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How Physicians Can Prepare for the Financial Impact of MACRA

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If all goes according to plan, the first performance period for the new Medicare Access and Chip Reauthorization Act (MACRA) is just around the calendar corner. It’s a complicated reimbursement structure with multiple tracks that are guaranteed to reward with bonuses or inflict pain through penalties in CMS’s new zero sum game. To the physicians and practices that adopt this new program early and position themselves for the best fiscal outcomes, go the spoils. But for many smaller practices and those that consistently underperform, the outlook may be glum regardless. Here are some highlights of the new program and the financial impact it will have on clinicians and practices.

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How Physicians Can Prepare for the Financial Impact of MACRA

  1. 1. How Physicians Can Prepare for the Financial Impact of MACRA ̶ Bryan Oshiro, MD
  2. 2. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Medicare Access and CHIP Reauthorization Act MACRA The proposed MACRA rule has already generated enough pain to warrant its own ICD-10 diagnosis code. The rule redefines the core of how physicians and other healthcare professionals (now all referred to as Eligible Clinicians or ECs) will be reimbursed. MACRA is easily the most profound change to the payment program in the last 60 years and will alter the way care is delivered and ECs practice.
  3. 3. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. MACRA Highlights MACRA will consist of two payment structures: • Merit-based Incentive Payment System (MIPS) • Advanced Alternative Payment Models (APM) The American Medical Association provides excellent resources that summarize and answer questions about both structures, as does CMS, which published a Quality Payment Program fact sheet with well-illustrated details on the new payment models. Bobbi Brown Health Catalyst – VP of Financial Engagement The 7 Best Ways to Prepare for MACRA Today
  4. 4. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. MACRA Highlights ACOs, patient-centered medical homes, and bundled payment models will all qualify under the APM structure. The majority of providers, those who practice outside of these models, will default to the MIPS structure. MIPS will not apply to hospitals or facilities. The CMS proposal is that, eventually, almost all providers will be reimbursed through these mechanisms rather than a fee-for-service arrangement, although the latter will be retained. There will be MIPS exceptions Physicians newly enrolled in the Medicare program Physicians with less than or equal to $10,000 in Medicare charges AND less than or equal to 100 Medicare patients annually Physicians who are already involved in an advanced APM through their hospital systems
  5. 5. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. The Financial Impact of MACRA The fee schedule for all providers will adjust upward by 0.5 percent annually from now through 2019. Physicians aligned with certain APM structures will assume a certain amount of penalty risk. To encourage participation, the APM track will provide 5 percent bonus payments every year from 2019 to 2024 to providers joining new models.
  6. 6. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. The Financial Impact of MACRA Physicians under this structure will only need to adhere to the quality reporting requirements of the APM and will be exempt from the MIPS quality program. MIPS providers who score well will receive annual bonuses of 4 percent in 2019, 5 percent in 2020, 7 percent in 2021, and 9 percent for 2022 and beyond. On the flip side, physicians who don’t meet all requirements will face penalties of those same amounts for those years.
  7. 7. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Five Key Points that Demand Attention CMS, in designing these programs, anticipated winners and losers. The reimbursement scores center around quality, advancing care information, clinical practice improvement activities, and resource use. The metrics for these categories will zero in on providers focused on population health and coordinated care, so they will be the ones that experience significant positive adjustments in their reimbursement rates. 1. Smaller practices will feel the biggest pinch
  8. 8. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Five Key Points that Demand Attention The medical home model, which includes primary care providers and patients empaneled across the continuum of care, will qualify as an advanced APM. Thus, the specialties that interact closely with primary care in providing services for heart disease, diabetes, or other chronic diseases, are also going to benefit the most from this thanks to the already- established coordination. 1. Smaller practices will feel the biggest pinch
  9. 9. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Five Key Points that Demand Attention Unfortunately, small and rural practices, as well as those that practice preventive maintenance, such as chiropractors, dentists, optometrists, and behavioral health providers stand to lose the most because they tend to operate in isolation. It stands to reason that many physicians in smaller practices will seek employment with hospitals and large independent physician groups, or affiliate with hospitals via joint ventures. 1. Smaller practices will feel the biggest pinch
  10. 10. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Five Key Points that Demand Attention As physicians, we make diagnoses, tell patients what to do, write prescriptions, and tell them we’ll see them in three months. Under the new models, the physician will be just one part of the care team. The proposed rule will move beyond this style of care and provide for community partnerships in helping to care for patients. 2. Issues such as care coordination and shared decision making will need to be worked into the normal practice workflow in order to fully benefit from, or at least not get penalized under, MACRA.
  11. 11. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Five Key Points that Demand Attention Patients will need to be an integral part of their care and really understand the care plan. This is where care coordination and shared decision making will come into play. The team may include a nurse, a pharmacist, and a social worker who are all managing a group of patients with chronic conditions to make sure their needs are being met, such as arranging transportation, prescriptions, planning meals and exercise programs. 2. Issues such as care coordination and shared decision making will need to be worked into the normal practice workflow in order to fully benefit from, or at least not get penalized under, MACRA.
  12. 12. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Five Key Points that Demand Attention The provisions of MU will still be in effect. Under MACRA, it will change from focusing on EMR use into an expanded usage of electronic health systems allow more patient access and interaction with their information. 3. Meaningful Use (MU) will not disappear, but will morph into a different program encompassed by MIPS. …the Meaningful Use program as it has existed, will now be effectively over and replaced with something better.” Andy Slavitt CMS Acting Administrator
