Healthcare

Many physicians are subject to participation in the new Merit-Based Incentive Payment System (MIPS) through CMS’s ongoing payment model reform initiatives encouraging providers to deliver better healthcare at lower costs.

CMS is just the tip of the spear. Commercial payers are developing their own pay-for-performance contracts as they slowly transition away from fee-for-service reimbursement. Yet many independent practice physicians and even employed physicians lack a strong strategy to participate in a healthcare environment where the Triple Aim is the ultimate mission.

For the 1^st time ever, HIMSS (the annual meeting place for all things health IT) and ACLC (Accountable Care Learning Collaborative) held a joint conference, in Orlando, Florida.  Suffice it to say it was a HUGE (no pun intended, Mr. President) event with over 40,000 (yes, 40K) attendees and 1,200+ exhibiting companies. 

The main topic—transforming healthcare. 

The most astute executives in health systems are rightfully concerned about compliance risks in physician contracting. Among these risks are that a transaction or an arrangement between a hospital and a physician are consistent with fair market value (FMV) and are commercially reasonable (CR) as those terms are defined in the healthcare regulatory context.

Participation in value-based programs is on the rise. Growth of ACOs is up 11%, and CMS estimates that 30% of Medicare payments are currently flowing through alternative payment models (APM). This milestone was reached 11 months ahead of schedule according to the Department of Health and Human Services (HHS), which expects Medicare payments flowing through APMs to reach 50% by the end of 2018.

Welcome to MACRA—the Medicare Access and CHIP Reauthorization Act. MACRA represents the end of a long history of perpetually delayed Medicare physician fee schedule cuts that were to be automatically triggered under the punitive SGR formula absent Congress’ annual postponement ritual. After providing for a series of annual physician payment increases, MACRA’s reimbursement methodology transitions to a value-based model that includes two pathways—the Alternative Payment Model (“APM”) and the Merit-Based Incentive Payment System (“MIPS”).

Rural hospitals have some tough decisions to make about their level of participation in the new CMS Quality Payment Program created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). 

For a number of reasons, the MACRA cards are stacked against small and rural providers. Given the limited number of Advanced Alternative Payment Models (APMs) that are being approved, many providers will start out in the Merit-Based Incentive Payment System (MIPS), and that track offers limited upside potential compared with APMs.

During AHLA’s Physicians and Hospitals Law Institute this week, we saw three recurring themes as sessions focused on issues affecting the industry.

We’re gearing up for what’s in store in the healthcare arena in 2017 by attending HFMA’s Mid-South Institute. Attendees from Missouri, Arkansas, Mississippi, and Tennessee have gathered to learn of updates in healthcare and how to embrace for the year ahead. Here are a couple of themes that were reinforced during the conference:

It is important to recognize that the road to long-term success does not end with the implementation of the Merit-based Incentive Payment System (MIPS). In CMS’ own words, MACRA’s final rule was established, in part, to incentivize and promote participation in Advanced Alternative Payment Models (APMs). These incentives include a 5% participation bonus from 2019 to 2024 and a 0.5% annual increase above the MIPS track beginning in 2026.

Like it or not, MACRA is here. MACRA created the new Quality Payment Program (QPP), comprised of two pathways to higher quality: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs). MACRA changed the rules, leaving many to face an uncertain future. Amid the uncertainty, however, one thing is sure: passivity will be costly. Indecision will not prevent or delay physician’s placement into the quality and efficiency compensation measurements of MIPS.

January 20 is a significant date for healthcare providers—but not necessarily for the reason you think.

Yes, there is the inauguration of the 45^th President of the United States, who has vowed to “repeal and replace” the most significant healthcare legislation in recent history.

But that date has even greater significance for the many providers across the country who are struggling to cover the cost of care of an increasingly high-risk, low-income population.

Last week, I had the privilege of attending the Health Care Advisory Board’s National Meeting in St. Louis, Missouri. One of the topics that really struck me was the last presentation about the importance of building a consumer-focused organization and increasing consumer loyalty.

We described in the previous installment in this series how recent case law and DOJ settlements provide clear evidence of the position of qui tam relators, prosecutors, and government experts that losses on hospital operation of physician practices are being targeted. Because evidence suggests that hospital losses on physician practices are common in many markets, the questions on everyone’s mind are whether health system losses on physician practices put the organization and key individuals at significant fraud and abuse compliance risk, to what degree can existing physician practice losses be justified through documentation, whether the health system has a functional Fair Market Value (FMV) and Commercial Reasonableness (CR) enterprise risk management process, and—the subject of this series--is a plan at the ready to begin mitigating practice losses?