Healthcare providers, you work hard - we know you do. But a new "merit-based performance program" may have you feeling a little nervous. This new system is like a bonus plan set by your employer but in this case, your employer is the federal government. Let's break down each category of the new era of healthcare.
Under the Fee-For-Service system, say you receive $100 for an office visit, and you receive $100 every time this is done. So the more patients you see, the more that guaranteed payment keeps coming in. Under the new system, that same office visit will now pay you $80 - BUT if patient health improves, you get a bonus of $27. If patient health remains the same or worsens, you will receive nothing more beyond that $80.
Fee-For-Service is based on the volume of patients a doctor could see and bill for in a day with some doctors being under scrutiny for having 5-minute long visits and pushing patients along like a conveyor belt. This pivot is now focusing on the VALUE of care provided.
Two words: Clinical Outcomes. Are your patients test results showing an improvement in health? Don't worry, you get to choose the services you get measured on. If you're a pain management doctor, you're evaluated on how well your patient's pain symptoms are alleviated over time via what is documented in follow up visits. Simple enough, right? Keep doing well as a provider and you will be just fine. Rightfully so, this category is weighted at 50% for your evaluation.
2. Advancing Care Information
What this basically means is: Do you have an EMR (Electronic Medical Record) system where you store and submit patient information? This is essentially the status quo of all practicing clinics today. Much of your progress is automatically documented via the EMR and reported to Medicare. There will be further emphasis on ordering prescriptions and transferring patient information ELECTRONICALLY to their respective healthcare organizations such as pharmacies and insurance providers. This will be 25% of the overall evaluation.
3. Improvement Activities
Population Management, Care Coordination, Integrating Behavioral and Mental Health, and Emergency Preparedness and Response are among the few categories considered as "Improvement Activities." Many clinics do this already, so it's really ensuring that your patients are taken care of, especially in any sort of handoff situation to a referral. For example, if you had a patient visit and determined their COPD requires an oxygen concentrator. An Improvement Activity would be ensuring the referral to the DME provider is fully followed up on and the patient is set up in a timely manner. This is 15% of the total evaluation.
4. Cost and Resource Use
This is where things get a little tricky. Medicare is basing this off the procedures and how much they cost. This is the government putting the pressure on your practice to find more cost-effective avenues for the same routine testing your patients go through. At the same time, only 10% of your full evaluation is based off this, so no need to scramble right now, but definitely keep gathering information as time goes on in case you need to make a cost-cutting decision down the line.
The Bottom Line
Just like any other government entity, there is a budget Medicare has set to adhere to. Which one would think this means the system is banking on providers to fail in order to compensate for bonuses given to providers who do a good job. One question remains: What if an enormous majority of providers qualify for these incentives?
In the meantime, one way to further prepare your practice is by having patients undergo diagnostic testing to ensure all your bases are covered. You may have a set regimen for a patient's treatment plan, but how do you know for sure those prescribed drugs are actually being taken? Compliance testing is the best way to for sure know what is in your patient's system and if they're taking their prescriptions. Compliance testing is your proof to show you are doing all you can as a healthcare provider to improve clinical outcomes with your patients.
To learn more about MIPS and MACRA, the Lab Lowdown has a podcast worth listening to on this specific subject.