MACRA is a game changer for providers. It represents the most significant change in healthcare payments since Medicare was introduced 60 years ago. The baseline for calculating MACRA payment adjustments starts January 1, 2017. The purpose of MACRA is to lead healthcare providers from a fee-for-service payment model to a value-based care model where reimbursement is determined by patient outcomes that includes quality of care, utilization of care, improved patient outcomes, and improved cost control.
The MACRA payment program has to be budget neutral so there will be winners and losers. Under MACRA, providers will have to choose to operate under a merit-based incentive program (MIPS) or transition to an Alternative Payment Model (APM). While there are a few exceptions for providers new to Medicare and/or with low Medicare payment volume to participate in MACRA, most providers will be impacted by MACRA.
Under the MIPS default option, there is a potential for a maximum plus or minus 4 percent or payments in the first year (2019). A bonus payment (not to exceed 10 percent) for exceptional performance is part of this program for the first five years. An overall MIPS score will be calculated according to performance in four measures (weighted by performance, with potential changes in weight by year): Quality =50%, Cost (Resource Use) =10%, Advancing care information (interoperability, etc. = 25 percent, and Clinical practice improvement activities (care coordination, etc.) = 15 percent.
Under the Alternative Payment Model (APM), Medicare providers will be paid based on value of services rather than service volume. Providers meeting the criteria for this track cannot move to the MIPS track. Physicians receiving a significant portion of their payments through eligible APMs can be exempt from MIPS—and they receive a lump sum payment of 5 percent of covered services.
In regards to software requirements – some requirements can be met with a certified EMR system – while other requirements such as care coordination and interoperability will require software beyond most EMRs. eTransX’s XCare Community system provides a solid robust software as a service platform that can be used to maximize value based payments under either MIPS or Alternative Payment Models (APM).
A robust MACRA software plaform will not only need to support capturing and reporting metrics and sharing information electronically, it will also need to support robust team based care coordination to maximize payments and performance bonuses. For example, to maximize performance, patients will need to be an integral part of their care and really understand their care plans. The care plans should be evidence based and personalized. In addition to the physician, the care team for the patient may include a nurse, a pharmacist, and a social worker who are all managing a group of patients with chronic conditions to make sure their needs are being met, such as arranging transportation, solving prescription problems, planning meals and exercise…this will require a robust care coordination software platform.
Providers can start generating value based payments now with the eTransX XCare Community system – through programs such as the Medicare Chronic Care Management program and/or Transitional Care Management program. In addition, using the XCare Community system now – will help practices improve their patient outcomes and quality metrics in 2017 which will serve as the basis of future value based payments under MACRA.
Now is the time to start evaluating your software options to maximize MACRA payments.