Think of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) as a 1,500-piece jigsaw puzzle, or a pathway to success in tying payments to value. Every piece of the puzzle is integral to strategic planning and sustainable mapping, but until the pieces are aligned, they can’t create an accurate picture of the future. 

So, how does the puzzle look today for rural health? Let’s move from the previous storyline of Centers for Medicare & Medicaid Services (CMS) recommendations for rural providers to the current realities for those providers, and then continue with an update on the CPC (Comprehensive Primary Care Plus) Plan and whether that means anything for them.

What Size Do MACRA and Rural Healthcare Fit Into?

MACRA isn’t one size fits all; it has a different impact, meaning, implications, and results depending on provider structure – whether you’re talking about an urban or rural health system, an independent or small practice, critical access hospitals (CAHs), rural health clinics (RHCs), or federally qualified health centers (FQHCs). 

  • Some providers won’t face any pressure in the near future to attain a high Merit-Based Incentive Payment System (MIPS) score, because they just won’t be required to do so. The exclusions in the MIPS attestation process include clinicians newly enrolled in Medicare, QPS-qualifying alternative payment model (APM) participants, certain partial qualifying APM participants, and those providers that practice with a low-volume threshold. 
  • As it relates to CAHs, RHCs, and FQHCs, CMS has proposed that services provided at these entities meet a type of criteria to be counted towards qualifying APM professional determination.
  • Due to how these entities are paid under Medicare, RHCs and FQHCs are currently exempted from reporting to MIPS.
  • Many CAHs and other rural hospitals might not participate in MIPS due to the low-volume threshold. Stay tuned, though – the final proposed rule for rural providers might have enhanced changes.

Upside and Downside for Rural


Currently the MIPS criteria stems from the following: if providers’ Medicare patients, billings, and/or service volumes are beneath a set level, they may be excluded. Known as a “low-volume threshold,” this applies to clinicians who have Medicare billing charges less than or equal to $10,000 and who provide care for 100 or fewer Part B-enrolled Medicare beneficiaries. 

It is important to recognize (per CMS) though that even if a smaller practice or organization is exempted from MIPS, that doesn’t mean that it can’t participate in an accountable care organization (ACO) through the APM model. In fact, this just might be a pathway to success for rural providers, as they voluntarily provide coordinated quality healthcare to their respective Medicare patients. In fact, the CMS Innovation Center created this program with rural healthcare in mind so that upfront payments could be made to those smaller entities that want to participate as an ACO in the Medicare Shared Savings Program (MSSP).


So while CAHs can opt out of the MIPS and/or other programs without any foreseen penalty, due to many a harsh rural reality – lack of resources, diminished operational planning and capacity, lack of patients, absence of technology, thin margins, etc. – those providers will also miss out on the potential to garner substantial rewards built into the system for providers that need it the most. Creating better financial sustainability for long-term viability, improved patient outcomes, enhanced provider-patient engagement, and improved outcome measurements won’t be rewarded as per usual in the new progressive era of healthcare reimbursement.

It is important to note that the incentives represent considerable funding, and while some rural providers might wipe their respective brows and breathe a sigh of relief that the “performance pressure” on the MIPS score is off, they must also recognize that the gap of care, access barriers, and measurements between “rural” and “urban” providers could widen the longer one stays on the outside looking in, whether or not this is due to circumstances that can be controlled.  At the heart of this is the opportunity to gain a bonus for high performance – and that bonus could be substantial, given that the law permits a total of $500 million to those deemed high achievers within the MIPS scoring ranks. So again, while initially a pass might really help rural providers, the longer they wait, the more difficult it is to get in the game later.

Transparency Without Benefits?

As if providers aren’t busy enough when it comes to doing what is required, there is talk that the U.S. Department of Health and Human Services (HHS) likely will encourage exempt providers to still contribute data regarding MIPS performance metrics even if they aren’t technically a part of a MIPS program as a way of readiness in garnering better data collection and more familiarity with a performance-based program. The hope is that it will raise the bar for information collection, keep providers’ fingers on the pulse of expectations should individual or system changes take place, and allow for providers to participate in these value-based models.   Top 20 Best Next Steps for Rural Providers

