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by implementing our system.



MACRA – Medicare Access and CHIP Reauthorization Act

  • Repeals the Sustainable Growth Rate formula (SGR)

  • Changes the way Medicare rewards Clinicians for Value over Volume

  • Streamlines multiple quality programs under the new Merit Based Incentive Payment System (MIPS)

  • Provides bonus incentives for partnering in eligible Alternative Payment Models (APM)


MIPS – Merit Based Incentive Payment Systems

Aggregate set of guidelines and reporting programs that will drive reimbursement bonus and penalties beginning in 2019.

There are currently multiple individual quality and value programs for Medicare practitioners, including:

  • Physician Quality Reporting Program

  • Value-Based Payment Modifier

  • Medicare EHR Incentive Program


MACRA streamlines (funnels) all of those programs into MIPS.


Based on MIPS Composite Performance Score, provider can receive adjustments up to the percentages below.

  • 2019: +/- 4%

  • 2020: +/- 5%

  • 2021: +/- 7%

  • 2022: +/- 9%


Which one will your hospital be – pay or receive?

Keep in mind that these adjustments are budget neutral. So if 80% of providers don’t meet the performance score thresholds (aka are penalized), the 20% of the well performing providers share all penalties fees. Historically 80-90% of providers miss the mark on the first two years, meaning that the 10-20% who DO meet the mark can get as much as a 25% revenue boost.


There are 4 performance categories:

  • Quality Measures (aka PQRS)

  • Resource Use (aka cost savings – very similar to Value Based Modifier program)

  • Clinical Improvement Activities (will comment later)

  • Meaningful Use of Certified EHR Technology

Of these 4 performance categories, we effectively completes all but meaningful use. We gather enough data for PQRS, not to mention produce phenomenal scores. Our ability to get out in front of problems before they become problematic, turning ED and hospitalization into E/M visits, has a tremendous downward impact on resource use (aka cost savings).

Clinical improvement activities are initiatives to improve the value of care that are unorthodox by traditional practice measures. CMS put together a list of 90 options for healthcare organizations, and they are assigned a high/medium/low score for how much weight the activity carries in the overall score. Some examples of clinical improvement activities are:

  • Expanded practice access – High

  • Population Management – longitudinal care management – Medium

  • Population Management – episodic care management – Medium

  • Care Coordination – Medium

  • Beneficiary Engagement – regular coaching calls – Medium

  • Beneficiary Engagement – remote monitoring – Medium


We do all of these for the practice!


Last but not least, it is very important to note that the reimbursement adjustments don’t come into affect until 2019, but the adjustments are based on 2017 performance.


Now that we have a baseline understanding!

Healthcare organizations aren’t designed to be proactive. From the onset it has been the responsibility and discretion of the patient to determine if/when they need to see a doctor. Lack of medical knowledge, human nature, and any number of factors can be pointed to as why this is fundamentally flawed. However, that’s the result of FFS payment programs.

A year ago “Value Based Care” was still an idea that no C-Suite exec. or independent practice provider really acknowledged as real. If you wanted to take a crack at VBC, you could join an ACO.

However with the recent introduction of MACRA and MIPS, the VBC transition is imminent and coming very, very fast.

The way medical organizations are structured, they would have to turn themselves inside out to transition from reactive medicine to proactive medicine. How do you go from being dependent upon patients to decide if/when to see a provider to remotely monitoring patients, and keeping a constant pulse on their health. Patients haven’t stopped coming to the doctor’s office just to give providers time to figure this out, and provider’s time is one of the scarcest resources in the US today.

To make this happen, hospitals would have to effectively create from the ground up a technology company, a call center, and a staffing company all married together for one coordinated purpose.

Hospitals are in the business of providing care. Not in the business of tech, call centers, and staffing solutions.

So the question becomes – how to you completely reverse your model of providing care when your existing model already has you working around the clock?


This is where we come into play.

By bolting our program onto a hospital (insert any type of healthcare organization) EMR, and letting us get to work, we will effectively transition hospitals to proactive care within a matter of months.


Here’s how we do it.

The initial step is conducting a health risk assessment such as an AWV. All healthcare organizations claim to be doing AWVs, but there is a reason never more than 15% of the Medicare population has received an AWV in any given year – there is no excess time.

We will place our own staff onsite, and schedule patients to come in to complete a HRA. This is a huge revenue driver for the hospital, but most importantly, this will establish a baseline health from which the chronic care management team can work. The HRA will identify patients as eligible for CCM, and enroll them right then and there.

The beauty of the HRA is that not only does it identify what the patient already has; it identifies what conditions the patient is at risk for, but has not been diagnosed. These pre-conditions (i.e. pre-diabetes, pre-hypertensive, etc.) become the first order of business for our care managers. From the onset, they and the patient make it their goal to never become diabetic, hypertensive, etc. They make a plan of how they are going to do that. Ensure the patient gets all appropriate screenings, and follows through on any appointments identified as necessary by the HRA and PCP.


Next up, there is the power of our CCM solution. There are two primary objectives our Care Managers have, and do extraordinarily well:

  • Get patients actively involved in managing their own health

  • Identify problems before they become problematic


By keeping constant tabs on the patients, our MAs Care Managers are able to prioritize providers time. They do this by keeping people who may or may not have stubbed their toe out of the office, and by bringing those in who have a “wait and see what happens” mentality for something as alarming as blood in their urine.  Effectively we run a monitoring and screening service to ensure we stay ahead of problems, and get the patient in at the first sight of an issue.