Measuring Up To the New MACRA Quality Standards

David Zavala, Senior Manager Technology Strategy, Healthcare and Life Sciences Industry

On November 2, 2017, the Centers for Medicare & Medicaid Services (CMS) released the 2018 requirements for Year 2 of the Quality Payment Program (QPP) as established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The final rule reinforces CMS’ ongoing goals of shifting the industry toward value-based care, with objectives that are intended to improve the quality of healthcare by forcing physicians to critically assess care strategies and focus more on outcomes.

The Quality Payment Program creates two options for Medicare Part B reimbursement beginning in 2017: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). Under MIPS, providers will be reimbursed on a sliding scale based on performance data they were to have begun collecting by October 2, 2017 in order to achieve the possibility of positive adjustments in reimbursement payments in 2019.

Although these requirements are aimed at physicians, hospitals and other organizations that employ or contract with physicians may share in the financial and compliance burden. The financial impact of performance scores can amount to millions of dollars over several years in the program for healthcare organizations with a large number of eligible clinicians.

The details of these new qualitative reimbursement requirements are complex. Any meaningful discussion would require a baseline assessment of an organizations’ participation strategies, including governance, monitoring and reporting processes; a gap analysis; and remediation plan — options discussed at greater length in our recently published paper, MACRA — Does Your Quality Measure Up?

There are several things that healthcare provider chief financial officers, chief quality officers, and chief nursing officers, among others, should be doing right now to ensure that their organization has a good governance structure in place.

  • MIPS vs APM — Know which track your organization is in, and whether this will change in 2018.
  • Data Collection — Under Year 1 (2017) of the QPP, providers were required to begin collecting data on patient outcomes no later than October 2, 2017 in order to obtain possible positive adjustments in 2019 reimbursement payments. Healthcare organizations should be clear on what data is required and work with vendors, internal teams and clinicians to ensure that the right data is being collected and reported accurately.
  • Awareness — Industry surveys show that less than half of clinicians are aware of the requirements established by the QPP. Healthcare organizations should be taking steps now to ensure that the providers they rely on are educated on the requirements, are aware of the changes taking place in 2018, and are taking appropriate measures to maximize their reimbursement potential.
  • Analysis — Assess current provider performance, including Quality and Resource Use Reports (QRUR), and the related financial impact of reimbursement adjustments in 2019 and beyond. Include a detailed mock scoring assessment. Address gaps and optimize performance.
  • Reporting — Understand reporting options, the mechanisms for reporting, and individual versus group (and virtual group) requirements.

Consider these steps just the beginning. While some providers are adopting a “just enough” approach to participation in 2017, that certainly should not be the case going forward. Organizations should keep in mind that their scores under the Quality Payment Program will be made publicly available. This information will likely proliferate across the internet and be easily discoverable with a simple online search — which will, no doubt, become a factor in patient provider selection.

If you have any questions, feel free to start a conversation in the comment section below, or reach out to us on our website. The detailed paper outlining this topic can be downloaded, free, here.

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