Value-based health care reimbursements in rural care markets

By nThrive | Posted: 07/20/2018

Rural Health and MACRA

Legislative requirements resulting from the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) have shifted medical payor and provider thinking across all of America. From large population centers on the coasts to the small towns and communities everywhere in-between, everyone is impacted by these value-based health care changes.

While there are exceptions for rural health care providers to help prepare for this, as the MACRA Quality Payment Program (QPP) enters its second year, those that serve large percentages of Medicare beneficiaries need to take substantial steps towards value-based care. Failure to take these steps during these transitionary years significantly increases the risk of non-compliance and could result in the loss of hundreds of thousands to millions of dollars in reduced reimbursements.

Recently, in a Medicare webinar hosted by the National Rural Health Association (NRHA), nThrive Senior Director, Value-based Reimbursements and MACRA expert Moshe Starkman teamed up with nThrive Chief Medical Officer and value-based care expert Dr. Carl Couch, MD, MMM, FAAFP, to discuss “Value-Based Care in Rural America.”  Starkman explained the history, intent and expectations of the health care law as it relates to rural health. Dr. Couch expanded the conversation with keen insight into the implications of value-based care services and for health care providers and patients while sharing some of his extensive, successful experiences in implementing value-based care to new markets.

How MACRA came to be

What is MACRA? Kicking off the webinar, Starkman discussed the origins of Medicare as a precursor to MACRA. He reviewed the history of the Medicare program – how it was implemented and why it was implemented the way it was. He then demonstrated how these factors led to substantial increases in Medicare spending and how the current program is plagued by inflationary spending models and no longer viable by any long-term projection.

“Today, the government cannot afford Medicare,” Starkman emphasized. “Poor planning and program design have created a very expensive, untenable U.S. health care reimbursement model. MACRA is an attempt to move away from fee-for-volume towards fee-for-value payments, with the rationale to better manage costs and promote quality improvements that support evolving Medicare Part B reimbursement models.”

“All health care organizations should know that the shift to MACRA fundamentally effects the way health care is measured, paid for and rendered to patients, forever changing the relationship between government and the clinicians caring for Medicare beneficiaries,” Dr. Couch added. Efforts of both hospitals and physician practice operations to deepen their competency in both quality (improved outcomes) and cost of effective care (especially avoidance of waste) were discussed.

Barriers to MACRA implementation

A key component to success under the MACRA QPP is technology that enables health organizations to secure and share data between health care providers, payors and patients. In rural areas where EHR integration and adoption is lower than in urban markets and high-speed internet connections are less available, Starkman noted that raising technology standards poses a formidable challenge to small medical practices and should be recognized as a significant barrier to success when it comes to value-based health care in a rural environment.

“Rural health markets are slower to adopt and implement comprehensive but expensive IT solutions,” he explained. “The Centers for Medicare and Medicaid Services (CMS) acknowledges this and has given more leeway to small and rural practices to reduce the competitive edge gap between large and small practices. But this doesn’t improve the cost of care! The exceptions, exemptions and bonus points merely mask the inherent challenges that are unique to small practices and rural markets.”

For example, all things being equal, meaning if you take out the small practice exemptions, almost 90 percent of solo medical practices would not meet the requirements of the MACRA QPP’s Merit-Based Incentive System (MIPS) track, which is the easier of the two choices (Advanced Payment Models or APMs being the other). Exemptions and bonus points make those physician practices that need to compete slightly more competitive, but it does little to improve the actual capabilities of the disadvantaged.

“The message to rural providers is this: even if you bill at $90,000 or less per year or see 200 or fewer Medicare Part B patients, you will still be impacted by the changes in thinking that MACRA introduced,” Starkman explained.  “Eligible clinicians (ECs) or entities will see a maximum negative payment adjustment for non-participation, that’s true. But even if you’re not eligible this year, it is prudent to study the fundamentals of value-based reimbursements, shared risk, bundled payments and risk-based contracting, etc., to be prepared for when small market exemptions are no longer applied.”

To mitigate the financial risk, he encouraged even ineligible clinicians to opt-in to participate, even at the most basic requirements. “If you submit data for even just one of the four MIPS categories, eligible clinicians can avoid a downward payment adjustment and ineligible clinicians can gain valuable experience with quality reporting. Going a step further and exceeding the minimum threshold will earn a positive payment adjustment that will offset costs associated with moving towards value.” Starkman further added that “those who submit a full dataset and score above the exceptional performance threshold can earn additional bonuses above the year’s positive adjustment levels.”

Delivering better care for patients

Dr. Couch emphasized that the motivation to comply with MACRA goes well beyond the financial benefit – or penalty. “MACRA is all about moving toward a population health model, which is about delivering better care for patients. Unfortunately, under today’s fee-for-service model, health care organizations don’t get paid for much of the pre- and post-episode care that is so extremely important in a population health model. It is critical to support the full care continuum to attain value.”

Instrumental in leading Baylor Scott & White Health’s Accountable Care Organization (ACO) on its population health journey, Dr. Couch noted that the medical service organization improved quality while keeping costs flat over five years and achieving $65M in savings.

To achieve similar results, he stressed “ownership and the ability to clinically integrate are important. Effective communication and the ability to share data through electronic health records and other methods is fundamental to comprehensive care.” He added, “I’ll end with this, it is important to remember that it’s not just about numbers. We need to recognize success and highlight exemplary doctors who achieve good clinical quality. The physician industry as a whole is under stress and it’s important that we recognize success and promote value-based care organizational alignment.”

To learn more about how MACRA quality measures will impact health care providers in a rural environment, access the free medical webinar recording of “Value-Based Care in Rural America.” To achieve the highest results, learn how we can help your health care organization meet MACRA quality measure requirement in 2018 through our nThrive CMS-certified registry.