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The Health Plans’ Role in Meeting MACRA Requirements – MACRA Monday

Posted on July 17, 2017 I Written By

The following is a guest blog post by Karen Way, Health Plan Analytics and Consulting Practice Lead at NTT DATA Services. This post is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program.

When the Medicare Access and CHIP Reauthorization Act (MACRA) became an official federal ruling for the healthcare industry in 2015, the act replaced the previous Medicare reimbursement schedule with a new pay-for-performance program focused on quality, value and accountability. In short, the legislation rewards healthcare providers for quality of care, not quantity.

While many discuss the impact on providers, what is the health plans’ role in aiding health systems and physicians to meet MACRA requirements?

MACRA provides multiple opportunities for health plans to increase and improve collaboration with provider networks. Recommendations on how health plans can accomplish this include sharing information and services, creating new partnerships and bringing about financial awareness as the legislation continues to take effect.

Sharing Data

One of the requirements under MACRA is for providers to enhance clinical measures and data analytics to strengthen members’ experiences. Health plans can assist by recognizing where providers lack expertise in data-related facts to offer input and support where it’s most beneficial.

For example, a provider may not have as much knowledge on advanced data science, but health plans can share their predictive models and tools to strengthen analytics. Sharing advanced technical infrastructure to facilitate data exchange will enable providers to access a more complete picture of members’ profiles. In return, the picture will provide a higher quality service to individual members, as well as opportunities for health plans to continue offering tailored consulting and data support.

At its best, sharing data to improve clinical measures is a win-win scenario. The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of America’s health plans to measure performance on important dimensions of care and service. Just as HEDIS calls for measurement, MACRA also encourages health plans to aid providers with reporting standards. Under these rules, health plans are required to record a wealth of information on members, and when shared with providers, the tide lifts all boats.

Partnering to Manage Risk

Some of the changes under MACRA are reminders for providers to be highly aware of risk management. Providers will seek strong partners with the necessary skills, experience and knowledge to ensure they do not take on risk greater than they can support. To assist, health plans should enter into risk-sharing relationships, such as value-based contracts, with high-performing providers.

Health plans should actively strive to be strong partners by enabling robust data analytics that support quantitative action plans in the areas of quality and clinical care gaps, medical cost and trend analysis, population health, as well as member-risk management. As health plans partner with providers, they should also stay flexible on potential changes to provider payments as the pay-for-performance model(s) mature over time.

Financial Awareness

Health plans also need to be aware of the financial considerations that result from increased value-based contracting for small and large providers.

Under MACRA, smaller providers and individual physicians are more likely to be exposed to potential increase in costs, which may result in additional provider considerations. As Medicare payments shrink, these providers will look to shift costs to other payers, making contract negotiations more difficult and potentially increasing unit costs for some services. Large physician groups, or those located in markets with progressive healthcare systems, will look to negotiate even higher reimbursement rates due to the potential for increased competition.

Health plans should also be aware of potential impacts beyond Medicare fee-for-service (FFS), which is the initial focus of the MACRA legislation. Pay-for-performance is likely to extend beyond Medicare FFS into other health plan lines of business, such as Medicaid or commercial plans. For example, under MACRA, Centers for Medicare and Medicaid Services stated it would consider permitting Medicaid Medical Homes to count as an alternative payment model if participating practices would risk at least four percent of their revenue in 2019 and five percent in 2020.

Why This Matters

Overall, MACRA creates a tall order as it aims to increase pay-for-performance and decrease care based on quantity. This notion is an altruistic adjustment for the health system and each party has a specific role to play to achieve the dream. But the backbone of this goal is collaboration between health plans and providers. Collaboration will result in shared clinical measures, awareness and management of risk, lower healthcare costs and, most importantly, improved patient outcomes.

The Top Three Hidden Impacts of MIPS – MACRA Monday

Posted on July 10, 2017 I Written By

The following is a guest blog post by Tom S. Lee, PhD, CEO & Founder, SA Ignite. This post is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program.

While most providers know the Merit-based Incentive Payment System (MIPS) will have escalating financial impacts, there are additional strategic and operational concerns that go along with managing MIPS participation. The MIPS score will impact areas beyond just clinicians’ Medicare reimbursement, including public reputation, clinician recruiting and compensation, and reporting for participants in alternative payment models (APMs).

