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From the Consultant’s Corner 4/6/17

Getting the Lay of the MACRA Land This Year and Next

Despite the change in administration, MACRA, with its Quality Payment Program, is here for at least awhile, having received tremendous bipartisan support in Congress. Because there is significant upside and downside Medicare payment risk, it is essential for all providers to prepare for this new QPP.

Who Participates

If your organization is actively participating in advanced Alternative Payment Models, then the participation in this QPP is covered. However, only 10 percent of providers fall into this category. If there are few Medicare charges or patients, or a new Medicare provider, you do not have to participate. Therefore, most physicians and practice groups will fall under the category of participating under the Merit-based Incentive Payment System program.

Core Components

While MACRA is very similar to the PQRS, Value Modifier, and Meaningful Use programs, it attempts to align all three programs via four components:

  • Quality (numerous metrics to choose from)
  • Resource Utilization (cost will not be a factor in 2017 and only 10 percent in 2018)
  • Advancing Care Information (use of an EHR, with numerous metrics to choose from)
  • Clinical Practice Improvement Activities (process improvement – demonstrate core capabilities plus a few additional metrics to choose from)

Performance in these categories is weighted and begins with 60-percent quality, 25-percent advancing care information, and 15-percent process improvement. In two years the weighting will change to 30-percent quality, and 30-percent resource utilization, while advancing care information and process improvement will stay the same at 25 percent and 15 percent, respectively.

Just as with PQRS, there are still multiple ways to report. You can report as an individual provider with an NPI/TIN or as a group of physicians under one TIN. Reporting can take place via claims, registry, CMS website, Qualified Clinical Data Registry or through the EHR system.

There is a significant upside and downside to starting at 4 percent of fee scheduling and ending up at 9 percent over the next four years. This will be based, in large part, on balance budget. Therefore, there will be winners and losers, and providers will essentially be competing against one another. Above all, there is a $500 million pool of money to be shared by the exceptional performers.

What is Important for 2017?

In recognition of the complexity of a new program, many individuals and practices that have not previously reported will begin reporting. CMS has decided that the threshold to avoid a negative penalty should be very low for 2017. As long as one metric – a quality metric, performance improvement project attestation, or the minimum standard of EHR use – is met, the provider/group will not be penalized for their 2017 performance. Because very few will be penalized, there will also be little upside gain. Providers can use 2017 as a year to develop overarching strategy and infrastructure, rather than worry about whole-scale reporting.


Typically, many practices put their finance and IT departments in charge of selecting measures that are feasible to report on, reporting, and ensuring accuracy. However, this is a good time for organizations to step back and take a broader look at their organization, which typically includes:

  • CIO – Meaningful Use
  • CFO – PQRS
  • CMO – Quality
  • Population Health Lead
  • CMIO – EHR Deployment and Optimization

This program provides an opportunity to pull together these leaders and consider organizational strategies. It allows the leadership to then pick metrics and projects that will support their long-term vision, and focus resources on those areas that will most likely help the broader quality goals of the organization. This would create sustainable improvement and optimize performance.

This year is a great one to select a few metrics that are easy to perform to get one’s feet wet and develop a strategy and infrastructure to support MACRA and QPP for the long run.


Nancy Gagliano, MD is CMO at Culbert Healthcare Solutions in Woburn, MA.


Jenn, Mr. H, Lorre

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From the Consultant’s Corner 3/2/17

Value-Based Reimbursement: Five Success Factors for Medical Groups

Despite uncertainty about the future of the ACA, value-based reimbursement will remain an unwavering reality in healthcare. While leaders may disagree over specific legislation, all approve the overall goal of value-based reimbursement, which is to encourage both cost reduction and improved patient outcomes.

That means medical groups should continue to explore value-based opportunities through commercial payers and CMS. For example, MACRA, which takes effect this year, consolidates previous programs including Meaningful Use, PQRS, and Value Based Modifier. Approved by a bi-partisan Congressional vote, MACRA is likely to stand as enacted and impact a significant portion of practice Medicare payments starting in 2019. Yet MACRA isn’t the only initiative designed to enhance revenue and patient care. Medical groups can also take advantage of programs such as Chronic Care Management, Transitional Care Management, Patient Centered Medical Home, and Bridges to Excellence.

No matter which value-based path a practice chooses, there are five factors that will be integral to success:

1. Patient engagement. Reports show that patients who are engaged in their care have better outcomes,[i] and most patients desire deeper involvement. So what’s the obstacle? Transparency. Medical groups will need to be more transparent about their services and costs to engage their patients.

2. Investments. Achieving transparency requires access to information. Practices need to invest not just in EHR and PM systems, but also in frequent training to expand their use. By now, most providers have an EHR; 78 percent of all office-based physicians and 96 percent of all non-federal hospitals had a certified EHR as of 2015.[ii] The key going forward is to optimize those systems and workflows to accomplish value-based objectives.

3. Data and analytics. Data truly is king. Creating appropriate data in EHR and PM systems — and then analyzing it through business intelligence software — enables practices to best evaluate the needs of their patients. Ensuring accurate ICD-10 coding, for instance, helps practices paint a more precise patient picture.

4. Population health. With data and analytics, practices can better identify gaps in care and the target those patient populations most in need of intervention. For example: The PQRS and MU quality measures that are now part of MACRA are also being used by many commercial payers. Obtaining this quality data at the point of care — rather than from retrospective reports — allows practices to effectively use resources to proactively engage patients and improve their care.

5. Practice performance/EHR workflow. Efficiency will continue to gain importance as value-based reimbursement models reward reduced costs and increased patient satisfaction. To fuel the kind of efficiency that lowers cost and makes patients happier, make sure providers are maximizing the EHR’s capabilities at the point of care.

Together Toward Value

While data, technology, and patient engagement will lay the foundation for value-based reimbursement, be careful not to overlook the importance of governance as well. More than ever before, practices must bring together their CMOs, CMIOs, CFOs, IT directors, and other organizational leadership to develop a unified value-based care strategy. Consider establishing a governing council to evaluate value-based opportunities, inform and train staff, and implement plans. Solidarity, communication, and attention to the five factors listed above will go a long way toward achieving a smooth transition to value-based reimbursement.


By Randall Shulkin, executive consultant, Culbert Healthcare Solutions

[i] Patient Engagement Report: Improved Engagement Leads to Better Outcomes, but Better Tools Are Needed; Insights Report; May 12, 2016; Kevin Volpp, MD, PhD & Namita S. Mohta, MD

[ii] Health IT Dashboard; The Office of the National Coordinator for Health Information Technology; January, 12, 2017


Jenn, Mr. H, Lorre

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