Healthcare providers weigh accountable care vs. Merit-Based Incentive Payment System

Providers must be among the top performers to receive benefits, but many still struggle to meet and report quality requirements.

Many providers are at a crossroads right now: Either join an accountable care organization or be placed into Medicare’s Merit-Based Incentive Payment System. Set to begin in 2017, MIPS uses value-based modifiers to rank providers by quality and is expected to fold together with meaningful use, essentially merging the current pay-for-performance models under one umbrella.

MIPS is part of the Medicare Access & CHIP Reauthorization Act of 2015, or MACRA, which repeals CMS’ Medicare Part B Sustainable Growth Rate reimbursement formula and replaces it with a pay-for-performance model. Providers can choose to join an ACO or be part of MIPS.

“People are waiting with bated breath for MIPS rules, just like they were for meaningful use,” said Tom Lee, CEO and founder of SA Ignite, which develops analytics tools to help providers keep track of complex government programs. “The biggest thing on the horizon is there are a lot of details on this that will come to light when the rules come out.”

“MIPS has higher bonuses, but higher risks,” Lee said.”Providers don’t need to choose a physician group to be a part of the program, but those providers who don’t remain on top of the heap lose money.”

The rules are due to be finalized by November. Although Acting CMS Administrator Andy Slavitt has hinted draft rules may come out as soon as this spring.

When choosing a program, providers must assess the risk and whether they want the guaranteed 5 percent from ACOs or choose the Merit-Based Incentive Payment System where the value-based swing between the lowest and highest reimbursement could be up to 36 percent when accounting for bonuses.

“ACOs are unproven, and most have been penalized; weigh that against costs to get the ACO up-and-running,” Lee said.

The trouble is that many providers are struggling with a lack of resources, which makes it difficult to “poll through the information to meet these requirements,” said Darren Barnes, director of quality and performance improvement, Southern Illinois University HealthCare.

“In today’s world of quality improvement, you not only have to provide quality care, but prove you can deliver,” said Barnes.

Many ambulatory providers in particular are having difficulty transitioning into a quality management system, as “hospital measures are better defined than with multi-specialty ambulatory care organizations,” Barnes said. “With data requirements and support, healthcare organizations are being asked to do more with less.”

Hospitals have a leg up on quality measure improvements, compared with physician practices. Where hospitals can assess workflows and certain measures on a daily basis, that’s more challenging for small ambulatory facilities, posing a special challenge for participating in a physician reimbursement program.

Moreover, data is hard to pull from the EHRs, said Barnes, and providers will continue to struggle “until we can build these systems to look at patient needs and improve the ability for patients to have access to the data for more personalized care.”

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