The Centers for Medicare & Medicaid Services (CMS) had almost 4,000 responses from providers and health plans regarding the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). With almost 1 million provider groups potentially impacted by the proposed rule, small groups and individual practitioners (primary care physicians (PCPs) and specialists) are being forced to think of their medical practices as a real business. Most of these providers do not have the robust infrastructure compared to their clinical counterparts that fall into the Alternative Payment Model (APM) buckets — Accountable Care Organizations (ACOs), Independent Practice Associations (IPAs), or Clinically Integrated Networks (CINs).
In order to align with the proposed legislation, demonstrate quality, report data, and position the medical practice for shared risk programs, the providers who fall into the Merit-Based Incentive Payment System (MIPS) bucket will need to make some critical decisions. That is if they actually want to realize a positive Return on Investment from participating in the program.
Keep in mind, the following will apply to PCPs and specialists alike:
- Revamp and deploy a data strategy that reconciles and reports patient-level data across multiple delivery systems and sources. Data integrity, quality, and accuracy will make or break a practice’s success. It will get worse before it gets better, but everything can be fixed.
- Conduct a comprehensive chart review and risk adjustment program analysis, collecting the baseline health and condition statuses for your attributed patient panels and evaluating the coding patterns of your clinicians with diagnostic authority (Physician Assistants, Nurse Practitioners, Medical Doctors).
- Build and implement a Quality Oversight and Operations work plan that oversees the delivery of superior patient experience activities and aligns clinical practice models with imposed Clinical Quality Metrics.
- Bridge the communication with consulting specialists and network health systems and mid-level clinicians to coordinate care, make informed clinical decisions, and avoid redundancies in care that historically incur unnecessary medical expenses (which would carve into any anticipated financial benefits that were forecasted at the onset of any risk-based payment model).
The way I see it, if the proposed legislation moves forward, providers will have the following choices:
- Join an established APM, like an ACO or a CIN (if they’ll have you)
- Jump in with both feet and make a HUGE investment in the infrastructure outlined above
- Find “MIPS friends,” create consortiums, IPAs, and other qualified practice models that meet the CMS criteria
- Become an employed provider in a health system or academic medical center
- Transition to a concierge medical practice model and succeed
Gorman Health Group’s experienced team is currently working with the provider, health system, and health plan communities to determine the best approach to achieve success. This is not a one-size fits all program, and Gorman Health Group can help find the most realistic, effective, and actionable approach for you and your organization.
Please contact me directly at firstname.lastname@example.org or at 202.774.8016.
What will the consequences of MACRA be? Will the money at risk motivate physicians to be more efficient? Or will it lead them to shun traditional Medicare patients? Read more in another article recently published on the GHG Blog >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>