Monthly Archives: August 2016

In Defense Of MACRA

The changes made in the healthcare space by the Federal Government over the past few years has been a concern for the family physicians and small practices. In addition, the proposed Medicare Access and CHIP Reauthorization Act (MACRA) which is scheduled to come next year have been a major source of excitement.

“This piece is not to support or oppose the act but proposes a rational dialog about its advantages when the general sense has not been very receptive.”

Family physicians and small practices fear MACRA because of its complexity (the act is almost a 1000 pages) and also for the fact that it can impact their revenue generation capabilities. The opponents of the act point out that small and medium practices lack the capital and infrastructure to implement the changes required to adapt to the new reporting requirements. But the act also has a few benefits and the most important are listed below:

Declutter the reporting
Chance for positive revenue
Clinical Integration
Departure from fee-for-service

1. Declutter the reporting:

MACRA is an attempt to declutter the complex reporting requirements and make it into one, which will reduce the burden of separate reporting. With MACRA the PQRS, Advanced care, Meaningful use are brought into one Quality Payment program QPP. Although there are two models under this program, the provider is only in either of the two.

2. Chance for positive revenue:

MACRA proposes to incentivize providers on the basis of their published rank, which will be a direct increase in their revenue, unlike the system in place now which gives no incentives but penalties. MACRA allows for positive payment adjustments, besides MACRA’s maximum potential penalty for failing to meet standards are less than the current reporting programs.

3. Clinical Integration:

MACRA Act promotes clinical integration with incentives. The model is designed to encourage practice, to provide joining efforts and to improve population health. This aspect is, what the critics like to call ‘kills individual practices’, changing the old model. Yes, the old model is being changed, and it is not just MACRA. Every new legislation, step, the procedure that CMS employs is to create this change in the system, not just MACRA. Clinical integration can improve patient care quality and lead to the reduction in cost.

4. Departure from Fee-For-Service:

This is what it all boils down to. CMS aims to reduce the amount spent on healthcare and improves the quality of care the population receives. MACRA is yet another organized step in this direction; with its strong words MACRA will allow American healthcare industry to take a giant leap in the direction of value-based service.

It will not be easy to embrace MACRA, with all its complexity and questions, it is yet to answer. But, the fact remains that MACRA is absolutely an improvement on the systems now in place. A lot can be done to improve and make it easier for the benefit of all that is involved, but scrapping is not an option at this point. The unprecedented support this legislation enjoys from both side of the aisle is a testament to public support the act receives.

MACRA is certain to create a few hiccups which in any case can be discussed and ironed out. After all, no solution is perfect and results uncertain till testing.

The Coming of ICD-10

On October 1st 2016, the grace period for ICD-10 coded medical claim will end. Providers under Medicare, Medicaid and Private insurers (few who has yet to implement the change) will have to file reimbursement claims only under the new ICD codes.

International Statistical Classification of Diseases and Related Health Problems, 10th revision is a standardized coding of diseases, conditions, symptoms, complications, causes, etc., developed by WTO. ICD-10 is the updated version of ICD-9 code in general use now.

ICD-9 has 11,000 codes but the improved ICD-10 proposes a comprehensive 70,000 individual codes for each and every condition, treatment and diseases. Herein lies the reason for providers concern. It is feared that when providers are filing on, this may complicate the process, and also so many codes may increase the chances of error, leading to increase in claim denials.

Following are the reason why Federal agencies were ardent on ICD-10 and want to push on with it despite provider’s worries.

3.Public health concerns
4.Performance Monitor


ICD-10 is a more robust design, in accommodating new procedures and treatments. It can potentially store more data regarding a patient, treatment and is better in scaling the severity of the situation. Clarity of the situation will help tracking care quality, and for payers, it can identify patient population with their disease.


The effort behind the development of ICD-10 codes was the gathering of data about diseases and treatments. More data will lead to more clarity in healthcare deliverance and accurate identification of expenditure, care and result. Increase in number of codes will allow in standardization and will help remove ambiguity caused by fewer codes, this can also reduce fraud and diversion of healthcare fund.

