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How MACRA is Changing Advanced Illness Care

An important piece of legislation for advanced illness care went into effect this year. The Medicare and Children’s Health Insurance Program (CHIP) Reauthorization Act of 2015 (MACRA) repealed the previous Sustainable Growth Rate, which was a problematic way payments to Medicare providers were to be adjusted annually. MACRA changed all that and began to tie payment to value.

The shift to value-based payment will promote improved care for people with advanced illness, since it will reward providers for delivering better care while reducing costs. Such care was never fully reimbursable or sustainable under the previous fee-for-service (FFS) system because providers got paid for delivering more, not necessarily better, care.

Providers have two payment options under MACRA:

Merit-based Incentive Payment system (MIPS)– This is an adjuster on top of the current fee-for-service system to reward (or penalize) providers on their performance in patient outcomes, electronic health record/IT systems, clinical quality improvements, and cost control.

This will be a significant administrative change for providers and there are intermediate and phase-in options to help facilitate that change.

Obviously, providers will now be looking for ways to improve patient outcomes and control cost as together they are the largest factors affecting payment. Evidence shows that advanced illness care can do that by improving the quality of life for those with advanced illness while lowering costs through reduced ER visits and hospitalizations.

Advanced Alternate Payment Models (APMs)- The goal here is to promote clinical transformation via new validated clinical delivery models. Providers participating in such models will not report on MIPS criteria, but will get an incentive to implement new models and corresponding payment systems. They will, however, be responsible for some risk, and so will need to have systems in place to manage that risk.

For 2017, six APMs have been deemed “Advanced” by CMS. Beyond these, new models will be identified by the new Physician-Focused Payment Model Technical Advisory Committee (PTAC) at the U.S. Department of Health and Human Services (HHS). This committee evaluates applications for new payment models through a transparent and public process and provides a recommendation for the Secretary of HHS. All submitted proposals and committee work are available on the PTAC website.

APMs could promote integration of advanced illness care by more fully reimbursing for services like advance care planning, care coordination and support of the patient and the family. In fact, the new payment models will finally be a way to pay for the full range of medical and social supports for this type of care along with all the key members of the interdisciplinary teams delivering them.

C-TAC developed its Advanced Care Model, an APM, by working with payment experts over the last year. This was submitted to HHS in February 2017. If approved, it could begin testing and, if successful, become a national payment option.

A review of the MIPS process suggests it will be complicated for providers and there is the sense that over time this will make them shift to APMs if they can handle the risk aspects. Therefore, having an approved advanced illness model by PTAC will allow those providing care to this population a more accessible option.

C-TAC members interested in this work can be involved in several ways. First, they can track the PTAC proposal’s process via C-TAC’s Member Alerts. They can also submit a letter of support for C-TAC’s APM proposal. We encourage supporters to contact Khue Nguyen (KhueN@TheCTAC.org) regarding C-TAC’s model work. If members are healthcare organizations, they can look for ways to incorporate advanced illness care into their clinical programs to boost their MIPS payments.

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