On April 27, 2016, the Department of Health and Human Services issued a Notice Executive of Proposed Rulemaking to implement key provisions of the Medicare Access and Summary CHIP Reauthorization Act of 2015 (MACRA). This is a big deal as it will largely drive how our healthcare industry behaves in the coming years.

The internet has been a buzz with experts weighing in on the meaning and merit of the rule. There are discussions over the definition of Advanced Alternative Payment Models (i.e. MSSP Track 1 is not one) and whether or not small practices can survive the change. No doubt the debate will continue for some time up to and beyond the end of the public comment period. This dialogue is a welcome part of the process, but can be confusing and like most things the media and commentary can dwell on the negative. It’s a 100% certainty that CMS will get some of it wrong and some “bad” things will happen. That’s the nature of change: it can be painful, but it’s also laced with opportunity for those willing to dig for it. Like it or not, the healthcare industry is moving towards fee for quality (however we ultimately define it). For those of us working in the industry, it’s in our best interests to understand the new models and aggressively attack the opportunities they present.

The American Medical Association (AMA) has already produced some useful resources for understanding the rule and we’ll use their 11-page summary (PDF) to highlight 10 opportunities:

  1. It stabilizes physician pay under Medicare — physicians have been living with the SGR threat for years. Sure congress has been pretty reliable in annually kicking that can down the road, but it was an ever-growing ACME anvil hanging over physicians heads. it’s hard to build and operate a business with that kind of uncertainty. Now SGR is dead and there’s a predictable annual update in place.
  2. It gives practices the ability to focus on and tool up for a single incentive model. Today you might participate in Meaningful Use (MU), Physician Quality Reporting System (PQRS) and/or the Value-Based Modifier (VBM). Each has its own rules and reporting requirements that need to be dealt with separately. Under MACRA physicians will participate in one of two tracks (PDF): the Merit-based Incentive Payment System (MIPS) or one of the Advanced Alternative Payment Models (APM) like CPC+. Both will have their own complications, but having just one model to think about will allow physicians to master that model and excel in it.
  3. MIPS gives physicians the opportunity to select which quality measures they want to be graded in. That means you can choose the subset of measures that are most meaningful to your practice, or that you are best positioned to do well on.
  4. HHS must issue timely (such as quarterly) confidential feedback on physicians’ performance on quality and resource use. This is huge. Today physicians must track their own performance throughout the year or risk having a huge surprise when their “report card” comes. If you don’t find out until after year 1 is over that you’ve been failing on a measure, you may be well on your way to failing again in year 2. With quarterly updates provided by HHS, practices will be able to course-correct earlier in the year and increase their chances for a favorable incentive payment at year’s end. BONUS: If you’re participating in commercial programs that measure the same things, Medicare’s quarterly reporting may serve as a useful indicator of how you’re doing on those as well. I would wager that practices’ inability to do this today contributes to revenue loss.
  5. Telehealth and remote patient monitoring are expressly recognized as examples of “Clinical Practice Improvement Activities,” along with care coordination, population health management, and monitoring of health conditions. Again, this is a big deal. Telemedicine proponents have been waiting for reimbursement to catch up for some time and this may be their opening. Most importantly, this signals that CMS is moving away from specifying the “how” of healthcare delivery and truly focusing on outcomes.
  6. Sliding scale assessment instead of “all or nothing”. The ability to collect some of the money if you meet some of the requirements creates new flexibility in operational planning. Since they’ll be reporting your performance regularly and you can figure out how much each incentive is worth to you, you can make better decisions on where to focus your energy to maximize your incentive. For example, you may decide it’s good enough to get 50% of measure X as long as you get 100% of Y and Z — then apply your resources accordingly.
  7. $100 Million for technical assistance to small practices — this is money available to help practices with up to 15 physicians tool up for the new delivery models. I’m sure it won’t be enough, but it’s help and small practices should find out how to maximize their share.
  8. Smaller practices (up to 10 MIPS-eligible professionals) can also elect to report together as “virtual groups” and receive a MIPS composite score for their combined performance. This presents a huge opportunity for Independent Physician Associations (IPA) and likely opens the door for new startup ventures to help practices pool resources.
  9. $75 Million in funding and opportunity to define new evidence-based measures that can be adopted without endorsement by the National Quality Forum (NQF). This may provide the framework for physician defined quality metrics.
  10. The opportunity to define who/what you want to be — since a majority of healthcare organizations will be greatly impacted by the new rule, they will all be on the hunt for the best partners. This great shakeup gives you the opportunity to learn the rule, come up with a solid strategy and communicate to the rest of your community what role you want to play in the new system. That may sound idealistic, but we all know most organizations will be slow to move. Pick a problem that you want to own and take the steps now to “be the solution”. As the rest of your slow-moving potential partners get around to that issue, they’ll be glad to have found you.

I’m not saying that MACRA is right or wrong. I’m definitely not saying that any of this is easy. I’m simply suggesting that we see this for what it is and take the opportunity to reinvent ourselves. So, by all means, participate in the dialogue and public commenting period, but once the chips fall you’d better be ready to move.

Discussion Details

On Wednesday, May 4, 2016 the Business of Healthcare community will take our first crack at MACRA in #hcbiz 12).

12:00 PM EST – Tweet Chat

The tweetchat begins at 12:00 PM EST and will ask 3 questions in 30 minutes:

Q1: What issues do you hope to see addressed during the MACRA public comment period?

Q2: What advice would you give to healthcare organizations that will be participating in the new models? What should they do right now?

Q3: What are the biggest opportunities created by MACRA? Think physicians, payers, health IT vendors, startups, etc.

(Follow the #hcbiz hashtag on Twitter or use an app like tchat.io to join the conversation).

12:30 PM EST – Blab

Then at 12:30 PM EST, the #hcbiz Show will dive deeper with a live 1-hour panel. Subscribe here!