or-nothing” EHR measurement of metrics that was all combined together. This led to administrative headaches and difficulty because it essentially allowed people to throw all relevant data together even if it wasn’t relevant or necessary, ACI hopes to change that by allowing the clinicians to choose which measures to report as well as provides flexibility in the hopes of emphasizing interoperative, information exchange and security measures.
- Alternative Payment Model (APM) – The other way is to participate in an APM, which helps to increase quality of care and improve patient outcomes. There are many different APM portfolios that the clinicians can participate in all with varying metrics that must be met, but similar criteria in them all requires a burned of financial risk, eivdenced-based quality measures that are reliable and valid, as well as use of certified EHR software in regards to clinical care information.
Overall, MACRA is supposed to be seen as the big brother evolution to meaningful use and the medicare portions of the ACA. It’s meant to make it, in a sense, actually meaningful and useful now. By streamlining and sterngthening value with quality-based incentive payments, I hope that this will lead to a higher quality, coodrinated, and efficient kind of care. Although this will hopefully lead to increased patient engagement and improved outcomes and impact, this is a massive undertaking that will require time and most likely a lot of scheduling setbacks but I hope that this can help revitalize the economic sink of healthcare and medicine.