  1. Prepare a Path: No matter the size or circumstances of rural providers, or whether CMS extends the date of implementation, this sector needs to position itself for the future. (Note: the issuance of the final proposed rule is currently set for Nov. 1, with implementation on Jan. 1, 2017, according to Andy Slavitt, acting CMS administrator – however, he also indicated that the implementation date could change based on responses received from rural and independent providers). Rural healthcare has always been exceptional at collaborating, so perhaps participation in an ACO can help get providers where they need to be when their own respective patient numbers and margins don’t add up. Remember that MACRA replaces the former electronic health record (EHR) incentive program known as meaningful use, the Physician Quality Reporting System, and the Value-based Payment Modifier programs with the four measures of cost, quality, information technology (IT) use, and clinical practice improvement activities – so there will be lots of details to be familiar with and take into consideration throughout the review and decision-making process.
  2. Participate In Learning Sessions: CMS keeps issuing fact sheets and will continue to make recordings and information available for providers, recognizing that recent studies are showing that half of all providers haven’t had the time nor the opportunity to examine basic elements (or consider the impact these programs would have on their respective futures).
  3. Engage Providers on what MACRA Means: Groups need to seek engagement and education, and ensure that everyone plays a crucial role. Many may not be aware that their MIPS scores will be published on Physician Compare for public review. 
  4. Organize C-Suite Strategic Planning and Provider Compensation Review: Providers need to recognize that it is imperative that provider compensation/plans be reviewed and that incentives are aligned with MACRA objectives. Start now – this takes time. and many contracts are in the process of being renewed this time of year.
  5. Develop an Internal Support Team: Whatever plan of action is selected, even if it is exemption, a team of stakeholders including providers, IT, management, nursing, and others should be formed to help assess capabilities within performance monitoring, data collection, workflow, and risk mitigation/gap assessment of quality and performance efficiencies. From there, organizational detail will be paramount in order to establish a through timeline and deliverables. Teams could begin and end with a SWOT (strengths, weaknesses, opportunities, threats) analysis to make sure all elements are discussed and planned for thoroughly.  Balance scorecards are also excellent for tracking without having to use a lot of additional transformational change workflow software. 
  6. Achieve Pathway Clarity: Some reports are showing that up to 90 percent of medical groups (most likely this is an urban gauge) will join MIPS, and groups that initially begin there will move into an APM in subsequent years.
  7. Remember the Devil in the Details: It can’t be stressed enough that how well a provider group performs on the aforementioned measures compared to peers (though it’s to be determined if it will be an apples-to-apples comparison and what the scope will be) will ultimately determine whether Medicare payments to them are increased by up to 9 percent or decreased by up to 9 percent by 2022.
  8. Perform Risk Assessment: The APM path has been developed for groups that are willing to take upside and downside risk under the new payment models – and this would be inclusive of select bundled payments, medical homes, and ACOs.  The APM has a dangling carrot of a 5-percent bonus payment.
  9. Consider the Big Ticket – A Technology Evaluation Yes, you got ready for meaningful use and ICD-10, but now healthcare IT is the MACRA focus, and it requires participants to use CEHRs – certified electronic health records. This might cause some angst due to lack of exchange of information and interoperability. Vendors aren’t always streamlined, and there are still massive gaps in capabilities, features, and analytics.  Think of this in terms of a library – you can’t check out one book, you need a tool-chest of resources.  In this case, you need to meet MACRA through the library of needs of collecting, reporting and monitoring measures and scores and this might require other IT capabilities and funds beyond CEHRT.
  10. Anyone Heard of QCDR? Yes, there’s another acronym: QCDRs (qualified clinical data registries) will be necessary to collect clinical data, improve quality and performance, and manage the care of delivery.
  11. Measure Your Own Quality and Be Your Own Toughest Critic: It is important to note that within MIPS, providers will have an option to select measures, but within APMs, there will be a prescribed set of measures based on the program elements. As defined currently, quality measures used within APMs would need to be comparable to those defined within MIPS. So the moral of this story is to be selective in picking the right measures and hope that your group’s respective performance will be compared with that of a similar group.  
  12. Getting Quality Right Through the Use of a QRUR: Although this might not apply to rural providers, especially since there might not be enough volume, some experts have noted that a great resource to help shape and select quality measures is the use of the a quality and resource use report (QRUR). This tool helps track scores of provider peers, calculating the standard from the national mean for both cost and quality.
  13. ICD-10 Attention is Still Necessary: ICD-10 allowed for a streamlined method for achieving accurate coding and tracking of patient diagnosis and care coordination. Now, there will also be a high-risk bonus adjustment based on such accuracy.
  14. Maintain Communication, Navigation, and Peer Performance Review: To track transparency and make sure a baseline is established, benchmarks are noted, and the bar raised, providers might want to think about developing or selecting a tracking mechanism available within the marketplace. This continual gauge-and-review process will keep everyone in sync.  
