MACRA and CCM: How IT leaders can deliver value

Bond head shot
Travis Bond, Chief Executive Officer, CareSync

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which aims to replace the volume-based era of healthcare with value-based medicine, may not take full effect for another three years in terms of financial impacts, but the performance measurement period is quickly approaching, beginning this coming New Year’s Day.

As organizations prepare for MACRA, it’s essential to take into account how requirements can be met through chronic care management (CCM) programs – a CMS initiative to help providers bridge the gap between fee-for-service and value-based care by emphasizing care coordination between providers. While technically separate initiatives, CCM programs are an underlying component of MACRA, practically driving what the regulation is aiming to achieve: a push toward truly value-based, patient-centric care. It is, after all, nearly impossible to meet the requirements of MACRA without also performing the tasks of CCM.

IT leaders, especially in mid-sized or larger group physician practices, play a key role in preparing their organizations by ensuring all tools and infrastructure are in place now to meet basic CMS requirements for care coordination and value-based care. In doing this, IT leaders have the opportunity to lay the foundation for a truly effective CCM program – that benefits the financial health of the organization and, more importantly, the physical and mental well-being of its patients.

Regardless, time is of the essence: For every day that physician practices fail to meet care coordination requirements under the MACRA performance period, currently scheduled to begin in 2017, they risk a reduction in Medicare reimbursements beginning January 2019.

First, some quick background

Passed into law by Congress last year, MACRA authorized the Centers for Medicare & Medicaid Services (CMS) to establish the Merit-Based Incentive Payment System (MIPS) to encourage all practices to deliver better quality care and patient value through programs such as CCM for their Medicare populations with two or more chronic diseases.

MIPS combines parts of the former Physician Quality Reporting System (PQRS), the Value-Based Modifier (VBM) and the Medicare Electronic Health Record (EHR) incentive program into one program measuring physician practices on quality, resource use, clinical practice improvement and meaningful use of certified electronic health records technology.

MACRA also established the Quality Payment Program that CMS says will help it advance toward a model of paying for value and better care.  

Under MACRA, physician practices must not only be able to create a comprehensive care plan for each Medicare patient, but also be able to share that plan with each patient in print or electronic form and give 24/7 access to each patient and all of his or her other providers and designated caregivers. Among other provisions, providers also have to demonstrate patient engagement and care coordination capabilities, as well as the ability to communicate with other doctors, demonstrate interoperability with other systems, and leverage their EHR systems to their patients’ benefit.

Many of these are capabilities not easily handled by most current EHR systems. Healthcare organizations that have not already created a CCM strategy will likely have a difficult time meeting MACRA requirements, particularly with demonstrating patient engagement and care coordination capabilities. Indeed, it takes time for IT teams to build the infrastructure needed to get a CCM program up and running.

That said, the performance measures are currently scheduled to take effect Jan. 1, 2017 – meaning that provider Medicare payments will be reduced for every day that providers fail to meet the requirements – a financial impact that will hit in the 2019 payment period. Providers who do not have a CCM program in place will risk lower performance measures, decreased reimbursement and declining patient outcomes. Thus, it is important for IT leaders responsible for private and hospital-owned physician practices to help determine a strategy that doesn’t take their organizations six months to deploy. Practices that wait until December to start working on such a strategy risk taking a significant financial hit farther down the road.

In fact, practices that do not get their house in order until late in 2016 may find a 2-, 3-, or 4-percent reduction in all Medicare payments to be their entire operating margin. Smaller practices are even more threatened, because a negative payment adjustment will affect them more disproportionately – a 4 percent reduction in payments at the individual provider level may result in a 10 percent drop in personal income once the costs of practice overhead are taken into account. This is why it’s essential for providers to develop an effective plan of action and IT strategy now.

Benefits to outsourcing for small and large healthcare organizations

For many physician group practices, the best option may be to outsource all or part of their chronic care patient needs. While this is especially true for small physician practices, it can also be the case for larger practices.

One benefit to outsourcing is that CCM vendors typically take on the risk of plan development and provide the labor, including registered nursing care, up front, to get the program operational. This is especially helpful to small and mid-sized practices that cannot generally afford the upfront costs of hiring personnel to handle the patient care needs or buying new technologies.

Leveraging an outsourced provider of CCM services can also enable mid-sized and larger organizations to scale at a faster pace. Faced with the question of whether to buy vs. build new systems to meet the requirements of MACRA, the task of convening multiple committees to discuss issues of capitalization expenditures for new computers, new desks, new people and operation expenses, can take weeks, if not months, of valuable preparation time and resources.

A third benefit of outsourcing CCM services that applies to both small and large providers is the ease at which a practice can benefit from billing for CCM codes such as CPT 99490. As I mentioned at the outset of this article, it is virtually impossible to meet the requirements of MACRA without also performing the tasks associated with CCM. Billing CPT 99490 results in an average of $41 per Medicare patient per practice each month. Opportunities for additional revenue through expanded and added CCM codes will also be available to providers in 2017. In an environment of otherwise declining reimbursements, why turn down such an opportunity for enhanced revenue and improved clinical outcomes?

With the start of MACRA performance measures quickly bearing down, health IT leaders have an opportunity to bring real value to the organizations they serve by delivering a plan now on how to help build and maintain relationships with patients outside of where they live, work and play.

Don’t let this opportunity pass your organization by.

care coordination, CareSync, CCM, chronic care management, MACRA, Medicare Access and CHIP Reauthorization Act of 2015, Merit-based Incentive payment system, MIPS


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