MACRA - How to Prepare for Tomorrow's Healthcare Industry

MACRAHOW TO PREPARE FOR TOMORROW’S

HEALTHCARE INDUSTRY

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MACRA: How to Prepare for Tomorrow’s Healthcare Industry

The more your medical practice or organization is

prepared to embrace Value-Based medicine, especially

as it pertains to your Medicare patients, the better

you’ll be in terms of avoiding looming penalties that will

only increase over time. Optimally, you’ll even obtain

incentives for doing so.

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About the Author

Marc KlarVP of Marketing, Advanced Data Systems

Marc was introduced to medical software sales after several years working

in operations, management, and sales in the NYC hotel industry. He quickly

learned the medical industry/software and more than held his own in sales.

He got into assisting with marketing, created new business development

teams and marketing programs with two different vendors, one of which

became the largest vendor of that system in the country for three consecutive

years. He then moved to Advanced Data Systems; as VP of Marketing, Marc

oversees the company’s entire marketing effort. Among other things, Marc

enjoys reading, cooking, and performing comedy which sometimes isn’t funny

for him or his audience. He has an appreciation and respect for good music

and art (where an apple is an apple…not someone’s head). Marc became an

accomplished drummer and teacher after studying with some of the top jazz

drummers in NYC, all as a result of being told since early in life to “beat it.”









Table of Contents

What is MACRA? ................................................................................................. 05

What Is MACRA Supposed to Accomplish? ........................................... 06

MACRA’s Value-Based Payment Programs ........................................... 07

What’s Needed for MIPS or APM Reporting? ...................................... 09

MACRA Implementation Timeline ............................................................. 09

Who are ECs, and which ECs are Exempt? ............................................ 10

Where Do I Go for Complete Details On the Options,

Reporting Criteria, and Anything Else MACRA-Related? ................ 11

A thought on the Election, and a Conclusion ......................................... 11

Key Takeaways ...................................................................................................... 12









What is MACRA?In 2015, the Medicare Access and CHIP Reauthorization Act became law.

The buildup to MACRA seemed inevitable in the face of skyrocketing fees

for healthcare. MACRA would create a new approach in terms of delivering

better, higher quality medical care while actually expending fewer resources

in the process.

Better care, more efficiently delivered. In other words, Value-Based (VB)

medicine instead of fee-for-service. Or, quality vs. quantity.

By operating under a VB medicine approach, CMS has calculated that billions

of dollars can be saved by having physicians (aka, “Eligible Clinicians” or ECs)

focusing on quality of care rather than quantity of care. Things like repetitive

and / or unnecessary tests, “over and over again” office visits, etc. would be

eliminated. Even readmissions to inpatient facilities -- at least within certain

time periods such as thirty days -- are projected to be reduced under VB

medicine.









What Is MACRA Supposed to Accomplish?Off the bat, MACRA replaced the Sustainable Growth Rate (SGR) formula

which, as you’ll no doubt recall, had been an ongoing issue itself for years.

There are many aspects to MACRA, one of which is the Quality Payment

Program (QPP). The QPP, in turn, covers the two major tracks ECs can follow

for embracing VB medicine:

• MIPS (the Merit-based Incentive Payment System) and

• APMs (Alternative Payment Models or advanced Alternative Payment

Models).

By adopting (reporting) under MIPS or an APM, ECs would be able to

document (eg. prove) their VB medicine statistics in order to avoid being

penalized for not operating in a VB medicine kind of way. In fact, they could

also obtain incentives for reporting.

So by providing an opportunity for ECs to obtain financial incentives and

avoid penalties, being in VB medicine becomes alluring. ECs could also opt to

not participate, be penalized, and not get any incentives.









MACRA’s Value-Based Payment ProgramsIn a nutshell, MACRA value-based programs are based on two new structures

for reimbursement, as already mentioned: MIPS and APMs. Becoming

familiar with these programs is essential for getting into VB medicine.

MIPS

ECs who move forward under MIPS can do so based on three options

recently announced as part of the MACRA final ruling. The options range

from being very easy with a bare minimum of reporting required in 2017, to

reporting on all criteria for the entire 2017 calendar year. Penalties are up to

4% and incentives could exceed 4%, each as calculated against the EC’s 2019

Medicare reimbursements.

Option 1 was designed essentially to help ECs avoid their penalties. ECs

would select very minimal reporting on any of three reporting criteria.

There are no incentives under Option 1, but the EC will at least avoid being

penalized. It will also help ECs “get into” VB medicine and perhaps do more

involved reporting in 2018 and beyond, thereby obtaining incentives as well

as avoiding penalties.

Options 2 and 3 call for more involved reporting, from a minimum of any 90

days in 2017, to a minimum of 90 consecutive days in 2017 even up to the

entire 2017 calendar year. And, the reporting measures in Options 2 and

3 are way more comprehensive than the very simplified, single measure

required for Option 1.









Of course, rewards are higher under these options with an opportunity to

obtain at least some incentive calculated against the EC’s 2019 Medicare

reimbursement, up to the full incentive which could exceed 4% based on the

quality of the reporting.

