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How Payers Could Adjust to MACRA Regulations, Value-Based Care

Private payers could benefit providers by implementing more value-based care payment models and aligning with MACRA regulations.

By Vera Gruessner

MACRA regulations may seem overly complex and lengthy for the average medical practice but there are steps that providers can follow to succeed under MACRA’s quality payment program. Providers can work with payers to better identify similar quality measures that align with MACRA regulations and slowly begin meeting the requirements of the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs).

Value-Based Care Reimbursement

Providers will also need to advance their population health management programs in order to reach MACRA requirements, which health payers can assist with through better claims data sharing and sending their members reminders about health screenings. Danielle Lloyd, MPH, Vice President of Policy & Advocacy and the Deputy Director DC Office at Premier Inc., told how MACRA regulations are likely to bring commercial payers to adopt alternative payment models as well.

“Over the years, you can always rely just on Medicare to have the path to get the 5 percent bonus, but in all likelihood, many providers can’t reach the revenue threshold to get the 5 percent bonus,” Lloyd said. “In other years, in all likelihood, they will need support from the private payers. The whole implication is that the available models will also increase on the private payer side. There’s some availability at this point, but we’re hoping that there will be more options available on the private payer side.”

Aisha Pittman, MPH, Director of Quality Policy & Analysis, Premier Inc., discussed some of the steps that commercial payers have taken to align with MACRA regulations such as building value-based care contracts and configuring their payment systems with MIPS. Healthcare providers have also faced a wide variety of challenges in implementing new payment models and now adhering to MACRA regulations, said Danielle Lloyd.

“There’s now something called the quality payment program and that’s what the new program emits advanced APMs,” Lloyd explained. “In terms of challenges, the first and foremost is that this is a 2,400-page regulation and it is a lot to absorb and understand and figure out how it relates to a clinician’s practice.”

READ MORE: Payers Benefit from Aligning with MIPS, Value-Based Care

“The first step is really just understanding the rule and its implication,” she continued. “The second thing is that data access is really paramount and can be challenging for the providers and certainly to the extent that providers are able to utilize data, they’re going to be better off because they will have a better understanding of where their opportunities are to improve quality and efficiency.”

Providers will also need to address some of the complexities of advanced alternative payment models especially whether or not it will be the correct path for them to follow. It may be difficult “to determine the right strategic move,” Lloyd said.

The Premier experts predict that the tide of value-based care payment models will increase among health payers and providers over the coming years partially due to the push for alternative payment models by the Centers for Medicare & Medicaid Services (CMS). Lloyd has specifically seen payers and providers partnering through accountable care organizations, which are based on a shared savings payment model.

When asked how payers and providers are advancing value-based care reimbursement, Lloyd responded, “We have a very large accountable care organization participation and many of those that are participating with private payers in ACO-like arrangements had hoped for more opportunities. There are opportunities with payers already but we do believe that opportunities would pick up the pace.”

Lloyd said that within their membership, many are collaborating with accountable care organizations through private payer contracts. The final advice offered regarding MACRA regulations and the quality payment program delves into how health payers will need to make more alternative payment models available for their provider network.

READ MORE: Why Value-Based Care Reimbursement, MACRA are Here to Stay

“The main issue is to make more models available to providers since many are eager to enter these type of programs and are looking for partnerships with payers,” Lloyd concluded.

In a previous interview, Beckie Croes, Senior Vice President of Provider Engagement at Care Allies, told how providers that have had experience working within the value-based care arena will be more likely to succeed with MACRA legislation.

“Providers that have already embraced value-based reimbursement models through commercial or Medicare Advantage insurance are a step ahead in this whole process. They determined these models are necessary and a growing component of their revenue stream and, more importantly, they’ve already committed resources to help them internally to ensure success in value-based care,” Croes said.

“Those folks are going to find the transition relatively simple. They’ve already developed systems around how you work in those populations and they won’t be as traumatized by the impact of MACRA regulations,” Croes pointed out. “For providers that have not been working in a value-based care reimbursement arrangement and resisted entering into those arrangements with payers, they really need to pick up a strategy fairly quickly.”


READ MORE: Quality Metrics Pose Problems for Value-Based Care Reimbursement

Dig Deeper:

How Payers Should Prepare for Value-Based Reimbursement

How Medicare, Medicaid, and CHIP Guide the Health Payer Industry


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