The Centers for Medicare and Medicaid Services rolled out a value-based care incentive program in late 2016 and has plans to improve these models continuously. Eligible providers have been expected to supply CMS with specific reporting data. As the first stage of this plan comes to a successful conclusion, the industry prepares for more movement toward a truly value-based system.


MIPS participation is high, but some doctors face penalties

The merit-based incentive payment system (MIPS) has been operational since September 2016. Throughout the following year, providers with a significant number of Medicare patients were encouraged to submit reporting data to CMS. On May 31, 2018, CMS administrator Seema Verma reported that 91 percent of all eligible clinicians participated in the first year of the Quality Payment Program, which includes MIPS as well as alternative payment models (APMs). Furthermore, 98 percent of eligible accountable care organizations (ACOs) and 94 percent of rural practices submitted reporting data.

While these numbers are positive, they are only the beginning of a much larger process. In 2017, providers only needed to submit 90 days of reporting data to CMS. This year, providers will be expected to submit a full year of data. Providers that submitted data last year should have a better handle on processes, or at least understand what kind of technology will help them meet their reporting goals in 2018.

It’s also important to note that the number of providers eligible to participate in MIPS is significantly lower than the overall number of providers operating in the U.S. According to the Department of Health and Human Services, an estimated 39 percent of providers are eligible to participate in MIPS. Other providers may be able to participate in APMs, or they could be eligible for a small-practice exemption.

The 9 percent of eligible providers that did not submit reporting data to CMS could face a penalty of up to 4 percent of their Medicare reimbursement.

Administrator Verma announced that CMS plans to remove additional regulatory burdens from clinicians, and reminded the medical community that this is only the first stage of a much larger movement toward more affordable health care.

Value-based incentive programs have already been shown to reduce hospital costs.Value-based incentive programs have already been shown to reduce hospital costs.

Payers implement new value-based reimbursement options

As CMS shifts to a value-based care model, payers are looking for ways to implement their own value-based incentive programs. Some payers have already rolled out programs, while others are still testing the waters. According to a recent survey of 120 payers, early versions of value-based models have already created savings. The survey revealed that 37 percent of payers reached savings between 5 and 7.5 percent.

Additional roll-outs will take time, however. The survey found that 21 percent of payers require three to six months to initialize a value-based incentive program. Meanwhile, 34 percent said it would take between six and 12 months to launch a program. One of the bigger roadblocks to a quick rollout is a lack of analytics capabilities. More than half of the survey respondents revealed they are not satisfied with their analytics tools. Without clear insight into clinical and cost variations, payers will have a difficult time measuring the success of their new incentive programs.

Value-based care requires strategic implementation

Healthcare costs are rising, and payers looking for a solution are turning to value-based incentives to control those costs.  Consequently payers are developing performance-related incentives in an attempt to eventually lower costs.  As payers develop their own programs, they will need to identify groups with the highest risk of future cost increases, then work to develop measures to help those groups improve performance. Analytics are at the heart of this challenge. Organizations with access to robust analytics reports can utilize integrated technology to enact change in a managed and efficient manner.

Scaling value-based networks is a challenge

Once a valued-based incentive program has been established, getting it to scale is the next step. Rolling out to multiple small providers will likely cost payers resources — though the exact level of support will depend on each provider’s unique mix of technology. Providers with advanced electronic health record systems may already have much of the underlying technology necessary to implement a new reporting mechanism.

ACOs may represent an easier way forward. Because ACOs already have networks established, and many are already participating in MIPS, they likely have a head start on the process. However, that does not preclude independent physician practices from participating in incentive programs. Though they may not be up to full speed, with the right tools and technology partner, they can get to where they want to be.  In any event, payers should work with these groups to determine where the system can be improved and how best to make progress. Rolling out these incentive programs at scale will be an ongoing challenge, but with the right technology the challenge is not insurmountable.

Advanced analytics will smooth the transition to value-based care

There’s no guarantee that every incentive program will feature the same requirements. MIPS, for example, allows providers to choose which kinds of data they report to CMS. To achieve optimal reimbursements, care organizations will need analytics solutions that allow them to collect and utilize reporting data. Interoperability is key, because every program will have unique requirements. A flexible, responsive analytics solution will smooth the transition to managed, value-based care.

As CMS continues to roll out MIPS to more providers and payers develop their own incentive programs, care organizations will have a greater need for robust analytics. To learn more about how tailored technology can benefit your organization, check out our resources.

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