APMs

A fourth option is reserved only for ECs who have joined an Accountable

Care Organization (ACO), a Medicare Shared Savings Plan (MSSP), etc.

Those ECs will operate under an APM or advanced APM approach. These

ECs can obtain a 5% lump sum bonus calculated against their 2019 Medicare

reimbursements.

Indications are that ECs who are now beginning to adopt VB medicine’s

reporting will most likely do so via the MIPS route, although that’s certainly

not a rule. ECs can absolutely still go the APM way.









What’s Needed for MIPS or APM Reporting?The basic requirement is a Stage 2 certified EHR -- preferably one with a

specific QPP dashboard -- that can data mine and visualize the required criteria,

and then be able to report on it to CMS.

An EHR vendor who also has affiliations or collaborations with practice

transformation networks (PTNs) and registries is ideal. PTNs work with

practices to help transform them from fee-for-service to VB, often at no cost,

or at a very nominal cost and registries are needed for reporting.

MACRA Implementation TimelineThe timelines are now firmly established with MACRA’s final ruling having

been released in October 2016.

2017 is the reporting year. Reporting can be very minimal as outlined above

via Option 1, or can be aggressive and comprehensive starting right from

January 1 (see Options 2 and 3 above).

Based on whatever 2017 reporting is made, those statistics will be calculated

against the EC’s 2019 Medicare reimbursements. The result will determine

the amount of the penalty to be assessed against the EC, assuming the EC

didn’t avoid a penalty. It will also determine any incentives to which the EC is

entitled, again based on the quality of his or her reporting.









Penalties and incentives will rise annually over the ensuing years when the

EC’s 2018 statistics are reconciled against 2020’s Medicare reimbursement,

2019 for 2021, etc. They will level off at up to 10% and remain at that rate in

perpetuity, or until the next reporting can be done in whatever reporting year

the EC begins.

Simply stated, ECs will be Medicare-penalized for as many years as reporting

isn’t done, and will likewise not obtain incentives.

Who are ECs, and which ECs are Exempt?For 2017, Medicare considers the following to be ECs: MDs, DOs, DDSs,

DMDs, PAs, NPs, CNSs, and CRNAs who bill for Medicare Part B or Critical

Access Hospital (CAH) Method II payments assigned to the CAH. Non-

patient facing ECs (radiologists, pathologists, etc.) don’t need to report

on certain criteria. To make it fair, these ECs will have some of their other

reporting criteria levels elevated.

You’re exempt from 2017 reporting if you’re:

• In your first year of Medicare Part B participation

• Billing Medicare Part B for $30,000 or less in allowed charges, or

providing care for 100 or fewer Part B patients in one year

• In an entity sufficiently participating in an Advanced APM (see the

MACRA FAQs for more on Advanced APMs)







https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html



Where Do I Go for Complete Details On the Options, Reporting Criteria, and Anything Else MACRA-Related?Visit www.cms.gov or www.qpp.cms.gov. Your medical or specialty societies,

and practice administrator organizations no doubt have MACRA resources

available to their members as well.

A Thought on the Election, and a ConclusionThere’s been talk about repealing the Affordable Care Act (ACA, aka

“Obamacare”).

Yet, we’ve also heard that elements of it and other related programs will

probably remain intact. One of those intact elements would no doubt have

to be the QPP, because there’s simply too much money (billions and billions

of dollars) to be saved by Medicare under VB medicine…all while better

healthcare is provided at the same time.

So…if you’re an EC and you’re not exempt, a suggestion is for you to be in a

VB medicine frame of mind!







http://www.cms.gov

http://www.qpp.cms.gov



Key Takeaways:• MACRA is the Medicare Access and CHIP Reauthorization Act of 2015;

it replaces the SGR.

• QPP is the section of MACRA that contains MIPS and APM.

• Various reporting options can be selected in order to avoid Medicare

penalties, and to obtain incentives.

• A certified EHR that can compile and report on the selected option’s data

is needed; even better is if it has a QPP-specific dashboard.

• Some ECs are exempt from reporting, but any who aren’t should

embrace VB medicine or face annually rising penalties and no incentives.

• Suggested that the QPP section of MACRA should be thought of as

remaining as is.









Advanced Data Systems (ADS), is a company with a proven history of stability and

reliability in the industry.

Thousands upon thousands of physicians rely on systems from ADS, as do

hundreds of medical RCM companies for their clients. Our own MedicsRCM

uses the Medics Suite as well for our RCM clients.

And we still provide customer hosted implementations when that works best for

the client. Otherwise, it’s cloud!

You’re invited to contact us for more information on our Medics Suite and to

schedule a personalized system overview.

ADS: Advanced Technology. Simple Solutions™









WATCH THE WEBINAR

Go beyond surviving! Learn more about VB medicine in this

new healthcare environment by watching our on-demand

webinar as presented by Justin T. Barnes…a nationally

recognized HIT business and policy advisor.

The information presented in this ebook is done so according to our best understanding of the CMS

programs described. Links within the ebook should be visited if clarifications are needed. ADS is not

responsible for typographical errors.







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MACRA - How to Prepare for Tomorrow's Healthcare Industry