CMS, organizations and clinicians must embrace change to find success.
MACRA is the largest change in a generation for Medicare Part B reimbursement. As we come to the close of the first performance year, it’s a good time to reflect on the changes in 2017 and look ahead to 2018 and beyond.
Regulatory change
In 2017, CMS has done more to promote and educate the healthcare community about the Quality Payment Program than any other program in the past. Despite this, numerous surveys1 conducted throughout 2017 show the majority of clinicians lack the knowledge they need to be successful and they expect their employer to provide solutions and strategies for QPP success.
In addition to confusion at the clinician level regarding the QPP, messaging from the Department of Health and Human Services has been confusing as well. In recent communication, CMS Administrator Seema Verma has voiced her commitment to move from a fee-for-service model to a fee-for-value model, but at the same time, CMS cancelled two mandatory bundled payment models (the Episode Payment Models and the Cardiac Rehabilitation Incentive Payment Model) and removed the mandatory requirement for a third (the Comprehensive Care for Joint Replacement Model). In September the Centers for Medicare and Medicaid Innovation issued a request for information to solicit input on a new direction to promote patient-centered care and test market-driven reforms. The changes outlined in the RFI make it clear that all existing programs will be analyzed and the number of models currently being tested will likely be reduced.
In the RFI, CMS outlines six new guiding principles and provides a list of potential models they are interested in pursuing. The first guiding principle listed, “Promote competition based on quality, outcomes and costs,” provides insight into the thinking of CMS leadership and their desire to continue moving toward value-based care principals. Coming out of 2017, there is pressure on CMS to accelerate creation of new Advanced Alternative Payment Models and they are exploring options through multiple channels. The first option is to allow clinicians to use Medicare Advantage plans to meet the criteria for an Advanced APM. This would require a change to the MACRA legislation, but CMS has included a demonstration project in the 2018 final rule to evaluate this option further, which has been celebrated by CAPG as a significant step toward a legislative change. A second iteration of the Bundled Payments for Care Improvement program, Advanced BCPI, is expected to be available in 2018, which will significantly expand specialists’ opportunities to participate in an Advanced APM. One of the most interesting models CMS has expressed interest in is Direct Primary Care. During an October speech to healthcare innovation leaders, Administrator Verma listed it as one of the top models CMS plans to pursue. In its current state, Direct Primary Care is based on monthly membership fees and excludes billing insurers, which may indicate CMS will pursue more per beneficiary per month payments similar to the Comprehensive Primary Care Plus program moving forward.
While these models are all under consideration/in development, it will be interesting to see if the CMMI RFI will drive additional choice or will the changes proposed consume CMMI for 2018 and reduce the capacity to introduce new models. Either way, CMS will look very different in 2018 and beyond.
Organizational change
Alongside the CMS evolution, the start of the QPP, even with the limited implementation of the Merit-based Incentive Payment System, has been a wake-up call to healthcare leaders. Organizations are realizing that success in value-based care programs requires organizational changes, including operational and clinical redesign, not just adding another set of tasks for employees and clinicians. 2018 will be a pivotal year, as sitting on the sidelines/doing nothing is no longer an option. At the MACRA/MIPS/APM conference held in Washington DC in October, leaders from across the healthcare spectrum stressed the importance of taking action now to prepare for a value-based care world.
2019 brings two significant changes to MIPS. First, the Cost category is required to equal 30% of the total MIPS score and will include episode-based cost measures. This elevates the importance of Cost to the same level of Quality performance and brings MIPS in line with Alternative Payment Models. Leadership must provide the direction, tools and support required for organizations to attack the Cost challenge head on in 2018 or they will find themselves at a competitive disadvantage in 2019 and beyond. Second, the performance threshold can no longer be set by CMS and must be the mean or median of prior performance periods. Based on what we have seen in the field and per CMS’s own estimates, this will result in a 55+ point increase from the 2018 PT of 15 points, resulting in a much more competitive program in 2019.
Managing both the regulatory and organizational change simultaneously can seem overwhelming, but organizations that embrace the Quality Payment Program as a change agent rather than a compliance program will have a stronger financial future coupled with a reputation for providing higher quality care, better patient outcomes and lower costs. Take the first step toward achieving the gold standard by treating the QPP as a strategic initiative and setting multi-year goals, creating a strategy and evaluating the people, processes and technology you need to deliver for 2018 and beyond.
Matthew Fusan, Director, Customer Experience, SA Ignite
The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.