MANY OF US ARE FAMILIAR with the annual Medicare sustainable growth rate (SGR) discussion that Congress has regarding the physician fee schedule. What most do not realize is that this formula has now been replaced.
Why would Congress, in a bipartisan and nearly unanimous vote, replace an existing formula for payment to providers for Medicare? Clearly costs of care have been skyrocketing without the quality of care understood, and now pay for performance has finally arrived. For years, we have heard of pay for performance, reimbursement based on outcomes, value-based reimbursement, etc. For years, we have not seen any substantial progress toward coming up with a way to make this work, but in April 2015, President Obama signed into law the Medicare Access and CHIP Reauthorization Act 2015 (MACRA). This is an act to amend title XVIII of the Social Security Act to repeal the Medicare SGR and strengthen Medicare access by improving physician payments and making other improvements, such as reauthorizing the Children’s Health Insurance Program (CHIP), and for other purposes. Within this law are two different payment options: one is the alternative payment model (APM) and the other is the initiation of the Merit-Based Incentive Payment System (MIPS). This is the blueprint for pay for performance by Medicare.
There are five key principles of the MACRA law you should understand:
1) Every Medicare enrollee needs a dedicated and well-organized PRIMARY CARE team.
MACRA actively promotes patient-centered medical homes and patient-centered specialty practices. These are types of practice recognition programs accredited by organizations such as the National Committee for Quality Assurance (NCQA) to validate that these practices meet specific qualifications for value-based reimbursement.
2) Measurement must be specified appropriately for each different unit of ACCOUNTABILITY.
If you are familiar with clinical quality measures and meaningful use, then you will have a basis to help you understand this aspect of the MACRA. The MACRA states that measures must be specified for each payment model, or unit of accountability, yet still facilitate comparison between and among all payment models. Measures also must be tailored for the different types of care furnished by clinicians in different payment models.
3) Measurement should support rapid improvement and CLINICAL DECISION-MAKING.
Beyond assessing and paying for value, measurement also needs to help clinicians rapidly identify gaps in quality in order to improve their performance. The electronic health record (EHR) “meaningful use” program that MACRA incorporates into MIPS already encourages use of data for population health, decision support and measuring quality. Meaningful use requirements must include accurate and prompt reports for clinician quality-improvement efforts.
4) A core set of measures will let all stakeholders make COMPARISONS across programs.
Core measures will be specified appropriately for the differing situations for individual clinicians, practice teams, accountable care organizations and Medicare Advantage plans, yet aligned in concept and intent to allow meaningful comparisons. The measures will draw from data in claims, EHRs and patient surveys to aggregate up to levels that matter most to consumers, clinicians, plans, the community or state. Measures also must continually transform for advances in clinical evidence.
5) Quality, measurable RESULTS should be easy for consumers and payers to get and use.
MACRA provides for transparency through the Physician Compare website (http://go.cms.gov/1p0T6uw). All stakeholders need user-friendly information to make meaningful comparisons across all payment models. Clinicians need more specific data about how they compare with local and national peers to identify improvement opportunities and achieve value-based payment rewards. Clinicians also need timely, actionable feedback as close as possible to delivery of care. Embedding results in clinical care workflow is essential.
Doctors of chiropractic must begin now to understand this new payment environment that is quickly approaching; the MIPS program goes into effect in January 2017. The draft rules for MIPS will be issued by June or July and the final rule by November 2016.
Dr. Scott Munsterman is founder and CEO of Best Practices Academy (BPA) and is an acknowledged expert on the transforming model of health care delivery with a commitment to the promotion and advancement of the chiropractic profession. BPA teaches chiropractic physicians to focus on growth, risk management, technology and quality improvement through a value-based practice management system.