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Many organizations started preparing for the implications of MACRA implementation when the proposed Final Rule was released at the end of April. However, the numerous changes contained in the October 14th Final Rule will necessitate a critical re-evaluation of MACRA strategies for quite a few organizations.

Beyond the measure-specific preparation questions, such as which measures to select and how to best obtain and report data, MACRA implementation also raises some broader challenges and opportunities for all of us to consider – particularly heading into 2018 and beyond.

The management infrastructure supporting practices will need to grow.

MACRA participation will impose a greater strain on practices.

Dedicated MACRA expertise will be indispensable. Becoming familiar with and keeping up with an entirely new program will be difficult for day-to-day operational staff members. What is the latest MACRA information? How does it compare to past programs and requirements? What clinical and business operations or patient flow responsibilities need to change to maximize benefit and minimize harm? What are our options?

Practices will need a source of accurate, reliable information as the program evolves.

Reporting requirements increase with MIPS. While CMS rightfully emphasizes that the number of quality measures required by MIPS is less than the number required by PQRS (6 versus 9) and the number of measures reported with Advancing Care Information is less than Meaningful Use, MIPS introduces an entirely new performance category related to clinical practice transformation activities (Improvement Activities).

Even though CMS reduced the absolute reporting requirements for the 2017 and 2018 performance periods to make MIPS participation practical for more individuals, the new category forces practices to add a new point of emphasis, and potentially a new reporting mechanism, to their operations.

Technology continues to assume increasingly significant roles. Interconnectivity, interoperability, and effective interfaces between disparate systems are necessary to meet many of the MIPS related requirements (and succeed in a value-based care environment). Having data available at the point of care is critical – as is capturing care as data elements for MIPS reporting, population health management, and care coordination activities. Dedicated technological expertise focused on outpatient practices and services will continually stress resources.

Incorporating technology into daily operations. Just having the technology is not enough. Creative utilization of technology will allow patient care to advance – and be rewarded by MIPS bonuses.

Reporting mechanisms. MIPS requires consistent reporting mechanisms for each performance category and CMS espouses a future goal of having practices adopt a single reporting mechanism for all performance categories. Bonuses exist for automated end-to-end reporting.

Programmatic Performance Improvement support will be required. For every aspect of MACRA, performance matters. The changes bestowed on the 2017 performance period aside, just reporting data to CMS will not be sufficient in the future. Quality, cost, and EHR utilization performance will be compared to national external benchmarks. The benchmark values will continually rise, just as they have on the hospital side.

Even the anticipated future option of measuring individual improvement over time instead of against external benchmarks will require actual, measurable performance improvement. Just reporting measures or maintaining the status quo will not be sufficient if penalties are to be avoided and bonuses sought.

Identifying, implementing and executing pertinent clinical best practices will become even more critical for improved quality and cost outcomes – and attendant reimbursement success. These types of endeavors require more resources than the typical practice currently possesses or has access to.

Clinical practice transformation will foster future success. MACRA directly links clinical practice transformation tenets to the MIPS process. Accessing or developing expertise is this area will be critical for delivery of both primary care and other specialty care. Organizations like NCQA and regional QIOs offer training and support, but the impetus falls on the practice to do the work and make the changes.

While this can seem overwhelming, it does reap dividends for patients and practices – and is rewarded in MIPS. Consider investing in the PCMH (Patient Centered Medical Home), PCSP (Patient Centered Specialty Practices), or PCC (Patient Centered Continuing Care) processes to position the organization for success in both the value-based care environment and the MACRA reimbursement methodologies.

All of these factors lead to the question — Do I build it or do I buy it or do I just sell out?

Be prepared for increasing numbers of independent physicians to express interest in employment.

Many experts predict that MACRA participation will be the next major factor driving independent practices and physicians toward employment. The MACRA dynamic builds on the last wave – EHR technology pursuit, which will be a continuing issue for many independents as 2015 edition CEHRT becomes a 2018 MACRA requirement and technological capabilities become an ever-increasing component of value-based care delivery.

The stresses of additional MACRA participation requirements and potentially decreased reimbursement will severely challenge practice operating margins – particularly for the solo and small physician practices. The MACRA legislation acknowledged the potential adverse impact on these groups and included measures to mitigate the impact. CMS further strove to lessen the immediate impact by remarkably reducing participation requirements for the first two years of the new program.

Small practices will be challenged nonetheless. CMS reports that although 87% of all physicians participate in PQRS and should be expected to avoid penalties for 2019, only 58% of solo and small practices currently participate in PQRS. This may make 2017 MACRA participation difficult – even with the markedly reduced requirements. The requirements increase in 2018 and reach the full extent required by the legislation in 2019. Realizing the MACRA realities and risks may be the final straw for many independents.

Consider alternatives to employment to address small independent practice concerns.

Unless an organization wants (or can afford) to employ all that request it, alternatives to allow independent practices to survive, and even thrive, must be actively explored. What are some of these alternatives?

Revisit safe harbor regulations for direct EHR support. If you did not develop a program before, consider doing so now. Meaningful Use initiation spotlighted the need, but the wave continues to evolve with MACRA.

Participate in Health Information Exchange (HIE) development and utilization. Interconnectivity is crucial for successful value-based care delivery – and participation garners points in MACRA (a medium weight Improvement Activity). A functional HIE places additional clinical data in clinicians’ hands at the point of care that can increase the quality of care, decrease risk of adverse events (knowledge truly is power), and decrease the total cost of care (avoiding duplicate testing and needless adverse outcomes).

Build and offer MSO capabilities to help independent physicians with MACRA challenges. Traditional MSO offerings focused on practice management and/ or revenue cycle management. Organizations had to perform these functions well or face backlash from those with whom they contracted. The risk/benefit ratio for offering MSO support often favored avoiding it entirely.

The litany of management infrastructure needs associated with MACRA and value-based care may best be accomplished most cost effectively in a centrally supplied and managed fashion – which lends itself to the MSO concept.

Hospitals and health systems can offer services and/ or expertise to buoy independent physicians in their market for mutual benefit.

IPAs can expand their services to offer members additional assistance to remain independent (and members).

CINs will need to focus on more than quality and cost as a MIPS APM’s final score is only as good as its members’. Offering expertise in Improvement Activities, practice transformation, and CEHRT becomes even more crucial for success.

Start modeling support options, the likely financial impact, and plan for the future.

MACRA is not a one-time event but a program composed of progressive reporting requirements and expectations of continually improving performance. Don’t count on the presidential election results to change the legislation and resulting regulations since MACRA is separate from the Affordable Care Act and passed with tremendous (near unanimous) bipartisan support.

The 2017 reprieve affords a great opportunity for proactive planning and progressive action. Many organizations may consider the 2017 MIPS performance period as maintaining the status quo. Don’t be lulled into complacency. Evaluate MACRA’s potential global impact on your world and develop global strategies to turn the challenges into opportunities and successes.

Terrence R. McWilliams, MD, FAAFP

Chief Clinical Officer and Managing Director, Employed Provider Networks