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MACRA Continues to Catalyze Movement Towards Value
January 17, 2018

MACRA Continues to Catalyze Movement Towards Value

Founded in 1998, The Health Management Academy is a peer-to-peer learning and leadership development organization comprised of executive members from the country's largest integrated health systems and a strategic balance of the industry's most innovative companies. The Academy is a knowledge source for identifying and monitoring tactical and strategic issues, with educational programming that assesses the top priorities of its members, monitors the organization and development of large health system executive teams, and facilitates structured interaction among its health system members. Peer-focused, problem-solving based programs—where the latest Academy research, policy analysis and expert views on the issues driving healthcare are analyzed and discussed—create the foundation for developing the leadership strategies and skills needed to strategically guide critical health system decisions.
The multiplicity and overlap of programs under the QPP demand changes to internal governance and leadership.

As the QPP is structured, large health systems often participate in multiple APMs and other value-based programs simultaneously. Many systems have some groups of clinicians reporting under MIPS and others as Advanced APMs. Even amongst those reporting as APMs, systems are often managing multiple risk contracts, such as Medicare and commercial accountable care organizations (ACOs). As systems increasingly realize the overlap and redundancies in reporting requirements, they have been forced to develop more robust governance structures to manage and cohere their approach to these programs. Many systems continue to question how the scope of their markets—spanning many Taxpayer Identification Numbers (TINs)—will impact their ability to implement and strategize for MIPS and APM participation. Finding ways to manage TINs, clinically integrated networks, and other referral networks under the QPP framework remains an area of priority.

The reconciliation of these separate entities has motivated broader engagement in payment reform in which QPP implementation has taken a back seat to the larger transformation of the system’s governance structure. The result can be characterized as the establishment of a “Value-Based Care Enterprise Governance Model.” In this model, health systems are streamlining individual program committees to establish joint multidisciplinary teams responsible for coordinating all of the enterprise’s value programs (eg, ACOs, medical homes). This systematic approach allows the system to coordinate assets and extend the capacity and capability of its clinicians to use resources in ways congruent with the overarching goals of value incentives. The question then becomes, who within the health system owns MACRA, or broader value-based payment, implementation? According to the handful of systems with a reoriented governance model, the head of finance is instrumental in leading the entity’s value-based care teams. While the broadening of Finance’s responsibilities to encompass clinical care delivery and information technology is a cultural shift, a coordinated enterprise makes health systems more effective in their ability to strategize across payment models and streamline data reporting to maximize revenue potential and care quality.


By and large, health systems see a compelling business case for acting now, rather than later, when the market has more discernably shifted towards value-based care. Systems see programs such as the QPP as an opportunity to build alignment with physicians around the goals of value-based care. Many health system leaders see the QPP as an opportunity to facilitate “value processes” and handle the technical pieces like reporting for clinicians, limiting burnout and improving alignment. Health system leaders recognize that merely participating in a risk contract does not ensure improved care delivery. It is their responsibility as the organizing system to implement the necessary innovations and care practices to achieve the value demanded by the contract.

While the internal impetus on the part of the health system may exist, providers are still seeking external support from payers, both public and private. Despite such a strong ideological commitment to value-based care, health systems are still limited in their capacity to achieve its goals. As long as fee-for-service constitutes the majority of healthcare payments, health system progress in reducing costs and improving quality will continue to be hindered. Health systems need CMS to continue putting forth a variety of contracts and payment models, ranging from nominal risk to full capitation, to provide them with the incentive to make investments in care delivery innovation. Offering a range of options will give providers the flexibility to start small and gain experience with managing risk. In this regard, Comprehensive Primary Care Plus, bundled payments, and the MSSP Track 1 option are good starter programs to set health systems up for success in increased risk-bearing models. Thus, the health systems should continue building up their risk appetite via participation in starter APMs. The more health systems can demonstrate proof of concept in the delivery efficient care, the more continued and expanded support providers are likely to receive from CMS for value-based initiatives.

MACRA is a forceful catalyst pushing providers to transition from volume to value. While many large health systems have begun transitioning internally, they still depend on external support from value-based incentives and programs facilitated by payers such as Medicare and Medicaid. Payment transformation will only be successful if CMS can set the pace by creating broad, directional fiscal and quality targets that allow providers the flexibility to innovate. Ongoing APM development is instrumental to this approach, as providers need a range of options to build up their experience with managing risk. To garner such support, health systems must continue to signal commitment to moving forward with implementing value-based care.

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