  1. Public Reputation

Clinicians participating in MIPS and most Medicare accountable care organizations (ACOs) will have a MIPS score that determines their Medicare Part B reimbursement. The same score can impact public reputation because CMS will publish the scores on the Physician Compare website and make the data freely available to the public. Companies like Google, Healthgrades, Consumer Reports, Yelp, and others can use that data to incorporate the MIPS score into its clinician ratings and review systems. If an organization chooses to do just the minimum in 2017 to avoid the penalty, it means its clinicians could have a public performance score as low as 3 out of 100, while competitors who fully perform and report could have much higher publicly reported scores.

MIPS scores become a permanent part of each clinician’s resume because CMS binds the annual score to the clinician’s unique national provider identifier (NPI). So even if a clinician switches organizations, the historical score, along with the reimbursement or penalty, will follow the clinician, with the new organization absorbing the financial impact earned by the clinician up to two years prior at a different organization.

Estimates indicate that the revenue impact of consumers swayed by MIPS scores can be significantly larger than just the direct reimbursement impacts of MIPS. According to this article, a 1-star increase on Yelp leads to 5 to 9 percent increase in a business’ revenue. Using CMS’ data on Medicare Part B payments by specialty, this could mean an increase ranging from $4,468 to $8,042 per year per clinician for an internal medicine doctor and up to $10,705 to $19,269 per year per clinician for a cardiologist.

And, it may be much harder to convince a consumer who did not select a clinician based on an unfavorable MIPS score to re-evaluate that clinician in the future, even if the clinician’s score ultimately increases.

  1. Clinician Recruiting and Compensation

Understanding a clinician’s historical MIPS scores will be important to an organization properly evaluating and contracting with that clinician. When recruiting new clinicians or acquiring practices, healthcare organizations are mindful that they can inherit poor scores from other organizations’ program decisions. Conversely, clinicians will increasingly seek to join organizations with a good track record enabling its clinicians to achieve high MIPS scores, which positively impacts the resumes of all those clinicians.

In addition, organizations are seeking to align clinician compensation with MIPS financial and reputational impacts so look for an increasing number of compensation plan designs to directly incorporate MIPS scores and category scores as key performance indicators.

  1. Reporting Obligations of APM Participants

Although a healthcare organization may make a strategic decision to join an Alternative Payment Model (APM), such as a Medicare Shared Savings Program Accountable Care Organization (ACO), clinicians who are part of that organization are not necessarily exempt from MIPS. For example, if a clinician joins the organization after the final August 31st CMS determination of APM participation, then those clinicians will still need to fully report for MIPS or face a penalty. This is true for late-joining clinicians in both MIPS APMs as well as Advanced APMs, which typically qualify for a MIPS exemption.

Regardless of when clinicians join a Medicare Shared Savings Program (MSSP) Track 1 ACO, the ACO must manage MIPS eligibility, performance, and reporting for all clinicians, in addition to its ACO program obligations. This stems from the fact that MSSP Track 1 ACOs are not Advanced APMs.

How to Engage Clinicians Regarding MIPS

Beyond educating clinicians and leadership about the hidden impacts of MIPS, much of the important work to be successful under MIPS involves engaging clinicians in taking ownership of their responsibilities under the program. Some best practices:

  1. Recognize the importance of patient and clinician satisfaction
    • Reinvigorate support from leadership on the importance of both pillars
  2. Collaborate with clinicians
    • Let their voices be heard regarding both the explicit and hidden impacts of MIPS
  3. Provide feedback loop to clinicians and staff teams
    • Clinicians want to understand how they are being scored and where they have the best opportunities to improve
  4. Provide transparency
    • Communicating successful as well as failed efforts and the learnings accrued builds trust

Independent Primary Care Practice Success and MACRA – MACRA Monday

Posted on July 3, 2017 I Written By

The following is a guest blog post by Christina Scannapiego who currently writes the technical documentation and educational content for HealthFusion MediTouch. This post is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program.

Can participating in a PCMH and programs like Chronic Care Management improve your MIPS total score?

The shift to fee-for-value healthcare may feel like discouraging, foreign territory. However, if you’re already participating in value-based models like a patient centered medical home or chronic care management, your practice is more poised for success during this transition.

