Question

The impact of MACRA on Clinical Care ( Patient/provider interaction and workflow).

Answer 1

There is sweeping new federal regulation that will impact the future role of managed care nurses and physicians in the most challenging of ways. This new law is referred to as “MACRA.”

MACRA will overwhelmingly affect pre-authorizations, clinical coding review, claim reimbursements, policy development, performance measures and coordination of care, defining new roles for Medicare providers and managed care professionals in the United States.

You don’t serve the Medicare population in your current managed care position? Not to worry.Because of the over-arching theme of increased financial risk and variable incentive payments addressing performance in the value of care, the U.S. potentially stands to lose hundreds if not thousands of providers serving Medicare patients, which can also mold and impact the commercial health care markets.

Hoping to retire someday and sign up for Medicare? Here is some helpful information you should know as a patient and as a managed care professional. Let’s look at the history, the regulation and the impact it may have on your own physician, the provider space at large, and you as a managed care professional.

This isn’t your Granddaddy’s Medicare system anymore, so I’ve enlisted input from my colleague at URAC, Aaron Turner-Phifer, Director, Government Relations and Policy, for some basic information about MACRA first:

MACRA Basics

In a rare show of bipartisanship, Congress overwhelmingly passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) which replaced the much maligned sustainable growth rate (SGR). MACRA represents the latest policy meant to facilitate the transformation of America’s delivery system toward value-based care and away from fee-for-service.

To facilitate this shift MACRA creates the Quality Payment Program which is comprised of two different programs: the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APM).

Physicians and clinicians participating in the MIPS program will receive a bonus or penalty in their overall reimbursement based on a composite score compared to others in the MIPS program. The better a physician or clinician does, the higher the bonus. The inverse is also true, the worse a physician or clinician performs compared to the field, the higher the penalty. Beginning in 2019, the first year payment adjustments begin, the maximum payment adjustment for physicians and clinicians is four percent. This escalates to nine percent by the year 2023.

As an alternative to MIPS, physicians and clinicians can participate in the APM (Alternative Payment Model) program which excludes them from the requirements of MIPS. Physicians or clinicians in the APM program get an annual five percent lump sum bonus simply for participating beginning in 2019. APMs are defined as those that meet criteria for linking payments to quality measures, use of EHRs, and nominal risk. CMS has identified the following programs that meet this definition:

Track 2 and 3 Medicare Shared Savings Program ACOs

Next Generation ACOs, Comprehensive Primary Care Plus (CPC+)some Comprehensive ESRD Care organizations (ESCOs)

In 2015, the bipartisan reform legislation called Medicare Access and CHIP Reauthorization Act (MACRA) was passed. The goal of MACRA is to help change Medicare payments from quantity to quality based. It is also simplifying the reporting process for healthcare providers by merging Meaningful Use and PQRS together.

At close to 1,000 pages of legislation, MACRA is the biggest face lift of the medicare system in decades, which promises to change the way physicians are paid. Instead of the current fee-per-service model, it will be practice-driven, focused on connecting with patients, and rewards high quality care.

pages detail how CMS will manage the two programs stemming from MACRA: The Merit-Based Incentive Payments Systems (MIPS) and Alternative Payment Models (APMs).

Changes begin to roll out in 2017, so physicians need to begin now to understand the new structure.