Written by Bonnie Zickgraf, RN, BSN, CPHQ
Coauthor: Aaron Turner-Phifer
There is sweeping new federal regulation that will impact the future role of managed care nurses and physicians in the most challenging of ways. This new law is referred to as “MACRA.”
MACRA will overwhelmingly affect pre-authorizations, clinical coding review, claim reimbursements, policy development, performance measures and coordination of care, defining new roles for Medicare providers and managed care professionals in the United States.
You don’t serve the Medicare population in your current managed care position? Not to worry.
Because of the over-arching theme of increased financial risk and variable incentive payments addressing performance in the value of care, the U.S. potentially stands to lose hundreds if not thousands of providers serving Medicare patients, which can also mold and impact the commercial health care markets.
Hoping to retire someday and sign up for Medicare? Here is some helpful information you should know as a patient and as a managed care professional. Let’s look at the history, the regulation and the impact it may have on your own physician, the provider space at large, and you as a managed care professional.
This isn’t your Granddaddy’s Medicare system anymore, so I’ve enlisted input from my colleague at URAC, Aaron Turner-Phifer, Director, Government Relations and Policy, for some basic information about MACRA first:
In a rare show of bipartisanship, Congress overwhelmingly passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) which replaced the much maligned sustainable growth rate (SGR). MACRA represents the latest policy meant to facilitate the transformation of America’s delivery system toward value-based care and away from fee-for-service.
To facilitate this shift MACRA creates the Quality Payment Program which is comprised of two different programs: the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APM).
Physicians and clinicians participating in the MIPS program will receive a bonus or penalty in their overall reimbursement based on a composite score compared to others in the MIPS program. The better a physician or clinician does, the higher the bonus. The inverse is also true, the worse a physician or clinician performs compared to the field, the higher the penalty. Beginning in 2019, the first year payment adjustments begin, the maximum payment adjustment for physicians and clinicians is four percent. This escalates to nine percent by the year 2023.
As an alternative to MIPS, physicians and clinicians can participate in the APM (Alternative Payment Model) program which excludes them from the requirements of MIPS. Physicians or clinicians in the APM program get an annual five percent lump sum bonus simply for participating beginning in 2019. APMs are defined as those that meet criteria for linking payments to quality measures, use of EHRs, and nominal risk. CMS has identified the following programs that meet this definition:
- Track 2 and 3 Medicare Shared Savings Program ACOs
- Next Generation ACOs, Comprehensive Primary Care Plus (CPC+), and
- some Comprehensive ESRD Care organizations (ESCOs).
CMS released the draft rules to implement the Quality Payment Program enacted by passage of MACRA on April 27, 2016. The final rules are expected sometime in the fall but physicians and clinicians impacted by the program are encouraged to begin planning now in order to meet a potential implementation date of January 1, 2017. --- Aaron Turner-Phifer
So, as you can see, Medicare reimbursements left for physicians (that will still be accepting Medicare reimbursements after January 2017) can ultimately go up or down in 2019 as a high as 9% under one payment strategy (MIPS) or, under the APM strategy, require possible restructuring into Patient Centered Medical Homes or to join an Accountable Care Organization that may require greater financial risk by the physician or choose to participate in bundled payment models.
More information on the topic can be found here: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html (retrieved August 22, 2016)
Physicians will need to carefully consider all options and decide which program to participate in (or not to participate in) or whether to treat Medicare patients at all. So how will this affect you as a managed care nurse going forward?
CMS calculates the change due to MACRA will impact three-quarters of a million physicians, hospitals and other providers, especially the smaller independent practitioners. One very good article about impact to the providers can be found here: https://www.healthcatalyst.com/physicians-must-prep-for-the-financial-impact-of-macra (retrieved August 22, 2016)
Interestingly enough, what is most profoundly lacking in the resources today is the impact to nurses. In November 2015, the American Nurses Association (ANA) along with eight other nationally recognized nursing associations, submitted changes and voiced concerns to CMS about the proposed rule change, including the lack of recognition of the Advanced Practice Registered Nurse (APRN) and the roles they can most adeptly provide in light of the MACRA rule changes. This letter can be found here: http://www.nursingworld.org/DocumentVault/ANA-Comments/APRN-Comment-MACRA-RFI.PDF
For those of you working in an office or in the field as a health UM nurse or as a case manager, access to care will become paramount. Finding a suitable (or any) Medicare provider may become a bigger challenge. New patient resources will need to be gathered to address patient needs including access to timely care, transportation, transitions of care between acute, subacute and home settings and discharge planning, to coordinate the care with Medicare providers.
Underutilization will need to be identified and critically analyzed by networks and by nurses for hidden root causes such as lack of affordability to the Medicare patient, or lack of available providers or delays in care coordination. Providers under MIPs payment strategy are exempt if seeing less than 100 Medicare patients and therefore may limit the number of Medicare patients seen in a geographical area. Awareness of patient responses to questions posed to the Medicare population may benefit the wise nurse in terms of becoming a stronger patient advocate.
Nurses can also share MACRA and newly identified network resources with other nurses, physicians and other providers toward stronger patient advocacy and quality outcomes.
Education and awareness will become key attributes in managed care, no matter which way the regulations flow with MACRA or with others to come. Be prepared for future commercial and self-insured plans to follow suit. Reimbursements for quality care will come at a price to the patient and ultimately, to us all in the form of better quality care—when you can get it. I think our veterans know this system very well. Health care can only bear quality outcomes when and if the care is provided.