May 18, 2016 | Value-Based Care: A Guide for Primary Care Physicians

With 2016 underway, “value-based care” has been cemented as the go-to phrase when discussing healthcare IT. It also is one of the best ways for physicians to use these services to achieve and report optimal patient outcomes.

This was further demonstrated in January when the CMS announced a timeline for the industry-wide transition to a new system. Its meant to fundamentally simplify and change how physicians are paid for their services. For our primary-care audience, this raises several questions, chief among them this:

Now that we have a clear idea of value-based care, what will the “road” to this end goal look like?

The answer to this question is the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA. Devised as an answer to fragmented and often confusing incentive systems, MACRA is specifically meant to take the current patchwork of quality and value reporting programs and further streamline them into one unified “Quality Payment Program.”

Specifically, the Quality Payment Program will include two paths. They include the Merit-based Incentive Payment System, or MIPS, and advanced Alternative Payment Models, or APMs. Most Medicare physicians are expected to participate primarily in MIPS. These clinicians will be reimbursed by using certified EHR technology and then showing success in four categories. They include quality, cost, advancing care information, and clinical practice improvement activities.

For physicians participating in APMs, they will essentially be tasked with acting as an accountable care organization (ACO), by taking on a certain amount of risk-sharing responsibility with payers (either the CMS or commercial insurers).

With either MIPS or APMs, physicians will then receive a composite performance score that exceeds, meets, or falls short of the threshold set by the CMS. From there, they will receive a positive, neutral, or negative payment adjustment on their reimbursements beginning in 2019.

At its simplest, MIPS will work to replace EHR-incentive programs like Meaningful Use. It will also streamline quality reporting by overhauling and combining both PQRS and the Value-Based Payment Modifier. Most importantly, these initiatives have all been created with patient-centric care in mind. The different categories all related back to a central question:

“How can we help ensure a quality outcome?”

However, if one further examines the MACRA plan in its entirety, there is some cause for concern. A chart located on page 676 of the document shows that the CMS estimates that 87% of the nation’s solo practices (nearly 103,000 physicians) will face a penalty in 2019. It could be almost $300 million. The report predicts more of the same for practices of two to nine physicians (an estimated 124,000 physicians). They could see penalties that amount to nearly $279 million. For the individual practice, the impact will be a 9% penalty to their reimbursements. This is more serious considering that half of the average practice population will be Medicare patients by 2019.

As value becomes the driver of all facets of a primary-care practice, the importance of telehealth and increased reimbursements for using it will only continue to rise. Programs similar to Medicare’s Chronic Care Management will become commonplace under MACRA. It will be necessary in order to satisfy requirements around clinical practice improvement activities.

As the CMS’ predictions demonstrate, its Quality Payment Program will arrive with a period of growing pains for all providers. However, savvy physicians will be able to successfully mitigate risk and thrive in this transition. They can do this by examining the best fit for each practice, planning accordingly, and participating in incentive-laden programs using health IT.

Still curious about MACRA or the Quality Payment Program? The AMA has released a list of resources to help physicians understand critical questions about how they practice value-based care and achieve reimbursements.


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