LOUISVILLE Physicians across the United States are preparing for a new payment system, as a result of the Medicare Access and CHIP Re-Authorization Act (MACRA). MACRA was signed into law in April 2015, and makes important changes to how Medicare pays those who give care to Medicare beneficiaries.
The MACRA legislation creates a Quality Payment Program (QPP), ending the previous Sustainable Growth Rate (SGR) formula for determining Medicare payments for healthcare providers’ services. The SGR formula has been used to control spending by Medicare on physician payments. As a result of MACRA, two new payment tracks will now be used: Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APM). The change moves physicians more toward a system where they are rewarded for quality, rather than a flat fee-for-service payment model.
Updates to Medicare provider payment take effect on January 1, 2019, but will be based on 2017 data. Nearly all providers who are reimbursed under Medicare Part B will be subject to either MIPS or APM. As a result, Damian P. (Pat) Alagia, MD, KentuckyOne Health chief physician executive and KentuckyOne Health Partners (KHP), says KHP is leading the way in Kentucky, preparing physicians for the upcoming changes in advance of the official rollout.
Alagia added, “We are working with participants in our network – over 100 member organizations and 2,300 providers – to ensure they are ahead of the curve. We have created a MACRA resource center and are working directly with our physicians and their office staff to provide education. Our care management teams are rolling out the next version of our care management information system that helps physicians meet important quality metrics. In addition, we’re participating with national organizations that are shaping the roll-out of this program.”
Under the MIPS track, providers will be scored on four categories that will be used to calculate provider bonuses or penalties: quality, resource use, electronic health record (EHR) use, and clinical practice improvement (CPI). A provider’s performance will be weighted across the four categories and will change over time.
MACRA requires provider group practices to compete with one another. On an annual basis, providers will receive a MIPS performance score of 0 to 100. This score will then be compared to a performance threshold (PT) that will be used for all MIPS participants. Providers who achieve scores above the threshold will receive bonuses, and those that fall below will face penalties.
Under the APM track, providers must participate in an eligible APM, such as KentuckyOne Health Partners, which is moving in that direction. Based on requirements, the model must incentivize providers to meet quality measurements comparable to those in MIPS; must require the use of certified electronic health record technology; and must bear more than nominal financial risk for monetary losses or be a medical home model expanded under Center for Medicare and Medicaid Innovation (CMMI) authority.
Under the APM track, providers must also have a minimum percent of revenue-at-risk under an eligible APM to be considered Qualifying Participants (QPs). By 2019, providers are required to have at least 25 percent of their Medicare revenue tied to an eligible APM, 50 percent of Medicare or 50 percent of all-payer payments in 2021, and up to 75 percent in 2023 and beyond. Qualifying Participants receive a five percent annual payment bonus from 2019 to 2024.
Stephanie Mayfield Gibson, MD, KentuckyOne Health vice president for population health and the KHP chief medical officer, says, “It should be noted that under this law, expanded medical home models under the Innovation Center authority qualify as advanced APMs regardless of their ability to meet financial risk criteria. This special rule gives the primary care provider the opportunity to participate in advanced APMs.”
KentuckyOne Health Partners is the largest Medicare Certified Accountable Care Organization (ACO) in Kentucky, and one of the 20th largest ACOs in the United States, with more than 100 provider group companies as members and nearly 2,000 clinical providers in Kentucky, Ohio and Indiana. The group manages over 100,000 lives.
KentuckyOne Health Partners has earned a CAPG 4-Star “Exemplary” Standards of Excellence ACO status. The CAPG survey assesses the tools and processes an organization has in place to meet the escalating expectations of healthcare purchasers and patients. The survey helps set the bar for healthcare consumers to evaluate technical quality, responsive patient experience, and affordability.
While KentuckyOne Health Partners isn’t yet an eligible advanced APM at this time, we have applied for an advanced ACO status and are moving in that direction. Last year we applied and were approved as a next generation ACO, a more comprehensive organizational model that would move KentuckyOne Health Partners toward becoming an eligible advanced APM, however we deferred acceptance because we felt we weren’t quite ready. Now with another year and more quality success in the books, KentuckyOne Health Partners feels confident in moving forward with this pathway.
Due to availability of analytical information systems and quality improvement teams in larger organizations, the MACRA regulations predict that larger group practices and organizations, such as KentuckyOne Health Partners, will perform better than smaller organizations. “However, to the extent possible, MACRA aligns standards between MIPS and APM tracks,” said Stephanie Mayfield Gibson, MD, FCAP. “This alignment makes it easier for all providers to navigate the tracks, particularly those providers who may not meet criteria for the most advanced APM models.”
Small practices can survive this change because it is primarily about providing the highest possible quality patient care. For smaller practices, it’s a question of how they can get support, education, and resources.
KentuckyOne Health Partners is already preparing for the upcoming changes and recommends physicians get ready for MACRA well in advance. The MACRA Resource Center on the KHP website was established specifically for providers in Kentucky.
Providers should review their own Physician Quality Reporting System (PQRS), Star Rating System, and Group Practice Reporting Option (GPRO) metrics and see where they have opportunity. The time to make quality change is right now.
Alagia says that although MACRA has changed the way Medicare will pay providers, the hope is that the system will improve the quality and efficiency of patient care.
Donald Lovasz is the president and CEO of KentuckyOne Health Partners.