PCMH Congress: What You Need To Know

Health care leaders from all over the country met in Chicago last October 2016 at the PCMH Congress, held by the National Committee for Quality Assurance (NCQA). The congress was held to discuss the future of health care and what that means for health care providers. During this congress, Clarify’s CEO, Ms. Winkler spoke on Alternative Payment Models (APMs) and how they are changing health care finance. Most of the presentation discussed ways to capitalize on the high quality care your organization is already providing, specifically regarding APMs, MACRA, MIPS, PCMH and Population Health Management.

So what were the main points?

1.     Alternative Payment Models:

A payment method that aims to incentivize efficiency and quality, and reimburses for it. Payment is not only based on fee-for-service, there are shared risks, but also shared rewards. The goal is to shift some of the medical financial risks from payers to providers in order to incentivize quality and efficiency of healthcare delivery.

2.  Medicare and CHIP Reauthorization Act of 2015 (MACRA)

-       —Changes Medicare reimbursement

-       —Ends the Sustainable Growth Rate (SGR) formula

-       —Ends PQRS, MU & VBM reporting programs

-       —Creates the Quality Payment Program (QPP) with two paths: MIPS & APM

-       Establishes an advisory committee for assessing physician focused payment model proposals.

3.  MACRA has two paths… MIPS and APMs

-       Merit Based Incentive Payment System (MIPS)

-       Advanced Alternative Payment Models (APMs)

-       These will both go into effect starting in 2017 to 2026 with payments starting in 2019.

4. Medicare Payments under MACRA

5. What is a Merit Based Incentive Payment System (MIPS)?

Measures 4 performance categories:

1.     Quality (previously PQRS)

2.     Advancing Care Information (previously MU)

3.     Clinical Practice Improvement Activities

4.     Cost (previously VM)

You have options on how to start reporting this year:

 Source: Adapted MACRA Rule CMS webinar April 2016

 Source: Adapted MACRA Rule CMS webinar April 2016

Our goal is to make MACRA easier to understand. We break it down and communicate actionable steps to take, so health care organizations feel more confident in knowing that they can receive an increase in reimbursement, or at the very least remain payment neutral - rather than doing nothing and taking the penalty.

6. Medicare’s Alternative Payment Models (APMs)

“APMs are new approaches in paying for medical care through Medicare that incentivize quality and value.” - CMS

An APM must be available in your area and for your specialty in order to potentially participate. You must also qualify to participate.

To qualify for Advanced Alternative Models you need to meet the following criteria:

-       Base payment in quality measures comparable to those in MIPS.

-       Use of certified EHR technology.

-       Bear more than nominal financial risk for monetary losses.

7. The timeline for all of this:

A lot is changing in health care and it is changing fast. It is so important now more than ever to know what is going on and how to capitalize on it. We asked Ms. Winkler about her thoughts about MACRA and the future of healthcare finance.

Have you spoken at this conference before?

Yes, I also spoke at the 2015 PCMH Congress in San Francisco. It was the first year of the conference. I was quite excited to speak again this year. I felt honored to be selected two years in a row.

What benefits do you see MACRA having for healthcare provides?

It consolidates several other programs into one. It also refines and even reduces the amount a health care organization must report, in some instances. Over the years, I’ve heard some health care providers say they will invest and do more to transition from fee-for-service to fee-for-value when there’s more payment tied to it, and MACRA does just that.

What are the biggest challenges health care providers face in the new pay for performance reimbursement program?

I would say understanding it and getting up to speed quickly - it began January 1, 2017 and 2017 is the first performance year. Additionally, doing all of this while they’re providing care and facing so many other challenges, timelines and changes. It’s just a lot to do, so I feel for health care organizations trying to do all of this and do it well.

What were some of the key aspects you wanted people to take away from your presentation?

The goal was to help people better understand MACRA, and to present it in a way that helped visually break it down. MACRA is very daunting at first, so I hoped to present it in a clear, manageable way.  We now help organizations understand MACRA, but also show them financial projections, recommend measures for each category under MIPS, share with APMs they may be eligible for, give them action steps to do in 2017, and access to an extensive electronic MACRA toolkit. That helps bring MACRA to life, makes it more manageable, and helps people know exactly what they need to do in order to be successful.

By: Bethany Downs