Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Policy & Regulation News

Providers Need Time, Resources for MACRA Implementation

Providers are at various stages of readiness in complying with ACA healthcare models, so regulators should be flexible and give them time to adapt to provisions of MACRA.

By Catherine Sampson

- Driven by the Affordable Care Act, the implementation of Medicare Access and CHIP Reauthorization Act (MACRA) is expected to significantly impact the nation's healthcare system. Already, many physicians and various types of healthcare professions are currently preparing for a Medicare payment system that is based on quality instead of volume.

Providers need time and flexibility to adapt to MACRA provisions.

Providers need time and resources in order to adapt to functioning within value-based payment structures, such as alternative payment models (APMs), Jeffrey Bailet, MD, President of Wisconsin-based Aurora Health Care Medical Group, explained in a recent Congressional testimony.

“Many physicians are in various stages of readiness for a value-based payment system,” Bailet said before the House Committee on Energy and Commerce. Regulators need to process cautiously during this transition, he argued.

“Providing an incremental approach that includes flexibility and rational exposure to financial risk will be vital in ensuring a successful transition to value-based payment,” Bailet said.

Many providers will face a huge learning curve as they begin to take on the financial risk of transitioning to new payment models, whether they are the Merit-Based Incentive Payment System (MIPS) or APMs. The Centers for Medicare & Medicaid Services (CMS) should recognize that healthcare professions need time to “adapt and learn how to function in this new payment environment,” Bailet argued.

READ MORE: CMS Expects to Release MIPS Participation Status By May 2017

Both small group practices and larger multispecialty medical groups will be required to make significant investments in order to be successful in this risk-based environment, he explained. The level of financial risk that physicians are able to take on varies widely. Some need more resources and support more than others. Some need to improve their health information technology infrastructure. This can pose as a challenge for physicians in rural communities that have small practices and limited resources, he said.

Bailet noted that MACRA will provide for technical assistance to MIPS eligible professionals in small practices as well as practices that have a shortage of health professionals. From 2016 to 2020, CMS will be allocated with $20 million annual to execute this program.

Although MACRA will provide incentives to APM participants, CMS should still take a number of steps to ensure that healthcare professionals are able to participate in the program in a meaningful way. CMS should have a level of engagement with the healthcare community. The agency should make sure that providers have full access to claims data. Data exchange formats should be also standardized, Bailet said.

The transition to value-based care, also requires that healthcare professionals implement IT and EHR systems effectively. They will also need to migrate team-based care delivery and redesign care processes, Bailet explained.

However, purchasing an EHR system is only a starting point for improving healthcare practices, he argued. Data from these systems needs to be analyzed and interpreted in ways that make sense to physicians and care teams. Meaningful and actionable data can allow professionals to deliver high-quality, appropriate care for patients. Also, through collaboration, healthcare professionals can move these best practices across the entire healthcare system, he argued.

READ MORE: 2 APMs Take Next Step As MACRA Physician-Focused Payment Models

Bailet shared a few of Aurora’s success stories of implementing more quality to their healthcare system. Analyzing and protecting data was an important part of these efforts. Aurora launched two predictive analytic pilots that focused on preventing hospital admission and readmission for patients with congestive heart failure and chronic obstructive pulmonary disease (COPD). By using health coaches, outreach and patient engagement, Aurora was able to “take active ownership” of patients treatment and health status.

In a two-year period, this effort allowed Aurora to reduced congestive heart failure related admissions by 60 percent and COPD admissions by 20 percent.   

Aurora also worked toward reducing hospital readmissions by incorporating more team-based care in its organization. They achieved this by having a program where nurses follow patients that have a high-risk of hospital readmission. Through phone calls and in-person home visits, nurses monitor patients for 30 days after their discharge. Also, more than 70 percent of patients have a follow-up appointment with their primary care physician within seven days of discharge.  

Bailet also chairs the Physician-Focused Payment Model Technical Advisory Committee (PTAC), which was created by MACRA as an advisory panel that considers stakeholders’ and physicians’ proposals for new models of healthcare.  PTAC will be advising the secretary of the US Health and Human Services on payment models.

Many are in agreement with Bailet that transitioning to a new healthcare system comes with a unique set of challenges. “The common goal of payment reform should be to deliver high-quality care in the most efficient and cost-conscious way. However, there are currently major challenges to achieving that goal,” The Heritage Foundation said.

READ MORE: AAFP: Drop MIPS APM Pathway to Simplify MACRA Implementation

The transition toward a value-based payment system in Medicare may not be a smooth ride for all physicians and various healthcare professionals, but it has the potential to lead to better health outcomes, as Aurora experienced.  


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