Public health:

Code based monitoring of the public health can help identify general public health risks and problems.US has the worst record in population health among the whole of industrious nations. A standard, unique coding system can help in early detection and taking action against any population health concerns.

Performance Monitor:

Precise recording of medical conditions and treatments is crucial in measuring and comparing various parameters such as cost, medical procedures etc. In-depth details will allow providers to evaluate their own performance and payers to understand the population more preciously. As payers are connecting patient health outcome (performance) to cost (reimbursement), a detailed coding system will come in handy.

ICD-10, a more detailed code to mark diseases and healthcare procedures, and the sheer number of them may seem a bit too complicated. But, the fact is ICD-10 code by very reason of being so complex will eliminate ambiguity in reimbursement filing. It is one of the most anticipated change in healthcare, and also the most trained for, partially thanks to the delay.

MACRA – The Path to Value

As the Healthcare Industry is transforming from fee- for- service to value-based- service, Medicare Access and CHIP Reauthorization Act (MACRA) leads a way to reach value and quality. MACRA brings a powerful change in payment model.

Healthcare System aims to make people healthy by providing better care. And, this is achieved by focusing on incentives, care delivery, and information sharing.

MACRA prioritizes on quality than quantity. To deliver good care, a physician needs to perform well. And their performance should be evaluated and rated. Each physician is paid based on their individual rating score. This way of payment will improve care possibilities and lower cost associated with it.

MACRA will establish new reporting measures called Quality Payment Program (QPP). QPP opens two paths to reporting; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM). Physician or practitioner can choose any one of the models to participate in MACRA.

Merit-Based Incentive Payment System (MIPS)

MIPS will consolidate three existing programs which are Physician Quality Reporting System (PQRS), Value-Based Payment Modifier and EHR incentive program.

Physicians and practitioners who are evaluated under MIPS will have the score of 0-100. This score will either increase or decrease the payment by 4% to 9%.

An individual score is comprised of the following category (with relative weights)

1.Quality of care which replaces PQRS (50%)
2.Resource use which replaces value-based modifier program (10%)
3.Clinical Practice Improvement Activities (15%)

These activities are similar to PCMH. Clinical practices must have minimum 1 activity, and for every increase in activity, they will be awarded extra credits. Recognized PCMH will get full credit.

4.Meaningful Use certified EHR technology (25%)

EHR MU helps to advance care system. Ratings are given based on effective usage of EHR.

Based on this composite score, they will either receive positive, negative or neutral incentives. Starting from 4% of penalty or incentive in 2019 and it will gradually increase or decrease over years.

Physicians excluded from MIPS are:

The first year of Medicare providers
Provider’s Medicare patient volume below the threshold value
Eligible providers of APMs who qualify for the bonus payment

Alternative Payment Model (APM)<

APM is another approach to payment through Medicare. Most possible eligible players are ACO and PCMH. Not all providers of APM are eligible, but they still can participate in MACRA. In APMs, who are not Qualified Participants (QP) will receive a favorable score. If they participate their MIPS score will increase.

Meanwhile, eligible QPs come under Advanced APMs. Physicians of Advanced APMs are excluded from MIPS but will get a lump sum bonus payment of 5%. Also, they receive highest fee schedule update.

MACRA Impact on Small Practices:

Meeting the requirements of MACRA will be a time-consuming process for all small practices. They are at the high risk of facing negative payment adjustments during the first year implementation of MACRA.

CMS estimates there are 87% eligible solo practices clinicians and they all will face a penalty in 2019. On the other hand, large practices will receive positive payments.

To make this odd payment even, HHS announced they will spend $20 million per year for next 5 years in funding small practices to help them prepare for MACRA. Practices in remote areas will get benefitted from this program.

This could help them to improve their Clinical Practice Improvement Activities which will help in attaining the broader initiatives of CMS.


On April 27th 2016, CMS released a significant new ‘proposed rule’. Once this becomes a rule, it will chart Medicare payment course for the foreseeable future. MACRA or Medicare Access and CHIP Reauthorization Act 2015, which continues to be supported by both parties, will alter the way Medicare pays to providers who give care to Medicare patients.

