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Medicare Access and CHIP Reauthorization Act

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Change in CMS primary-care program seen scaring away some providers

Optimizing data use for PHM


Anil Jain, M.D. writing in H0spitals & Health Networks, looks at how to access and use the data that are at the heart of population-health management (PHM) programs.

He notes that with the Medicare Access and CHIP Reauthorization Act, hospitals systems “are under increased pressure to support the Centers for Medicare & Medicaid Services’ Advanced Alternative Payment Models and Merit-based Incentive Payment System” and writes:

No one data source is going to provide a ‘gold standard’ for population health management. Claims data alone has often been used for PHM, but it is not timely, making it less useful for care management. In addition, because administrative and adjudicated claims data are not as rich as clinical data, both fail to provide a granular picture of clinical situations. Therefore, it is important to reconcile administrative, adjudicated claims and clinical data to optimally risk-stratify patients.’’

“Here are three key points to remember when building your data strategy for PHM’’:

  • “Start with an inventory of data sources and analysts who have expertise in accessing, extracting and curating the various data. This advice holds true whether you are developing your data strategy in house or working with a partner.
  • “Although it helps to have as much data as possible and to be able to combine different data types as needed into a common data platform, keep in mind that data-use agreements, privacy and security policies such as the Health Insurance Portability and Accountability Act and other constraints may limit your projects.
  • “Finally, iterate through your data projects with a few data types and incrementally layer on additional types as needed.”

To read more, please hit this link.

CMS widens options for APMs

CMS  offering additional opportunities for physicians and other clinicians to join advanced Alternative Payment Models beginning in 2017 and 2018.

The advanced Alternative Payment Model is the more lucrative of two options under the Medicare Access and CHIP Reauthorization Act, (MACRA) a payment system for Medicare physician fees that replaces the controversial Sustainable Growth Rate formula.

CMS will offer the Oncology Care Model with two-sided risk as a qualifying advanced APM beginning in 2017 and  will reopen applications for the Comprehensive Primary Care Plus model and the Next Generation ACO model for the 2018 performance year.

Patrick Conway, M.D., deputy CMS Administrator,  said:

“With these new opportunities, CMS expects that by the 2018 performance period, 25 percent of clinicians in the Quality Payment Program will earn incentive payments by being a part of these advanced models. Thanks to MACRA and the Innovation Center, we’re striving to see more Medicare patients benefit from better care when they visit their doctor for a knee replacement, receive cancer treatment or have a coordinated care team manage their complex conditions.”

Physicians who participate in Medicare must submit at least some performance data next year to avoid a penalty under MACRA. These data will determine payment adjustments beginning in 2019. Physicians who qualify as an advanced APM will avoid some reporting requirements and be eligible for a 5 percent lump-sum bonus.

To read a Becker’s Hospital Review article on this, please hit this link.

Many physicians still worried about MACRA


Despite soothing words from CMS, and some adjustments based on criticisms from providers, many physicians remain worried that the  final rule to implement the Medicare Access and CHIP Reauthorization Act (MACRA) is still too narrow and complex to reach its  goal of creating a mostly value-based payment system.

Many fear that the final rule will hurt small and rural medical practices and set primary-care doctors against specialists.

Under MACRA, better-performing doctors will get bonuses and under-performers will face financial punishments based on a variety of metrics of cost and quality of care.

To read a MedPage Today article on this, please hit this link.


CMS to let providers set pace to move to value-based payments


The tortoise and the hare.

The Centers for Medicare & Medicaid Services has  announced that it   will let providers choose the level and speed at which they comply with the new payment-reform model  that emphasizes the medical value/outcomes of patient care over the volume of procedures. In the current, predominately “fee for service” system, the more procedures that providers order, the more they get paid. That is one reason that America’s physicians are by far the highest paid in the world.

Healthcare industry stakeholders have put the CMS under intense pressure  to ease implementation of the Medicare Access and CHIP Reauthorization Act, which is set to start Jan. 1, 2017. Two months ago, CMS Acting Administrator Andy Slavitt said the agency was considering delaying the start date.

And so eligible physicians and other clinicians next year will be given four options to comply with  such new payment schemes such as the Merit-based Incentive Payment System (MIPS) or an alternative payment model (APM), such as Accountable Care Organizations.

Modern Healthcare reported that under MIPS, physician payments “will be based on a compilation of quality measures and the use of electronic health records. About 90 percent of physicians are expected to pursue MIPS because a qualifying APM requires a hefty amount of risk.

“In the first option offered Sept. 8, any data reported will allow providers to avoid a negative payment adjustment. The goal is to ease providers into broader participation in the following two years, ” the publication reported.

The second option lets providers  submit data for a reduced number of days. “This means their first performance period could begin later than Jan. 1 and that practice could still qualify for a small payment if it submits data on how the practice is using technology and how it’s improving,” Modern Healthcare reported.

The third option is for practices that are ready to go in 2017.

To read the Modern Healthcare story, please hit this link.



Things to know about CMS’s Oncology Care Model


Here is a stripped-down version of Becker’s Hospital Review’s “9 things to know” about CMS’s five-year Oncology Care Model, one of  CMS’s first physician-led specialty-care models, meant to improve quality and cut  costs.

1. “HHS selected 17 payers and 196 physician practices to participate — almost twice the number it expected.”

2. “The program takes  episodic approach to cancer treatment to help contain costs and enhance patient care.”

3. “Under the OCM, physicians are paid in two ways.”

4. “Episodes last six months each and cover almost all cancer types.”

5. “Performance payments are awarded to practices based on how well they perform in relation to benchmarks calculated by CMS.”

6. “There are two risk options under the OCM.”

7. “The two-sided risk track is considered an Advanced Alternative Payment Model under the newly proposed Medicare Access and CHIP Reauthorization Act.”

8. “CMS will provide a learning system for participants to share and diffuse resources, tools, ideas and data-driven approaches to care.”

9. “Dual participation in OCM and other programs is allowed in some cases.”

To read the whole Becker’s article, please hit this link.


MIPS deadly for many small physician practices?

In this interview, Robert A. Berenson, M.D., a fellow at the Urban Institute speculates on whether Medicare’s new  new Merit-based Incentive Payment System (MIPS), which is part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), might be the death knell of many small practices.



Maximizing provider reimbursement under MACRA

Here’s some guidance on finding the best way to maximize provider reimbursement under the Medicare Access and CHIP Reauthorization Act (MACRA),  signed into law last year.

The law  is designed, among other things, to restructure how reimbursement rates are calculated for individual doctors in the Medicare Physician Fee Schedule.

MACRA  repealed the flawed Sustainable Growth Rate formula for  Medicare payments for clinicians’ services, and established  a new framework for rewarding physicians based on “value” rather than volume.

Modern Medicine noted that “By comparing physician compliance against national averages with mandated regulations across many specifically defined quality metrics and measures, CMS hopes to reduce what it considers costly medical redundancies and improve overall patient health and safety.”

According to the legislation, all eligible providers, “including physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists… shall receive annual payment increases or decreases based on their performance as measured by standards the Secretary [of Health and Human Services] shall establish according to specified criteria” from 2019 on.

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