MACRA: A Quick Study Guideline

The importance of learning and researching the details of MACRA cannot be overstated, especially since the topic is unknown to many healthcare entities.

EDITOR’S NOTE: At the American Health Information Management Association (AHIMA) 2017 Convention and Exhibit, significant attention was given to the Medicare Access and CHIP Reauthorization Act (MACRA). The following is a summary of a presentation on the new Quality Payment Program (QPP) by Michael Marron-Stearns, CEO and founder of Apollo HIT, and Bonnie Cassidy, MPA, RHIA, FAHIMA, FHIMSS, principal of Advisory Services. The presentation was titled “How 50 years of Medicare Reporting Changes on January 1, 2018.”

Healthcare providers face a new value-driven reality that can potentially increase clinician profitability, yet also have the potential to negatively impact a clinician’s financial health.

One focus area to embrace is payment change and reform, such as that emerging as a result of the Medicare Access and CHIP Reauthorization Act (MACRA). For example, the Quality Payment Program (QPP) and its payment track the Merit-Based Incentive Payment System (MIPS) and the Advanced Payment Models (APMs) that directly tie the quality of healthcare treatment to payment.

Health information governance and clinical documentation integrity are changing under MACRA. To visualize the future state of physician reimbursement, it is critical to know what changes are in the forecast due to MACRA. The legislation created the QPP that repealed the sustainable growth rate formula, changing the way that Medicare rewards clinicians for value over volume while streamlining multiple quality programs under MIPS and awarding bonus payments for participation in eligible APMs.

The goals of MACRA include the following. Specifically, providers are to:

1. Tie more payments to value.
2. Offer multiple pathways with varying levels of risk and reward to maximize participation.
3. Create opportunities to increase APM participation.
4. Minimize additional reporting burdens for APM participants to incentivize participation.
5. Promote understanding of each physician’s or practitioner’s status with respect to MIPS and/or APMs.
6. Support multi-payer initiatives and develop APMs in Medicaid, Medicare Advantage, and other payer arrangements.

It is important to read, learn, and research the details of MACRA; it is still an unknown in most healthcare communities. Only 27 percent of provider respondents stated that they are prepared for MACRA in a 2017 survey published by Healthcare Informatics.

The QPP is here to stay − understand it and identify opportunities to embrace.

The six goals of the QPP are the following:

1. Improve beneficiary outcomes and engage patients through patient-centered advanced APMs and MIPS policies.
2. Enhance clinician experience through easy-to-use tools.
3. Increase the availability and adoption of robust advanced APMs.
4. Promote program understanding of the QPP and maximize participation.
5. Improve data and information sharing.
6. Ensure operational excellence in program implementation and ongoing development.

The QPP brings forth a mandate to increase secure information-sharing and patient access through an emphasis on technology and practice improvement. Both health information management (HIM) professionals and clinical documentation professionals will play a key role in quality reporting for all providers across the continuum of care.

The impact of MACRA and components of MIPS address the role of the HIM professional as subject matter experts on information governance (IG), clinical documentation and coding compliance, and revenue integrity.

Other industries recognize the need to control their information, which makes sense in healthcare, too. Clinical data integrity requires organization-wide IG, and IT requires adoption of principles, a framework, rules, and managed processes. MACRA and the new QPP illustrate that the time has come for the healthcare industry to adopt governance of information, because trust in health information depends on it.

Success with the new QPP clearly cannot be achieved without the execution of HIM principles to ensure data integrity and compliance. The transition from fee-for-volume to fee-for-value cannot be done without engagement from the HIM profession.