MACRA will replace Standard Growth Rate (SGR) which determines Medicare’s payment to healthcare providers. To replace Standard Growth Rate, MACRA will establish a new value based reimbursement systems called the Quality Payment Program (QPP). Under QPP there will be two payment models

1. Merit-based Incentive Payment System (MIPS)

2. Alternative Payment Model (APM)

CMS predicts that most of the providers will be subject to MIPS for the first year of MACRA that is till 2017, this will include providers who reports PQRS and Meaningful Use and also those who are not part of any. ACOs that do not bear enough risk for exemption, will also fall in this payment model.

MIPS is the combination of the three existing models namely Meaningful Use, Physician Quality reporting System (PQRS), and Value Based Modifier (VBM). MIPS will categories four measures to compare provider performance to a MIPS composite performance score (CPS) of 100 points. Those four measures are

1.Quality (50%)

2.Advanced Care Information (25%)

3.Clinical Practice Improvement Activities (15%)

4.Cost Category (10%)

Composite Performance Score earned for a given year determines MIPS payment adjustment in the next calendar year and scores earned by each physicians will be made public. So, it is important to understand and prepare for the four measures.

1. Quality

Clinicians can choose six measures to report to CMS, that best reflect their practice. One among these measures must be an outcome measure or a high quality measure, and one a cross cutting measure. Clinicians can also choose to report a specialty measure set.

2.Advanced Practice Improvement Activities

Clinicians will report key measures of interoperability and information exchange. Clinicians are rewarded for their performance that matter most to them.

3.Clinical Practice Improvement Activities

Clinicians can choose the activities best suited for their practice, the rule proposes over 90 activities to choose from. Clinicians participating in medical homes earn full credit in this category. Those participating in Advanced APMs will get at least half credit.

4.Cost Category

Cost category points are calculated by CMS on the basis of claims and availability of sufficient volume. Clinicians do not have to report anything for this category.

CMS, has suggested a delay in MACRA implementation out of consideration for small physician practitioners. But even with the delay, MACRA will become a reality soon and it can have the following impact on practices.

1.Practice Revenue

MACRA will have two impact on practice revenue, annual inflationary adjustment to the part B fee schedule, by which there will be a small increase for payment years CY2016 to CY2019, which will be the first payment under QPP and MIPS payment adjustment on the group/physician’s Composite Performance Score based on which there can be significant variations in reimbursement.

2.Lots of Data to Collect and Process

The MACRA act is incredibly complex and precise in its details. With all the data to be reported for validation, physicians will have to have an organized system to collect and verify the data. For some providers this might be welcome upgrade, but for the small practices this would mean additional investment on infrastructure and staff.

3.Improve Care Quality

MACRA will effectively shift accountability focus so that there will be an increased counselling and follow-up. By connecting the payment model to care quality, providers will be more invested in population health of community they serve.

4.Practice Reputation

There is call for transparency in healthcare payment and MACRA CMS is heeding to that call. MIPS will publish each eligible physicians annual Composite Performance Score (CPS) within a year, after the end of the relevant performance year. These published results will have an impact on provider’s reputation and indirectly their revenue. A good score, probably higher than a national average will work in favour of providers and a bad score will do the opposite.

Over the past few years CMS and the Federal government have been pushing healthcare sector away from fee-for-service to value-based-service. With MACRA implementation scheduled next year, CMS will achieve a great much, in this direction. MACRA law may pose to disturb small physician practitioner’s quiet afternoons for a while, however the hope is that when the dust settles everyone will stand to benefit.

Mobile Health

Rapid growth in the healthcare industry and increasing technology innovations are transforming the way healthcare is being delivered. Mobile Health technology is one such disruptive innovation

mhealth apps has become popular over the past few years and is still trending. By 2017, over one-third of the world’s population will have smartphones. As people become more health conscious, the use of such apps will also increase.

Health apps record a large amount of data, and this data in sync with EMR will help providers and care team to track patient’s day-to-day activities and evaluate progress. Collection of data process will become easy but the real challenge is to engage patients and execute a care plan.

By using patient portal, providers can engage their patient through Mobile Health technology. Mobile Health can increase the outcome, based on the patient’s engagement level. In order to keep active, professionals have to educate their patients via portals, health apps, and educational programs.