Chronic Care Management

The Centers for Medicare and Medicaid Services (CMS) have increased reimbursement for Chronic Care Management (CCM) services. Now, a provider has the potential to earn more than $50,000 per year under the CCM program. Patient-centered care, patient engagement and better care coordination are the core objectives of CMS. Participation in CCM could weigh heavily on your total MIPS score. CCM helps patients by extending care support beyond face-to-face appointments. Participation in this program will help you move the needle in four performance categories by extending care between office visits, controlling costs, increasing care coordination, enhancing doctor-patient relationships to help improve patient outcomes.

CCM and MACRA overlap across several MIPS components:

  • Advancing Care Information: Previously Meaningful Use, meant to achieve patient engagement and promote the electronic exchange of information, practice analytics and reporting capabilities using an EHR.
  • Quality measures: At least 30 measures including many high priority items are common to the CCM program.
  • Clinical Practice Improvement Activities: Patient engagement is one of the main objectives of both CCM and MACRA. Providing 24/7 access to clinicians and coordinating care across provider settings plays an integral part in the CCM objectives and will boost your score in this performance category.
  • Cost: Although providers aren’t responsible for reporting data in this performance category, participating in CCM can lower costs due to preventable hospitalizations from poor medication adherence and care transitions to other providers. Patients with multiple chronic conditions can often pose the highest costs in healthcare. Effectively managing the care of patients will ultimately benefit their overall well-being and the health of your practice.

Patient Centered Medical Home

The PCMH model was established to help deliver patient-centered care through care coordination, preventative services, population health management and extended access to care services. This model thrives from robust patient engagement, which is one of MACRA’s most important goals. MIPS scoring methods favor those participating in PCMH by automatically scoring providers with 100% in the Advancing Care Information performance category. PCMH recognized practices will also likely get credit in the Advancing Care Information performance category because of their experience with NCQA standards.

The importance of both CCM and PCMHs in the new healthcare regime have placed primary care physicians in a unique and opportune position; one in which the independent provider stands to find success amidst change. The impact of MACRA on healthcare is “monumental” and “herculean,” said the Director of Provider Innovation Strategies at DST Health Solutions in her presentation, “The Role of PCMH Under MACRA.” MACRA isn’t a momentary, passing legislation — it’s had bipartisan support from the beginning and it’s here to stay. Luckily for PCHM and CCM participators, this new legislation and enormous impact becomes more manageable.

About the Christina Scannapiego:
Christina Scannapiego has been a technical, health and lifestyle writer for more than 10 years. Christina currently writes the technical documentation and educational content for HealthFusion MediTouch, an Electronic Health Records software platform. HealthFusion and its MediToch cloud software suite is a subsidiary of Quality Systems/next Gen. MediTouch is comprised of a range of web-based software solutions for physicians, medical practices and billing services.

2018 QPP Proposed Rule: What it Means for MIPS & Quantifying the Impact on Specialty Practices – MACRA Monday

Posted on June 26, 2017 I Written By

The following is a guest blog post by Justin Barnes, Board Advisor at iHealth Innovations. This post is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program.

The Centers for Medicare and Medicaid Services (CMS) recently released a Proposed Rule highlighting recommended updates to the 2018 reporting period of the Quality Payment Program (QPP). Like flexibilities extended in 2017, the proposal seeks to further reduce reporting burdens on small practices and rural providers in the program’s second-year reporting period.

Merit-based Incentive Payment System (MIPS) reporting track updates include:

  • Increased low-volume exemption thresholds (<200 patients or <$90,000 in payments)
  • New virtual group options for solo practitioners and groups with 10 or fewer Eligible Clinicians
  • Extending “pick your pace” flexibilities into 2018
  • Postponing introduction of the Cost category to MIPS composite scores
  • Factoring MIPS performance improvements into quality scores
  • Permissions for facility-based providers to report through the facility where they do most of their work instead of the practice
  • Permitting the use of 2014 CEHRT in 2018 reporting

The Rule introduces new MIPS bonus point opportunities for:

  • The use of 2015 CEHRT
  • The care of complex patients

Recommendations also extend small practice relief including:

  • Up to 5 bonus points for practices with 15 or fewer Eligible Clinicians
  • Hardship exemption for Advancing Care Information category measures
  • Additional points on Quality measures that don’t meet completeness requirements

Comments on the Proposed Rule are due by August 21, 2017. Physicians have until October 2, 2017, to begin collecting performance data for the inaugural 2017 MIPS reporting period.

