Slideshow 12 ways new fed reimbursement programs will impact healthcare IT

Published
  • July 07 2016, 4:00am EDT

12 ways new fed reimbursement programs will impact healthcare IT

While the final rule may not be out for weeks or months, provider preparation needs to start now.

CMS finalizing MACRA payment rule

The Centers for Medicare and Medicaid Services now is considering the final form of the rule that will implement the Medicare Access and CHIP Reauthorization Act (MACRA). It’s currently assessing thousands of comments reacting to the Notice of Proposed Rulemaking issued in April. Even though the final form of the rule may not be revealed for some time, it’s clear that the transition from volume to value has begun for clinicians providing care under Medicare Part B.

MACRA is confusing, and this synopsis of an analysis by Hayes Management Consulting will help get you going. Where appropriate, we add our take on what the potential impact on healthcare information technology will be.

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MACRA impact—broader than Meaningful Use

MU introduced the concept of “eligible professional” to the HIT industry. MACRA’s impact is much broader—any clinician billing for professional services under Medicare Part B is affected. It will include physicians, dentists, chiropractors, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, physician assistants, physical or speech therapists, and hospital-based eligible providers. Some exemptions may apply to some clinicians.

HIT impact: Technology implications may be more widespread than they were under the focused MU program.

MACRA doesn’t affect hospitals—or does it?

MACRA doesn’t affect eligible hospitals or critical access hospitals in terms of reimbursement. But it does have an impact in a few areas related to technology. Facilities will be involved in cooperating with the surveillance and oversight of EHR technology, and they’ll need to attest that the EHR technology being used does not block the bidirectional flow of data, Hayes Management says.

HIT impact: Attesting that the flow of data is unimpeded is a prime requirement.

MACRA’s scope—the great consolidator

MACRA consolidates and replaces a number of existing programs. These include: The Medicare Sustainable Growth Rate (SGR), which was repealed as part of MACRA; the Physician Quality Reporting System (PQRS), ending the adjustment at the end of 2018 (incentive payment and adjustments are all rolled up under MACRA); Value-Based Payment Modifier, which are incorporated into two components of the merit-based option of MACRA; and Meaningful Use, incorporated and expanded in the incentive-based portion of MACRA.

HIT impact: For eligible clinicians, a whole new approach to where HIT fits into reimbursement.

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Pick one of two choices

Eligible clinicians must choose between one of the two major segments of MACRA. The choices are either the Merit-based Incentive Payment System (MIPS), or the alternative payment model (APM). As such, all clinicians will move to a value/quality-based reimbursement scheme.

HIT impact: The focus of IT systems will need to change to enable improvement in value and quality, versus attention previously paid to charge capture and administrative functions.

MIPS, simply defined

The Merit-based Incentive Payment System (MIPS) comprises four components, each receiving a weighted score to calculate a composite performance score, which determines reimbursement. Components are Quality (50 percent weight, replaces PQRS and the quality component of the Value Modifier Program); Resource Use (10 percent weight, replaces cost component of the Value Modifier Program); Clinical Practice Improvement Activities (15 percent weight, based on improvement in selected measures in nine categories, such as care coordination and beneficiary engagement); Advancing Care Information (25 percent weight, effectively replaces Meaningful Use, although incorporating many of the EHR incentive elements).

HIT impact: For eligible professionals, this is where incentives for HIT now reside.

MIPS, the fine print

In some cases, clinician scores will be calculated directly by CMS on claims data, so no clinician reporting will be required. Under the Advancing Care Information component, providers will be required to attest to what they’re doing to protect patient information. “This requires a yes or no response, and if you can’t answer yes, you get ZERO points for the entire ACI component, regardless of your other achievements,” Hayes Management warns. And reporting data used to calculate scores for MIPS is not limited to providers’ Medicare beneficiaries. Since MACRA is intended to be budget-neutral some clinicians will see an increase in payment, while others will have a decrease.

HIT impact: An inability to protect patient information will negate all other HIT activity, as if you didn’t already know that was important.

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Understanding the APM program

The only option for clinicians other than MIPS is to participate in an Alternative Payment Model, or APM, which aims to increase the quality of care to improve patient outcomes. CMS has developed a variety of APMs in which a broad array of physicians and other practitioners can participate. In addition, there are multi-payer options and innovative models in Medicaid and commercial markets that qualify as APMs. Examples of these include accountable care organizations, patient-centered medical homes and bundled payment models.

HIT impact: Shifting reimbursement approaches will require new capabilities in IT systems to support the adjustments that provider organizations need to make.

One step further—an advanced APM

These are APMs that take on more risk for the health of a population. Participant groups must bear a certain amount of financial risk; payments must be calculated using evidence-based quality measures that are reliable and valid; and at least 50 percent of participants in an APM must use certified electronic health record technology to document and communicate clinical care information in the first performance year (this increases to 75 percent in the second performance year). Physicians who go this route qualify for a 5 percent Medicare Part B incentive payment, as long as certain conditions are met.

HIT impact: The use of electronic health record technology is a key to participation, and essential to manage the risk involved.

Joining the team—becoming a Qualifying APM Participant

Qualifying APM Participants are eligible clinicians who have met certain criteria and are exempt from the MIPS model. The design of the APM must meet the criteria the feds set for an Advanced APM, and other clinician participants meet other criteria. While there will be many hoops to jump through, qualified participants could stand to receive the 5 percent lump sum bonus payment based on estimated aggregate payments amounts for Part B for the preceding year.

HIT Impact: The prospects of taking on downside risk will force providers to become comfortable with analytics and population health applications.

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The impact of MACRA on Meaningful Use

Well, it’s huge. MACRA advances the CMS commitment to the use of technology in healthcare but focuses on clinicians in the Medicare environment. It phases out the existing Medicare payment adjustment at the end of calendar year 2018 but the EHR Incentive Programs for hospitals and professionals in the Medicaid program remain intact. Further, the Advancing Care Information component of MIPS mandates the use of certified EHR technology and compels clinicians to choose report measures that are specific to its use with an emphasis on interoperability and information exchange.

The MACRA criteria categories that replace Meaningful Use are Protecting Patient Health Information, Patient Electronic Access, Coordination of Care through Patient Engagement, Electronic Prescribing, Health Information Exchange, and Public Health and Clinical Data Registry Reporting.

How to prepare, starting today

Clinician organizations need to begin considering which elements in each MIPS component they’re going to report on, what incentives they’re going to be looking for, whether their workflows support the new requirements, and whether their technology supports the workflow and can meet the new reporting demands. Incentives and adjustments will not take place until January of 2019 but they will be determined by the data you report starting January 1, 2017.

Looking toward the future

Organizations should also make sure they have a 2014 or 2015 Edition Certified EHR in place when reporting starts in January 2017. (By 2018, they’ll need to be using a 2015 edition only). By Jan. 1, 2017, clinicians and organizations also will need to attest to their support for health information exchange and the prevention of information blocking. They also will have to attest to the Office of the National Coordinator for Health IT (ONC) that they are cooperating with surveillance and oversight of the EHR being used.