Practice Economics

Mastering MACRA: How to thrive under new payment models



As MACRA makes quality-based care the law of the land, don’t just glide under the new expectations, thrive. That advice comes from accountable care experts who are seeing firsthand the tools leading to success in the new payment landscape.

Rule No. 1: Step up to the plate, said Julian D. “Bo” Bobbitt, a Raleigh, N.C.–based health law attorney and accountable care organization (ACO) specialist.

Julian D. Bobbit

Julian D. Bobbit

“MACRA changes everything,” he said in an interview. “This is massive. Indecision will not stop your placement in the value-based payment system. Why not control your destiny to achieve your professional and financial goals?”

On May 9, the Centers for Medicare & Medicaid Services published a proposed final rule that outlines key payment provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The proposal establishes parameters for the new Quality Payment Program, which includes the Merit-based Incentive Payment System (MIPS) and advanced Alternative Payment Models (APMs). Once final, the rule will consolidate three Medicare quality programs into MIPS: the Physician Quality Reporting System, the Value-Based Modifier Program; and the Meaningful Use program. CMS also proposes an APM pathway in which eligible clinicians can earn incentives.

The MACRA basics go as follows: From 2019 through 2024, well-performing physicians will be eligible for a bonus payment of up to 10% from a $500 million pool, according to CMS guidance released April 27. Poorly performing clinicians will see a pay cut of up to 4% in 2019, which increases to a max of 9% in 2022.

Jeb Dunkelberger

Jeb Dunkelberger

Taking small steps that focus on value now is key to excelling under MACRA, according to Jeb Dunkelberger, vice president for accountable care services at McKesson. “As an organization, ask: How can I get myself into a situation where I can maintain one foot on the boat and one foot on the dock, and be successful in the fee-for-service world, while starting to expose myself to fee-for-value?”

Starting a Medicare Shared Savings ACO is one way to accomplish this, Mr. Dunkelberger said in an interview. Track 1 of that program provides doctors with the potential for shared savings, while protecting them from financial risk. In his experience, practices have become successful after starting such ACOs, combined with a chronic care management initiative. Under this option, providers receive a fee-for-service payment, but they are also reaching out to patients and delivering preventive care, he said.

“You still have a traditional fee-for-service mechanism,” he said. “Your revenue cycle doesn’t change. Your coding doesn’t change. But at the same time, you’re simultaneously developing a competency that will be perceived as high-value in a futuristic world where we shift the location of care delivery and incentivize wellness and prevention more so than ever before.”

Joining an ACO sooner, rather than later, makes sense on many levels, Mr. Bobbitt added.

“Accountable care organizations seem to be an ideal vehicle to increase your value contribution and your reimbursement,” he said. “The law gives a 5% bump if you are in a qualifying ACO. There’s work involved and there’s infrastructure cost, but you can get into the plus side under MACRA and avoid the negative side, and you’re still open to the upside of the rewards for high performance.”

Dr. Grace E. Terrell

Dr. Grace E. Terrell

Transitioning early from volume to value has paid off for Dr. Grace E. Terrell and her large multispecialty group based in High Point, N.C. The group began adding components of value-based care in 2011 and is now part of an ACO with multiple payers and partners.

“We did this by changing the way we were providing care in specific care models and also investing substantially in information integration as well as changing our contracts so we were being paid based upon our outcomes, quality, and cost-effectiveness, rather than just fee-for-service,” said Dr. Terrell, the group’s president and CEO.

Since making the changes, the group has improved quality of care while reducing cost, said Dr. Terrell, who serves on the federal advisory committee for MACRA, officially known as the Physician-Focused Payment Model Technical Advisory Committee. Dr. Terrell said that her practice group had the sixth-highest quality score and the fourth-lowest cost among providers in the 2014 Medicare Shared Savings Program. The group has also launched a population health management company in collaboration with an academic medical center and a testing laboratory.

Maintaining a patient-focused viewpoint is essential to switching from volume to value, Dr. Terrell said. For example, her group focused on patients with severe chronic obstructive pulmonary disease and teamed them with a respiratory therapist, particularly after hospitalizations. Their efforts reduced 30-day hospital readmissions from 12% to 6%. They also created clinics for patients who have five or more chronic conditions; physicians are linked with nurse navigators, social workers, and other professionals to offer a more holistic approach.


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