  15.  Make a Leadership Stretch: No matter the specific programs selected, the new era of healthcare and new reimbursement models require the best of leadership development and growth at all levels – some might say transformational growth is required to keep pace with the progress – in order to balance the risks and rewards of these models. Yesterday’s routineswill not yield better results or allow an entity in any market, especially that of rural, to compete adequately. If rural healthcare does participate, that is where we should have an enhanced opportunity. 
  16. Seek Others in Collaboration and Calculate Your Risks/Rewards: Nimble movement should allow opportunities to partner more readily with. For rural providers, the best opportunities might be with an ACO and or a clinically integrated network (CIN). It cannot be stressed enough that there are pros and cons for both APM and MIPS models. The APM requires a group to take a downside risk. To that end, if there are entities that don’t have any experience with risk or have a low volume of patients, it would be very helpful in providing the best of tools, resources, and capabilities while spreading actuarial risk over a larger patient pool size. MIPS success equals access and implementation of care management tools, technology, and practice operability. It also requires wider margins for sustainability.
  17. PCMH a Lifeline Opportunity? Medical groups that have a patient centered medical home (PCMH) status can receive full status/benefit for achieving the MIPS Clinical Practice Improvement Activities measure – so that too can be another pathway for consideration.
  18. What ACOs Really Mean Under MIPS: The number of ACOs has grown to 18 since 2014, and the initial pioneer program has given rise to more participation – and some might say that data sharing and automation are drivers for future refinement of the model. As with many pioneer programs, the 2.0 version continues to improve in developing into structures that provide the opportunity for assertive, highly engaged, and results-oriented provider groups to achieve their financial targets and bonuses. It is vital that those within an ACO or seeking to be a part of an ACO recognize that only a few will qualify as an APM, and many other ACO participants will have to engage with the MIPS. To that end, CMS could use a modified MIPS scoring program to calculate value-based payment adjustments. For more clarity and information on ACOs navigate, the National Association of ACOs (NAACOs) has released a guide on how these organizations will be scored under a modified version of MIPS specifically designed for alternative payment models that do not qualify as advanced APMs.
  19. Eligibility for ACOs: We have already noted that ACOs thrive off of the power of numbers. Here are a few other details as it pertains to next steps: the MSSP tracks nos. 2 and 3, as well as the next-generation ACO model, will be considered advanced APMs, and these ACO programs would be exempt from MIPS and earn a 5-percent financial incentive payment. Additionally, all eligible providers must demonstrate participation thresholds to earn the financial incentive payments, and per CMS, providers must treat at least 20 percent of their respective patients or make 25 percent of their payments through the advanced APM in 2017, the first performance year for MACRA. For those not eligible via a APM, CMS has proposed a MIPS APM scoring standard that acknowledges their “value-based care” progress in an ACO model. Eligible providers will be given a composite performance score that determines adjustments per year, but CMS will only review and calculate one score at the ACO level for all those providers eligible within the program. Additionally, according to NAACOs, the “MIPS payment adjustments will be applied at the unique TIN/national provider identifier (NPI) level for each MIPS-eligible clinician in the APM entity group.”On a final note, the composite performance score under the MIPS APM scoring standard will be rendered differently than those of the general MIPS model. The scoring will include quality at 50 percent, advancing care information at 30 percent, and clinical practice improvement activities at 20 percent.  Categorically, the ACO model has several more considerations regarding cost measures, benchmarking, performance scores, interfacing, advanced care information, information, and data burdens. Due to the complexities of MACRA, those within ACOs could benefit from additional time to assess the new models.
  20. Overcome Challenges: Many studies are indicating that a majority of providers aren’t meeting goals for success; it may be as high as 60-75 percent of providers, as it relates to alternative payment models. Overall, they are struggling with performance metrics, analytics, data, patient engagement – on matters throughoutthe entire spectrum of the care continuum. The results seem to be indicating that 60 percent are falling short on goals to improve patient outcomes; 75 percent are not meeting goals to reduce administrative care costs; 70 percent are not meeting care coordination; and nearly 75 percent are failing to meet lower healthcare cost targets. Given these numbers, it’s no wonder that there is a need to evolve in order to change these results. Doing so takes time, resources, and relationships.

The End Is The Beginning

Remember when we used to refer to the lack of attention and decisiveness regarding the sustainable growth rate (SGR) as austerity – kicking the can down the road? Folks, the can has been replaced with a puzzle, so let’s see how the pieces of time, timing, and critical elements fit together to create the best rural and urban picture possible, removing the “puzzling” from the puzzle.

About the Author

Janelle Ali-Dinar, PhD is a rural healthcare expert and advocate with more than 15 years of healthcare executive experience in many key areas addressing critical access hospitals (CAHs), rural health clinics (RHCs), physicians, and patients. Dr. Ali-Dinar is a sought-after speaker on Capitol Hill. A former hospital CEO and regional rural strategy executive, Janelle is also a past National Rural Health Association rural fellow, Rural Congress member, and Nebraska Rural Health Association president.  She is currently the Nebraska DHHS chair of The Office of Minority Health Statewide Council, addressing needs of rural, public, minority, tribal, and refugee health, and she serves on the Regional Health Equity Region VII council as co-chair of Rural Health and Partnerships. Janelle holds a master’s degree and doctorate in communications and is a recent graduate in public health leadership. Janelle is currently the vice president of rural health for MyGenetx.  

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