A survey indicates that people with one chronic condition are not consulting their primary care physician not more than once in three months. Though certain services like Telehealth and Mobile Health has been initiated to ease the care process, people are reluctant to embrace it for various reasons. The only way to do is encourage them to participate.

Using digital health tools we can bring better health outcome and help patients stay connected to healthcare professionals. There are many wellness applications but a customer standard tool for providers to extract data from multiple tools is a challenge. Using a common platform help will help in data accuracy and effective usage.

Many Americans use health monitoring devices. But the story changes when you evaluate the subsets; survey tells those newly insured people are more interested in using apps to monitor their health activity than people who already suffer from one or more chronic conditions which is not a positive sign, as people with chronic conditions are in high health risk probability.

Patients now expect providers to interact digitally, like in other services. Provider’s attempt to satisfy their expectation level but due to the absence of a reliable secure solution, it may fail to rise up to the demand.

Hospitals are now developing their own app. But only two percent of patients are using this app, mainly to access their health record, appointment scheduling, and prescription refills.
In that 2 percent, some patients face difficulty to access or enter data. When the patient attempts to enter data, after a short time they get tired and stop entering resulting in incomplete data, which in turn means incomplete patient data.

Developers always focus on customer’s needs. Increase in needs will increase the competition, which results in more application and all those are customer-driven products. Some apps help people to self-diagnose. Chronic patients who use fitness app have gradually decreased their visit to the physician. Knowing that some physicians also have stopped suggesting those apps to patients. But providers need to realize the benefits of Mobile Health and should encourage their patients to use those apps.

The customer plays an essential role in transforming the healthcare industry. Technology is useful only when customer understands the use of a product.

HealthCare Data Management

Data Management in healthcare requires a meticulous approach, Accountable care organizations or the ACO’s usually have many hospitals associated with its network, which makes data management all the more difficult.

Hospitals have patient’s medical records either in electronic form or paper-based. ACO’s will have to
consolidate data from all hospitals and convert it into an actionable format, and make it available to be accessed across the network, to achieve better population health.

There’s a considerable challenge in a consolidation of Healthcare data. Data line in healthcare is typically lengthy and complex in the structure which is not easy to consume as it is possible in any other field. Each time data has to be retrieved and handled through secure communication, to ensure data protection.

In order to update or retrieve a patient information without any interchange, data arrangement should be perfect. Indexing is one method which helps in loading or recovering files in an orderly pattern and gives a clear and complete view of an individual patient record without any case of missing information. Data gathered and stored are reliable and acts as a primary source of information for an ACO.  Integrated data approach combines patient-centered data from smartphones, wearable, and other connected devices and gives a comprehensive, near to real-time data.

Recent technology advancements help to perform advanced analytics that can yield a better diagnosis and enhance right treatment. This encourages people to engage in their own care, as unified data makes the process simpler. ACO admins can access these files to monitor the patients and measure the performance of the physicians through an actionable dashboard. Providers can schedule physician meeting with patients, whereas physician’s role is instrumental to communicate with patients and induce continuous engagement for better results.

One of the most common reasons why data management is challenging in healthcare is that of the lack of training to the participants. Payers might be doing data mining for years to monitor claims but providers are yet to leverage the advantages of data to the fullest.

Present system needs analytics assistance to drive the agenda of high-quality care at a low cost.
ACO’s may not be keen to hire a data analyst to do this process. All they require is an integrated, built-in analytical tool that can be easily installed, and be used like any other critical business application.

Another major problem is storage. To be able to arrive at a meaningful information from the data file, one must ensure collected data set covers a lot of ground data including provider, physician details along with the patient, and has to compatible to data warehouse it. Some organization prefers outsourcing where security is a major concern but they are left with no choice.

The volume of data increases day by day which is directly related to cost. The next option would be Cloud computing for many large organizations and mid-level company. And migration has already started because of its fast and secure data sharing benefits.

When it comes to payment issues analyzing cash flow is no longer difficult for hospitals with performance-based payment. Data analytics being able to analyze real-time data provides immediate information which helps in better decision making and to optimize the operations at regular intervals.

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