Calculating MIPS: The Financial Impact on Specialty Practices

Results from a crowdsourced survey fielded by Black Book Research among nearly 9,000 physician practices from February through April of 2017 reveal that 94 percent of physician participants were unaware or unsure of how to predict their 2017 MIPS performance scores. Seventy-seven percent of practices with three or more clinicians reported intentions to purchase MIPS compliance technology solutions by the fourth quarter of this year, largely driven by an inability to independently determine earning potential under MACRA.

Orthopedics, cardiology and radiology are among the highest incentivized specialties under MIPS. To help specialty practices quantify the fiscal impact MIPS poses, we evaluated average Medicare earnings by specialty to establish the MIPS calculations below. These estimates are based on bare minimum earnings and losses that could be greater for practices with larger Medicare patient populations and/or more physicians. (Calculations are strictly illustrative estimates.)

Cardiology Practices
Estimated average payment adjustment for a 5-clinician cardiology practice in 2019 alone: $43,601
Number of cardiology-specific QPP measures: 20

Orthopedics Practices
Estimated average payment adjustment for a 6-clinician orthopedics practice in 2019 alone: $34,603
Number of orthopedics-specific QPP measures: 21

Radiology Practices
Estimated average payment adjustment for a 6-clinician radiology practice in 2019 alone: $30,117
Number of radiology-specific QPP measures: 22

Note: The above projections assume the full incentive and penalty will be paid out as outlined in the MACRA law. However, the positive and negative payment adjustments will be scaled so the program is budget neutral. This means that the positive payment adjustments will have to be offset by penalties.

Navigating the Transition to MIPS
As clinicians prepare for reporting under MIPS, establishing specialty-specific expertise on financial, clinical and technical objectives can help practices thrive rather than just survive.

Tips as you for prepare for MIPS:

  • Know your reporting options and pick your path.
  • Choose measures that play to the strengths of your specific specialty practice. Review your current billing codes and Quality and Resource Use Report to help determine these areas.
  • Do a technology asset inventory to make sure you can track the required CQMs.
  • Customize your EHR for track your selected measures or ID an outsource vendor to assist.
  • Work towards minimum reporting requirements to avoid a penalty with a stretch goal to report on the full required measures to maximize positive adjustment earnings potential.

Additional resources:
QPP website
An overview and support documentation is available at the CMS QPP website here.

MIPS EDU Program
A new “Quality Payment Program in 2017: Pick Your Pace Web-Based Training” course with Continuing Education Credit is available through the Learning Management System. Learn more here.

2017 CMS-Approved Qualified Clinical Data Registries
Additional specialty-specific measures are available via approved 2017 QCDRs to meet MIPS reporting requirements. Options for cardiology, radiology and orthopedic practices are included. Learn more here.

About the Author:
Justin Barnes is a nationally recognized business and policy advisor who serves as Chairman Emeritus of the HIMSS EHR Association as well as Co-Chairman of the Accountable Care Community of Practice. As Board Advisor with iHealth, Justin assists providers with optimizing revenue sources and transitioning to value-based payment and care delivery models. Justin has formally addressed Congress and the last three Presidential Administrations on more than twenty occasions on the topics of MACRA, value-based medicine, accountable care, interoperability, consumerism and more. He is also host of the weekly syndicated radio show “This Just In.” Justin can be found on Twitter at @HITAdvisor.

There Are Some Things You Just Can’t Do Without an EHR

Posted on March 24, 2015 I Written By

The following is a guest post by Tom Giannulli, MD, MS, Chief Medical Information Officer, Kareo. Follow and engage with him on Twitter @drtom_kareo or @GoKareo.
Tom Giannulli - Kareo EHR
Over the past two years, there has been a lot of talk about a big EHR switching trend. Some of this has been because of Meaningful Use, and some of it has been because of market changes. There are simply more options today if you are unhappy with your current EHR.

Surveys show that many physicians are frustrated with the cost or functionality in their EHR, which has prompted considering a switch. There is also frustration with too much third party interference and regulation. Despite some of these challenges, one thing is clear. Most physicians believe EHRs improve care, reduce errors, and improve billing.

