Evidence-based Guidelines Can Lead ACOs Toward MACRA Success

Despite the uncertainty surrounding healthcare reform, strong growth of accountable care organizations (ACOs) continues unabated. For example, the Centers for Medicare & Medicaid Services’ (CMS’s) Medicare Shared Savings Program (MSSP) expanded this year to 480 ACO participants—up from 434 in 2016.

However, these ACOs, as well as most of the organizations participating in the estimated 900 commercial ACO contracts, have another set of requirements to follow in 2017 within the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program (QPP).

ACOs have many things to consider when it comes to MACRA, but one of the key pieces for these organizations will be how to more easily achieve the care-quality and cost-savings goals required in these value-based payment programs. Many ACOs have discovered that offering support tools and using technology to tailor and estimate durations for treatment plans can go a long way in improving outcomes and decreasing costs. This approach supports better patient engagement, quicker results, and a more cost-effective return to health, enabling providers to improve clinical and financial outcomes.

MACRA QPP Opportunities

The QPP’s two tracks—the Merit-based Incentive Payment System (MIPS) and the advanced alternative payment models (APMs)—carry not only new compliance challenges, but also financial opportunities. The advanced APM track, for example, can boost qualified ACO physicians Medicare payment by 5 percent just through qualifying and participating.

The National Association of Accountable Care Organizations warns in its guide to MACRA’s QPP that some ACOs, such as those unaffiliated with a CMS program, will not qualify. Those physicians will need to report data for the MIPS track, which is more time consuming and based heavily on care quality performance against peers and cost. Worse yet, penalties for nonparticipation in either QPP track can reach 9 percent of Medicare payments by 2022.

Regardless of which QPP track ACOs providers choose, CMS’s goals are the same: better clinical outcomes with less spending, especially among the high-cost, high-need patients that comprise only 5 percent the U.S. population but account for 49 percent of total healthcare expenses. These patients also are at a higher risk for avoidable hospital readmissions within 30 days, for which CMS can penalize a hospital by as much as 3 percent of its payment.

Tailoring Treatment for Faster Recoveries

Certainly, the high-cost, high-need population’s complexity requires greater care resources than are required by a healthier population, but significant progress can be made to reduce associated spending. For example, overtreatment—defined as “subjecting patients to care that, according to sound science and the patients’ own preferences, cannot possibly help them”—is estimated to cost the industry between $158 billion and $226 billion a year.

Physicians utilizing evidence-based clinical guideline decision support tools at the point of care can combat such overtreatment, especially when the tools are integrated into the electronic health record and the physicians’ workflow. Evidence-based guidelines that have been subjected to adequate scientific rigor can help ensure that the most effective protocols are considered to maximize care efficiency toward positive outcomes.

For patients with highly complex conditions who require more tailored treatment plans and timelines, recovery duration tables and predictive modeling capabilities can be leveraged in conjunction with the guidelines. These tables offer concrete estimates based on millions of real-world cases across several activity levels. The predictive modeling allows physicians to input demographic and comorbidity information for an even more precise recovery estimate that can help physicians design effective treatment plans informed by the guidelines to help patients return to activity and stay healthy following treatment.

The results are more productive, meaningful, point-of-care physician-patient discussions that can help improve outcomes and reduce costs, further helping to meet CMS value-based care standards. Likewise, the increased patient engagement resulting from patients’ faster return to health can lead to longer term benefits for providers and patients regardless of the value-based care program.

Joe Guerriero is senior vice president of MDGuidelines Westminster, Co.