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MACRA, Measures, and MIPS: how will it change your organization? | symplr Blog Feature
Joni Orand

By: Joni Orand on April 12th, 2019

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MACRA, Measures, and MIPS: how will it change your organization? | symplr

Quality | Provider Management | macra

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a legislation that was signed into law in 2015 with overwhelming congressional support. MACRA has a significant impact on how healthcare is delivered, evaluated, and reimbursed. But are healthcare organizations and providers ready for the sweeping changes it mandates?

MACRA Overview

The intent of the legislation was to fix issues that rewarded and paid for the quantity not quality of services provided. MACRA set out to fix that by:

  • Repealing the Sustainable Growth Rate (SGR) Formula
  • Changing the way that Medicare rewards clinicians for value over volume
  • Streamlining multiple quality programs under the new Merit-Based Incentive Payments System (MIPS)
  • Providing bonus payments for participation in eligible alternative payment models (APMs)

Essentially, MACRA’s goal is to incentivize, pay, and reward organizations and providers practice value based care and step away from traditional models that emphasize low cost, high volume treatment approaches.

What is value based care?

The industry is evolving to put patient experience and outcomes at the center of the healthcare delivery model and MACRA is designed to support that goal, holding all parties accountable.

Value-based healthcare is a healthcare delivery model in which providers, including hospitals and physicians, are paid based on patient health outcomes. Value-based care differs from a fee-for-service or capitated approach, in which providers are paid based on the volume of healthcare services they deliver.

MACRA takes this goal one step further with its payment approach. Value Based Payment (VBP) is a concept by which purchasers of healthcare (government, employers, and consumers) and payers (public and private) hold the health care delivery system at large (physicians and other providers, hospitals, etc.) accountable for both quality and cost of care.

Making the shift

Adopting this new approach doesn’t happen overnight. It will require coordination of healthcare organizations, providers, physicians, revenue payment systems, and value measurement collection systems at minimum. Four critical shifts the industry will have to make include making the shift from:

  • Volume to value - serving the most patients to providing the most value to patients
  • Becoming a low-cost, high-value provider - providing cost effective, high quality care
  • Satisfying physicians to engaging with physicians - supporting the professionals at the center of care with knowledge and tools to provide quality care
  • Traditional models of care delivery to multiple alternative models - to embrace how patients receive care, from hospitals and offices to telemedicine and retail outlets.

MACRA hurdles to overcome

Complying with MACRA will be no small task for healthcare organizations and providers. A few roadblocks that must be addressed include:

Educating Physicians - While physicians receive data regarding productivity and quality issues, few receive cost information that is now vital to MACRA reimbursement standards. Only 28% receive cost information, such as cost or resource use for their attributed patients, for physicians and facilities to which they refer, or estimated patient out-of- pocket costs.

Measurement Data - MACRA and MIPS incentives are based on the organization’s ability to provide required data. Unless healthcare systems can collect and report this data, they will be at a loss. For instance, data for oncology care may require hospital and ED admissions, depression screening, pain management, timeliness of chemotherapy and patient experience - in addition to EHR data.

Ensuring that data is collected consistently and accurately across all departments is a big task. It’s a costly and time-consuming effort that may require upgraded systems and alignment of all departments to collect the data. Finally, ensuring that the data collected is meaningful and supports the goal of value based care is essential.

Aligning Measurement Across Payers

While these hurdles may seem daunting, there is an industry effort to help healthcare organizations collect and standardize measures. America’s Health Insurance Plans (AHIP) has created the Core Quality Measure Collaborative (CQMC), a broad-based coalition of healthcare leaders with three goals:

  • Identify high-value, high-impact, evidence-based measures that promote better patient outcomes, and provide useful information for improvement, decision-making and payment.
  • Align measures across public and private payers to achieve congruence in the measures being used for quality improvement, transparency, and payment purposes.
  • Reduce the burden of measurement by eliminating low-value metrics, redundancies, and inconsistencies in measure specifications and quality measure reporting requirements across payers.

The coalition includes stakeholders from the Centers for Medicare & Medicaid Services (CMS), the National Quality Forum (NQF), health insurance providers, medical associations, consumer groups, purchasers (including employer group representatives), and other quality collaboratives.

The areas they are currently focusing on include:

  • Accountable Care Organizations/Patient Centered Medical Homes/Primary Care
  • Cardiology
  • Gastroenterology
  • HIV & Hepatitis C
  • Medical Oncology
  • Obstetrics & Gynecology
  • Orthopedics
  • Pediatrics

How will MACRA impact your organization?

The shift to value based care will no doubt impact how your organization delivers and is paid for the care you provide. Moving forward, healthcare organizations will need to develop new systems to collect and track required measurement data that meets MACRA requirements and provides information for MIPS incentives and Alternative Payment Models (APM). These payment models will help organizations prove they are providing value based care and impact their bottom line.

It will be vital to educate and align all department to provide value based care and measure the results. It is especially important to engage and educate physicians to participate in this new model which is a departure from traditional fee for service models. Quality standards are dependent on those who provide the care, so physicians and providers must understand quality measurements, costs, and the importance of the patient experience in every interaction.

Join us!

I host a detailed webinar titled MACRA, Measures and MIPS, OH MY! What you need to know, where I explain how MACRA and value based payment works and the impact it will have on your organization. The webinar is available here.

Need help?

Balancing the patient experience, rising costs, and incentive based revenue streams is critical to your bottom line. Your EHR system is valuable, but may not be enough to ensure your organization meets the highest standards. Compliance should be the easiest part of your day with symplr’s provider credentialing and management platforms.


About Joni Orand

Joni Orand has worked in the healthcare industry for twenty eight years’, in both managed care and hospital environments, working with providers and staff gaining unparalleled experience in all aspects of provider management and quality improvement initiatives. She holds a degree in Corporate Communications, with minors in Interpersonal Communication and International Studies in Communications. Joni is a certified trainer, speaker and coach, and is known for helping, educating, and supporting clients as they develop quality improvement plans. Currently working as a Senior Solution Consultant for symplr, Joni speaks as a Subject Matter Expert at industry events.