Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Value-Based Care News

Payers Benefit from Aligning with MIPS, Value-Based Care

CAPG's Mara McDermott discussed ways payers could assist providers in reaching value-based care goals and aligning with MACRA.

By Vera Gruessner

While healthcare regulations like MACRA legislation often centers around impacting medical providers, the health insurance industry is also integrated into the tapestry of value-based care and alternative payment models. When providers start adopting the requirements of the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs), healthcare payers would be wise to align their reimbursement structures alongside these quality metrics and value-based care payments.

MACRA Legislation

There are various steps that payers can take to better position themselves with MACRA legislation such as improving claims data exchange and sending their members yearly reminders in the mail about important health screenings.

Danielle Lloyd, MPH, Vice President of Policy & Advocacy and the Deputy Director DC Office at Premier Inc., spoke with earlier this month about the importance of commercial payers to assist providers in meeting MACRA legislation and aligning with alternative payment models.

“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,” Lloyd said.

It’s also important to note that many commercial payers have not kept up with public coverage programs aimed at advancing value-based care reimbursement. Whether it’s bundled payment models or risk-based shared-savings contracts, private payers have fallen behind some of the advances coming from the Centers for Medicare & Medicaid Services (CMS), said Dr. Farzad Mostashari, Founder of Aledade Inc. and former National Coordinator for Health IT, in a previous interview.

READ MORE: Communication Key for Transition to Alternative Payment Models

“I see some positive trends just in the past two years, but private payers, by and large, are still behind CMS in terms of making it easy for organizations to apply for and qualify for these models,” Mostashari told “Medicare has an application process that is complicated but predictable whereas with many private payers, the process itself is opaque and the outcome uncertain. I would strongly suggest that private payers institute more predictable processes and requirements as well as boilerplate contracts that are based off of CMS templates and a clear process for how organizations can apply for and get those risk, value-based contracts.”

Mara McDermott, Vice President of Federal Affairs at CAPG, spoke to about ways that private payers could help providers overcome the challenges of value-based care reimbursement and align with MACRA legislation.

“The single biggest challenge I see right now for providers adopting value-based care payment is uncertainty. Certainly, in light of the election on Tuesday, November 8, and the appointment of new cabinet officials, new government, and new administration, has created an uncertain environment that may cause some to consider whether they should should stay the course with value-based care or continue to move in that direction,” McDermott noted.

Health insurance companies can assist providers through streamlining quality measures, sharing data quickly, and listening more to their provider network, said McDermott.

“In terms of what payers can do, our members have certainly identified streamlining quality measures as a high-priority item. Many physician groups are reporting multiple sets of quality measures - one set for Medicare, one set for  every commercial contract, and one set for every Medicare Advantage arrangement,” McDermott continued. “Certainly, streamlining quality reporting requirements would be helpful. Payers can be supportive in other ways such as sharing data and information more quickly. Talking to the providers and really understanding the supports that they need on the ground is another way that payers can be helpful in the movement from volume to value.”

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

Education around MACRA legislation will need to be a major goal for providers in the coming months so that the healthcare industry can see greater success in improving care for Medicare beneficiaries and reducing medical spending.

“Right now, the biggest hurdle is education. For many in the physician community, MACRA is new and MACRA is unfamiliar. Once physicians familiarize themselves with MACRA, they will come to see that the requirements may be less intimidating in practice than they may sound in theory,” explained McDermott. “Education is a big one. In terms of the future, familiarizing yourself with the options is important. Do you want to stay in MIPS or do you want to look at those Advanced Alternative Payment Models? That’s a big thing coming at us.”

McDermott also pushed for greater alignment between commercial payers and the value-based care payment structures coming from CMS initiatives.

“We’re at a time right now where these efforts toward value-based care need to be better aligned and one of the problems that we see is everyone pushing in the direction of value but that value means different things to different people,” she explained. “One way for payers to support this transition is to try to better align efforts with what’s going on elsewhere in the delivery system. One of the things that CAPG has been very focused on is making sure that the incentives to move to risk and advanced alternative payment models are in line for both traditional Medicare and Medicare Advantage.”

When the different sides of the public Medicare program and the private plans behind Medicare Advantage are both incentivized to adopt value-based care and alternative payment models, the entire healthcare industry gets closer to focusing on value instead of volume in terms of reimbursement.

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

“Both the federal government on the Medicare side and the private plans on the MA side are rowing the boat in the same direction towards advanced alternative payment models. They are putting that infrastructure in place at the physician group level and allowing those physician groups to be successful in risk-based contracts across their entire Medicare population. To me, it’s all about that alignment of strategy across different the payer types. That is the best way for payers to support this effort - to pursue that alignment,” McDermott pointed out.

In the coming year, more providers are planning to meet the requirements of the Merit-based Incentive Payment System instead of the Advanced Alternative Payment Models.

What I see for 2017, the vast majority of physicians and clinicians will be in the Merit-based Incentive Payment System or MIPS,” she continued. “The reason for that is that the available Advanced Alternative Payment Model options are pretty narrow and there was a bit of a timing issue when physicians were unknowingly making the choice between the two. We had a pretty compressed time frame for the first year of MACRA in terms of choosing Advanced Alternative Payment Models. What we see in terms of trends though or what we expect to see are more clinicians moving into Advanced Alternative Payment Models in the later years of MACRA.”

As such, payers would be wise to learn more about the particulars of the Merit-based Incentive Payment System to align their payment contracts and quality reporting around this platform.


Dig Deeper:

How Payers Should Prepare for Value-Based Reimbursement

How to Overcome the Challenges of Bundled Payment Models


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