  13. 13. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Five Key Points that Demand Attention The category of Advancing Care Information, will account for 25 percent of the MIPS score in the first year. It will transform the complexity and focus of meaningful use in terms of how electronic access is going to help, rather than just providing a check-off box to show that a practice did something. Advancing care information will require using an EMR for tracking patient performance and improving care coordination. 3. Meaningful Use (MU) will not disappear, but will morph into a different program encompassed by MIPS.
  14. 14. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Five Key Points that Demand Attention Patients are far more mobile now, moving between facilities and between providers. Interoperability is the access to patient information across all systems. With patients no longer limited to seeing a single doctor in a single facility, care must be more comprehensive and global in nature. The practice of having a single EMR confined within the walls of a single institution or clinic is no longer acceptable. 3. Meaningful Use (MU) will not disappear, but will morph into a different program encompassed by MIPS.
  15. 15. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Five Key Points that Demand Attention Providers will still need to protect medical records from outside intrusion. HIPAA remains intact. Electronic prescribing will still be a focus. But the bigger issue will be on sharing health information across a broader spectrum of care provider networks and settings. 3. Meaningful Use (MU) will not disappear, but will morph into a different program encompassed by MIPS.
  16. 16. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Five Key Points that Demand Attention These professionals aren’t normally associated with these types of programs, but CMS rules and regulations don’t stop with Medicare; they are also concerned with Medicaid patients. Some programs pioneered by MACRA will leap into the private insurance market as well, so there will be issues that need to be addressed by all healthcare providers, not just physicians. 4. MACRA will impact not only physicians and traditional primary care providers, such as nurse practitioners and physician assistants, but others, including physical therapists, nurse midwives, and clinical psychologists.
  17. 17. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Five Key Points that Demand Attention To track all of the metrics and participate in this new program successfully will require considerable ramp up time, which means physicians will need to get very proactive. We’ve had a lot of experience at Health Catalyst in getting services up and running at many hospitals and practices. 5. Preparation will be paramount.
  18. 18. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Five Key Points that Demand Attention We know that, even though improve- ments can be realized sooner, it takes a good six months to put a solid process in place and to have enough data to show that a new program is doing well. And this is for larger facilities with abundant resources. With all of the provisions related to MIPS and APMs, practices, especially smaller ones, will need to be very prepared in order to show meaningful outcomes 5. Preparation will be paramount.
  19. 19. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. More “MACRA-economics” The MACRA rule brings more transparency to healthcare than ever before. It will accelerate a lot of changes, where we will move from just treating acute illnesses after they occur toward a public health type of practice in the U.S. There will be a reduction in the way dollars are currently spent with all the rescue care that we do. We can’t afford to increase healthcare spending; it’s already a $3 trillion industry.
  20. 20. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. More “MACRA-economics” Right now we are independent practices siloed by affiliation, practice, payment mechanisms, and geography. MACRA will provide some hope on the interoperability frontier. It will take some steps toward developing a system of care. MACRA will reduce the amount of mandatory regulatory reporting by streamlining the reporting process for small practices that don’t have the wherewithal of larger systems.
  21. 21. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. More “MACRA-economics” CMS will be using claims-based data to track some of the measures and simplify the reporting. Physicians will be able to choose which programs they are part of, so their reporting requirements will be aligned with that choice. There will generally be much more control of what gets reported through this program.
  22. 22. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Smooth Sailing or Stormy Seas: Early Adoption Is Key There will be some stormy seas and we may temporarily lose the compass. Most providers won’t proactively research this until it’s absolutely necessary. To participate successfully in MACRA, requires proactive preparation. One good resource is the webinar I participated in, titled, Making Sense of the New MACRAAnnouncement. Besides the CMS, AMA, and ACP websites, good resources are also available from specialty-specific and payer websites.
  23. 23. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Smooth Sailing or Stormy Seas: Early Adoption Is Key Once MACRA is upon us, there will likely be a great deal of frustration and anger about how to navigate the MACRA environment, unless clinicians and their practices are well prepared. This will be the most profound transform- ation of Medicare reimbursement, possibly for decades to come, so it will literally pay to get out in front of it.
  24. 24. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. For more information: “This book is a fantastic piece of work” – Robert Lindeman MD, FAAP, Chief Physician Quality Officer
  25. 25. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. More about this topic Link to original article for a more in-depth discussion. How Physicians Can Prepare for the Financial Impact of MACRA The 7 Best Ways to Prepare for MACRA Today Bobbi Brown, VP of Financial Engagement Making Sense of the New MACRA Announcement Bobbi Brown, VP of Financial Engagement The Best Solution for Declining Medicare Reimbursements Bobbi Brown, VP of Financial Engagement 2015 Sustainable Growth Rate Repeal: The Future is Here Bobbi Brown, VP of Financial Engagement Surviving Value-Based Purchasing in Healthcare (Webinar) Bobbi Brown, VP of Financial Engagement
  26. 26. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Bryan Oshiro, MD joined Health Catalyst in January 2014 as the Medical Director. He received his medical degree and completed his residency in Obstetrics and Gynecology at Loma Linda University School of Medicine and completed his fellowship in Maternal-Fetal Medicine at the University of Texas in Houston before moving to Salt Lake City to join Intermountain Health Care and served as the Medical Director of the Women and Newborn Service line. He also was a member of the department of Obstetrics and Gynecology at the University of Utah. He then joined Loma Linda University where he became the division director of Maternal-Fetal Medicine and the vice-chairman for the department of Obstetrics and Gynecology. He co-chairs the American College of Obstetricians and Gynecologists Patient Safety Committee for District IX and received the Elaine Whitelaw Service Award from the March of Dimes for his work on a 5 state initiative to eliminate elective deliveries less than 39 weeks gestation. Other Clinical Quality Improvement Resources Click to read additional information at www.healthcatalyst.com

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