With just about everything the government touches requiring more and more regulations, stipulations and definition, it is hard to understand why they are getting so involved in healthcare and specifically Medicare growth. Placing more regulations in the healthcare industry is a necessary evil, and the government can offer many provisions that may not be otherwise available. Healthcare is a sacred cow for many politicians, so when there is talk of any sort of change, many hunker down for a good fight. However, this isn’t the case more recently; the Sustainable Growth Rate (SGR)Repeal and Medicare Provider Payment Modernization Act of 2014 has bridged the gap of inefficiencies, overpayments, lack of quality care and bipartisanship bickering.

Again, as with most things governmentally-based, the bills presented to Congress and the House are difficult to understand and interpret, so let’s break it down into more bitesize portions.

Across the Board Cuts

An across the board cut of physician repayment was scheduled to go into effect on April 1, 2015, but with bipartisan support and a signature from the President, the SGR formula was repealed. What this meant was that instead of losing out on a larger percentage of reimbursements for services, no matter how beneficial they might be, the new bill enabled physicians to increase their billing by 0.5% this year and every year until 2019.

However, there was a required change for this concession: Healthcare facilities are to shift from the normally accepted fee-for-service based pay to a pay-for-performance or outcome basis. This takes into account more of the outcomes and patient satisfaction instead of being able to charge for every service provided to a patient.

Changes of Service

As just stated, moving away from the standard fee-for-service based payments are going away. This is in an effort to see a higher quality of service and more value for that service as opposed to simply rewarding for subjecting a patient to unnecessary testing and procedures as a means of meeting a quote for a facility.

More than anything, this allows the Centers for Medicare and Medicaid Services (CMS) to penalize healthcare organizations who do not meet minimum standards of care and outcomes, as well as reward high performing organizations for meeting and exceeding standards along with increased patient satisfaction for care received.

To understand some of the expectations behind the move to pay-for-performance benchmarks, CMS was going to watch for things such as:

  • Treatment complications contracted while in a hospital
  • Inadequate treatment
  • Inadequate coordination of care and follow-ups within the community
  • Surprise worsening of diseases or infections after discharge from hospital
  • Increase hospital readmissions, usually within 30 days, after discharge

Patient-centered Care

Many people would agree that this has taken far too long in being implemented; physicians moving out of the driver’s seat to help the patient become more involved and knowledgeable with healthcare decisions. As doctors and other healthcare professionals step out of the role of making demands for testing, prescription orders, referrals, and hospitalization, and allow the patient to be more involved in the decision making process.

What truly is most important is the satisfaction of the patient. Physicians now need to account for how the patient is doing and feeling along with the outcome of a process or procedure. This affords the patient more involved as well as still receiving the insight and guidance of a doctor.

Working Hard for Your Money

Like many people involved in other industries who receive incentives to work harder and better, the concept is being brought to healthcare. Healthcare organizations that rank highly in patient outcomes and satisfaction or are willing to participate in alternative payment methods will receive the stipulated fee increase percentage, plus additional payments. Those that consistently struggle or are below par will receive the normal percentage for reimbursement but will not collect any further fees.

The reasoning behind this is to promote organizations that are working hard and applying monies to where they can be helpful, but not necessarily penalizing others who aren’t doing as well. Encouraging positive behavior leads to continued good performance and finding ways to better workflow and community involvement.

Time to Hit the Accelerator

When a good thing is found and proven to be such, sometimes it is necessary to push people and places to implement those changes. As such, quickly moving away from the fee-for-service to a value-based payment like pay-for-performance is what the government is advancing for the healthcare community. The Merit-based Incentive Payment System (MIPS) will be set up to assess reimbursements based on:

  • Quality of care
  • Use of resources
  • Clinical practice improvements
  • Meaningful use of Electronic Health Record (EHR) Technology

From this evaluation, providers can have their payments adjusted up or down. More importantly, the program looks to replace bureaucracy that exists in three different incentive platforms. It does put a lot of the decision and guideline making process in the hands of the Secretary of Health and Human Services. He or she would also be in charge of:

  • Development of methodology for assessment
  • Development of calculations for payments
  • Development of threshold for bonus payments

Medicare Growth

Making sure that healthcare is not only available for those seeking medical help but is improving along the way should be a national interest. Medicare growth is part of this process and the government is helping to make sure that the growth is happening with clinical improvement measures included as part of the process. The necessary evil that is government bureaucracy can aid in pushing good performance standards along and regulating out poor behavior.

Accountable Care Organization (ACO)

Clinical quality measures, also known as CQMs, are used every single day in the medical field by professionals, including doctor’s offices, critical access hospitals or CAHs, and nursing homes. Although patients don’t tend to participate in clinical quality measures personally, they are a crucial part of these measurements, which track all levels of patient care. From the moment that you enter a medical facility, all parts of your experience are recorded. This lets doctors, nurses, and other practitioners know that they are sufficiently caring for patients in a timely manner.  However, the rate of information requested by some quality reporting programs can cause CQM lag.