An ACO’s founding clinic realized that poor-scoring independent clinic members would reduce the founder’s MACRA reimbursement. The MACRA Program Manager introduced MACRA Monitor’s Concierge with all other ACO member organizations to ensure that 100% of ACO member clinics were properly registered into the QPP submission system, produced the appropriate reports from their EHR, met eligibility thresholds, and helped successfully attest. Along the way, the ACO and its member clinics documented principles to follow for upcoming reporting years.
MIPS has no regulatory impact on ACO Revenues. Since prudent businesses spend little or no effort or expense without supporting revenue, many ACOs leave MACRA/MIPS to member clinics as much as possible. Of course, prudent businesses also pay close attention to their customers.
Our client was a group with over 70 TINs and nearly 600 ECs reporting MIPS data. While the EHR was certified, its MIPS reporting was limited to providing individual level (no group) scores. Further, the EHR could not create the QRDA3 files necessary for electronic submission to CMS. We were only able to get PDF and CSV based reports.
Migrating away from fee-for-service into “outcomes-based” medicine is all the rage. CMS seeks to manage the cost of healthcare (interpretation: pay providers less) while providers envision the making more money through shared savings, capitation or lucrative quality adjustments. As CMS moves into Alternate Payment Models (APMs), commercial payers could follow suit, depending on their market power modified by perspectives of state-level Insurance Commissioners.
MACRA scoring for ACOs can get complicated by the independent nature of clinics participating in the ACO. When clinics are on separate EHR platforms, the ACO will need MACRA-Specific data analytical tools that calculate each separate MACRA Component (PI, CQM and CPIA). What principles simplify optimized results?
EHR or Registry software can create measures, or even do your annual submission. But improving scores with an explicit tie to financial outcomes requires an extra layer of analytical tools that your "core" vendors are not likely to build.
Entering into a risk-based model isn’t as simple as taking what the payer offers. There is a best balance answer for medical groups to maximize revenue while delivering efficient, high-quality care. Finding that balance and reaping measurable value from it requires changing the organization’s approach to Business and Clinical Processes, Skillsets, and Analytics in
order to be successful.
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