The MACRA Link to Population Health

The Medicare Access & CHIP Reauthorization Act (MACRA) became effective Jan. 1, 2017, making it imperative that rural providers and hospitals leverage some practical application so the promise of tying a greater percentage of payment to performance can be sought and achieved.   

No matter the noble the intent, this nonetheless has several rural providers and critical access hospitals (CAHs) concerned. The Merit-Based Incentive Payment System (MIPS) Quality Payment Program (QPP) is where rural providers will see the most participation/eligibility, while the Alternative Payment Model (APM) offered via Medicare will be limited to fewer providers.  

While the Centers for Medicare & Medicaid Services (CMS) has stated that MACRA isn’t about implementing a new score system that would in essence add more complexity to an already cumbersome system, many within rural healthcare believe that MACRA is putting providers on a “scoring scale” – and that a negative score will come back to haunt them. Or, if it is a good score, it could illuminate an easier pathway to success, because the scoring will be tied to National Provider Identification (NPI) numbers. The scores could very well impact providers’ respective ability to negotiate employment contracts and insurance compensation in the future.

A few other things to consider:

  • Many small rural providers include the Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs), and clinicians with low volumes of Medicare patients are exempt in 2017.
  • If eligible, rural providers can choose how much data they would like to report to avoid penalties and potentially earn a bonus.
  • Those who have Patient Centered Home Models (PCHMs) will already be foundationally aligned with MACRA principles, including ensuring patient access, care coordination, and population health.

What does MACRA success look like for rural healthcare, if providers want to participate?

MACRA success won’t be framed by just one story – it will be an evolution as time passes, updates happen, and policy changes are implemented. So consider this an eight-point roadmap to success:

  1. Population health is “in.” Rural healthcare needs to recognize that payment models will change and become more defined and refined over time via new initiatives and phases, but the transformation of population health is the new frontier in healthcare at large – and it’s here to stay. In fact, focus on population health diminishes the impact of chronic disease, improves patient health and quality of life, and can indeed help providers actually meet their respective value-based goals.
  2. In eligibility, pay attention to the details. Many rural providers have been given a “MIPS reprieve” in 2017, as this initiative focuses on Medicare Part B (this includes those aforementioned RHCs and FQHCs, which have low Medicare volumes and bill less than $30,000 worth of Medicare services and see fewer than 100 Medicare patients per year. Such providers will be exempt from MIPS participation in 2017).

Remember that the devil is in the details of the eligibility note: MIPS might apply to the CAHs, but this only applies if they are participating in the Method II billing, in which the participating CAH bills for both the professional services and for the facility. That said, for MIPS to apply to the CAH, providers must have reassigned their respective billing rights to the CAH, and if they haven’t done so, the CAH is not subject to MIPS.

  1. Focus on employment status. In addition to the billing and numbers of patients, remember that there are more providers and specialists included in this program than initially thought – based not only on the aforementioned, but also the “employment” status. There is also the inclusion of clinicians, or non-physician providers such as physician assistants, registered nurse anesthetists, clinical specialists, and nurse practitioners.
  2. Conduct an assessment. Remember that there are three MIPS categories, including improvement activities, quality, and advancing health information. Rural providers will be assessed on cost measures beginning in 2018. Rural healthcare did get another reprieve, though, as they only have to report on two improvement activities instead of the original mention of four.
  3. Transition and transform; don’t hesitate and procrastinate. While rural healthcare does get to select how much data to report in 2017, not being strategically and systematically prepared to provide a year’s worth of data in 2018 will put providers at risk for a 2020 penalty.
  4. Determine the cost of participation. Do the math – providers and CAHs should consider the costs and benefits associated with MIPS bonuses, which can account for 4 percent or lower in 2017. Determine the funding necessary and weigh it against the cost to implement the necessary processes and systems, because the costs may be more than what entities might be able to receive, leaving the bottom line struggling and other healthcare leaders (and even board members) disengaged. A living example might be a CAH with $50,000 in Part B billing, as outlined under MIPS, having to spend $50,000-$60,000 on data analytics and information technology just to have the potential to earn a 4-percent 2017 bonus. 
  5. Engage and communicate with your providers and among your providers. There needs to be a deliberate focus on building a strong team, with strategic planning, to successfully guide the next steps. There should also be at least one internal champion who is keeping his or her finger at the pulse of information for their respective rural entities – and a provider champion. MACRA not only needs to be on the agenda; it needs to be the agenda, along with the inclusion of population health. Optimizing preventive care is a good step to take, not only in patient care and reimbursement and measuring outcomes, but permeating the everyday language aspects of practicing medicine, including the culture, vision, mission, and planning steps. Assess the technology and resources needed to achieve the next steps and mitigate any barriers either in cost or information-gathering so that planning and deliverables can be mapped and achieved.
  6. Increase primary care (PC) needs resources. Remember that nearly 40 percent of all PC providers see anywhere between 22-35 patients each work day, leaving less than 20 minutes per patient face-to-face, plus the behind-the-scenes time necessary to document, write prescriptions, and return calls (plus attending provider meetings and attending to contingencies). Additionally, 30 percent of rural primary care physicians are at or nearing retirement age, while younger physicians (under 40) account for only 20 percent of the current workforce. With the rural population of 55-75 patients growing (people are living longer, needing more services, and more returning baby boomers are leaving urban areas to retire in rural areas), this means there are increased needs, demands, and stresses for more primary care physicians. Above all, primary care physicians must receive more support and excellence from physician assistants and nurse practitioners, especially where the scope of practice has been legislated. No matter what, there are increasing demands for PC that are outpacing the numbers of those being recruited and retained.  

The bottom line is that rural providers need extra support to do all they are called to do – primary care represents our first patients. If we don’t take care of them, it won’t matter how many patients are lining up for other services. As we tend to population health, let’s remember the primary care population health – it’s in a different context, but just as important.


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Janelle Ali-Dinar, PhD

Janelle Ali-Dinar, PhD is a rural healthcare expert and advocate with more than 15 years of healthcare executive experience in many key areas addressing critical access hospitals (CAHs), rural health clinics (RHCs), physicians, and patients. Dr. Ali-Dinar is a sought-after speaker on Capitol Hill. A former hospital CEO and regional rural strategy executive, Janelle is also a past National Rural Health Association rural fellow, Rural Congress member, and Nebraska Rural Health Association president. She is currently the Nebraska DHHS chair of The Office of Minority Health Statewide Council, addressing needs of rural, public, minority, tribal, and refugee health, and she serves on the Regional Health Equity Region VII council as co-chair of Rural Health and Partnerships. Janelle holds a master’s degree and doctorate in communications and is a recent graduate in public health leadership. Janelle is currently the vice president of rural health for MyGenetx and is a member of the RACmonitor editorial board.

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