The Michigan Value Collaborative

Helping Michigan hospitals achieve their best possible patient outcomes at the lowest reasonable cost

Unpacking Medicare’s MACRA Resource Use measure

Paige VonAchen

Paige is a MVC Research Intern and MD/PhD candidate at the University of Michigan Medical School

The Medicare Access and CHIP Reauthorization ACT (MACRA) Merit-based Incentive Payment System (MIPS) will begin payment adjustments beginning 2019, resulting in approximately $199 million in payment adjustments and $500 million in additional bonuses across physicians nationally each year. The program scores physicians based on their performance in four areas: quality, improvement activities, advancing care information and resource use. While the Resource Use category comprises 0% of the overall weighting in 2019 (based on performance year 2017), the weighting will rise to 10% in 2020 (based on performance year 2018), and then to 30% beginning 2021. Therefore, understanding how the new measure is determined and adapting accordingly will be critical to providers’ success under the new payment system.

So, what does Resource Use really mean? And how is it calculated?

First, let’s establish who is not being scored…clinicians participating in the Advanced Alternative Payment Models (AAPM) and clinicians that are non-patient-facing (e.g., pathologists and radiologists) will also not be scored (instead, the weights of the other categories will increase).

For those that are being scored, it’s important to know the three measures that comprise the Resource Use category:

  • Total per capita costs: this measure represents the total yearly costs (for Parts A and B) for all patients assigned to a physician, divided by the total number of patients assigned to that physician. Patients are attributed to the physician or physician group that delivers the plurality of “primary care services” (under Part B) to the beneficiary as compared to any other practice, and includes admissions due to COPD, CHF, CAD, and Diabetes Mellitus.
  • Medicare Spend per Beneficiary (MSPB): this is a measure of combined Part A and B spend incurred around a hospitalization beginning 3 days prior to admission through 30 days post-discharge. MSPB is attributed to the provider submitting the majority of Part B claims during the index hospitalization. The total cost of care for such an episode is attributed to the physician or physician group that spends the most time with the patient during the initial admission.
  • Condition- and Episode-Based Measures: this measure looks at episodes of care triggered by a specific diagnosis of procedure. Many episodes are surgical (e.g., hip or knee replacement); however, there are medical as well (e.g., CHF, and COPD exacerbation). Any physician that provides over 30% of inpatient E&M codes during the index event (inpatient stay) will have the Part A & B costs of that episode attributed to them. This is currently reported in today’s Quality and Resource Use Report (QRUR); however, now it impacts reimbursement. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/2016-QRUR.html

Needless to say, the Resource Use category of MACRA is complex and the implications for individual physicians depend on their type of practice and compilation of patients. Understanding and monitoring the payment and utilization of your own services will help you identify the most efficient services and allow you to adapt to MACRA’s new payment system.

Read more about MACRA at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Resource-Use-Performance-Category-slide-deck.pdf

 

Addressing social determinants through integrated care

Deby Evans

Deb Evans is the MVC Site Engagement Manager

Despite being one of the world leaders in medical care and research, the United States (U.S.) spends the most amount of money on healthcare, yet better patient outcomes are subject to debate. Not only do physical ailments and mental health disorders affect the health of the population, but social determinants, such as environmental factors, education and transportation availability, also play a prominent role in determining health outcomes. The U.S. healthcare system has typically focused on providing care for physical conditions and diagnoses, yet many patients may have a secondary behavioral health condition. In addition, all patients have their own specific set of social determinants that should be taken into consideration when providing healthcare. These factors ultimately impact behaviors and health outcomes of individuals.

A white paper published by Deloitte Consulting discusses the implications of social determinants on patient outcomes and healthcare costs. It encourages us to seek out and investigate methods to provide more integrated patient care within hospital systems and the U.S. healthcare system as a whole.

Addressing social determinants is a challenge for healthcare providers but a necessary one to help improve patient outcomes along with the added benefit of reducing costs. Some of the ways hospitals can respond to this challenge is by implementing coordinated care, care management or integrated care programs. However, despite varying existing program models, each type brings its own barriers with accessibility, communication and information management being the most complex. By working through these barriers and integrating care for patients, hospitals have the potential to not only affect patient outcomes but also reap the benefits of controlling costs. Rush University Medical Center, for example, is using a tool in their emergency department that allows them to screen for social and structural determinants of health. When used in conjunction with a recently instituted community health needs assessment and the community health implementation plan, this method helps address healthcare disparities in the local neighborhoods and brings positive changes to their patient outcomes.

For more information on the Deloitte paper: https://www2.deloitte.com/us/en/pages/life-sciences-and-health-care/articles/social-determinants-and-collaborative-health-care-for-plans-and-states.html

For more information on Rush University Medical Center: http://www.hhnmag.com/articles/8441-rush-university-medical-center-targets-community-health-disparities or https://www.rush.edu/sites/default/files/community-health-implementation-plan.pdf

 

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