What sometimes gets left out are the other opportunities created by using an EHR. Some of these are new revenue sources that might be impossible or very hard to access without one. Here are a few examples, but certainly not the only ones.

Medicare Programs
There are some new codes that have come out in the last two years for services that are revenue generators, but you really do need an EHR to manage them. The first is transitional care management (TCM). While TCM doesn’t require you to use an EHR, the complexity of it makes it hard to do without one. The ability to easily put in your notes and set reminders for needed follow up makes managing TCM much easier. With reimbursement ranging anywhere from about $100 to over $200 per patient, this can be a great opportunity for providers who see many patients who need post hospitalization follow ups.

The other Medicare program is newer and does require the use of a certified EHR. It is the Chronic Care Management (CCM) code that came out this year. The reimbursement is about $42 per patient and can be billed once a month. The requirement is that the patient has two or more chronic conditions that are expected to last at least 12 months or until the patient’s death. Clinical staff must spend at least 20 minutes performing CCM services for the patient each month that the code it billed. The services are non-face-to-face and direct supervision is not required, which means that nursing staff or non-physician practitioners can render CCM even if the physician is not in the office. Again, if your practice sees a lot of patients with chronic health problems, this can be a great way to add revenue by using nursing or mid-level staff.

Affordable Care Act Opportunities
By now I hope everyone knows that preventive care services are covered with no copays or deductibles. What many providers still aren’t very aware of are the other types of programs that are now covered by insurance that can be great revenue generators. While they don’t require an EHR, this is another area where using an EHR makes running these programs much easier. The two programs that make a lot of sense for primary care providers and specialists who see patients with certain types of qualifying conditions are group visits and weight loss programs.

With group visits, the practice identifies a group of patients who have a similar, chronic condition that requires frequent visits. You can do this using your EHR (it would be tough using paper charts). Some examples include HIV, chronic pain, COPD, and hypertension. Vitals are done individually as patients arrive and then the whole group spends the rest of the 1.5 – 2 hour visit together with the provider. Once a group visit is completed, each patient’s insurance is billed for the appropriate E&M code for their individual situation. The ability to use templates and copy note features in the EHR can make documenting after the group visit much faster and easier than it would be if done by hand.

For patients with certain conditions, a weight loss program may be mostly or fully covered by insurance like preventive care. The great thing about this is that it can be as simple or complex as you are willing to manage. You can do simple nutritional counseling and weigh-ins or go for a fully formed program through a third party that includes food and supplements. Again, using an EHR makes it much easier and faster to manage and track multiple follow up appointments, set reminders, and copy notes and simply update them each time. You can even have a group visit component!

The key to all of these opportunities is that an EHR helps reduce the complexity of managing the requirements and helps insure that you can quickly and easily show accurate, thorough documentation to payers. Without an EHR, these revenue generating programs would simply seem too difficult to manage. In a time when every penny counts, you can’t ignore opportunities like these.

Kareo, the leading provider of cloud-based software and services for independent medical practices, is a sponsor of EMR and EHR. Find out more about Kareo’s award-winning solutions at http://www.kareo.com/.

Creative EMR Price Reduction

Posted on November 12, 2010 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I always love creativity and so I have to give credit to the marketing people at meridianEMR. They’re providing an interesting price reduction in their EMR that keys off of many physicians anger over the potential 21.9% Medicare reimbursement cuts. Here’s a few portions from the meridianEMR offer:

In order to provide physicians with relief from Medicare fix uncertainty, meridianEMR is offering a special “meridianEMR Doc Fix.” This includes a 21.9% reduction on all new meridianEMR system orders for new Urology customers starting November 10, 2010 and ending December 31, 2010. This unprecedented offer during these uncertain times directly reflects one of the core values of meridianEMR, which is partnership with clients.

“If the government does not rescind the “Doc Fix” of 21.9%, our offer still stands. We encourage our potential new clients to move forward with confidence that they will be receiving the market leading Urology EHR at the most affordable price ever offered by meridianEMR. This is our way of standing by their side in a challenging economic environment,” commented Lawrence Drappi, Executive Vice President, meridianEMR.

I’m sure that many doctors will appreciate the gesture. Pretty creative to key off of cuts that have been seen as such a negative thing. I wonder if other EMR vendors will follow their lead. Many of the EHR software out there could use at least a 21.9% cost reduction.