As the presidential and congressional elections and nominations to the HHS and CMS have taken center-stage in healthcare discussions, providers continue considering the implications of Medicare Access and CHIP Reauthorization Act (MACRA)-related programs. The ruling was finalized in October 2016.
MACRA’s execution is complicated, and providers will want to know how MACRA will impact reimbursement and how they can position their organizations successfully for value-based payments in the future. Underlying the operational complexity are three data management challenges that need further examination: reporting, interoperability, and care coordination.
All three depend on maintaining accurate data about practitioners and patients. By managing accurate patient and practitioner data sets, providers can maximize efforts and efficiencies in the rest of the program.
Which quality metrics are reported on and when will depend on the ‘pace’ selected and requirements of specific Quality Payment Program (QPP) tracks. Regulators have specified that those who must report include physicians, Physician Assistants (PAs), Nurse Practitioners (NPs), Certified Registered Nurse Anesthetists (CRNAs), Clinical Nurse Specialists (CNSs), and pathologists and groups that include these clinicians, including some additions or exclusions.
One of the data management needs that has arisen is practitioners will be identified in different ways, depending on their participation in the merit-based incentive payment system (MIPS) or advanced alternative payment models (APMs). While MIPS will identify eligible clinicians through a combination of taxpayer identification numbers (TINs) and national provider identifiers (NPIs), the APM programs will likely identify eligible clinicians via a unique identifier utilizing APM, APM Entity, and TIN/NPI combinations.
So, in the instance where an eligible clinician joins a new group practice in mid-2017 or later, the identifier describing that individual will also change. Keeping these identifiers updated will ensure that reports to CMS are accurately submitted by and credited to the right individuals and groups.
Interoperability presents another data management challenge. It involves accurate patient matching, known semantics, patient authorization and more. Senders must know that they’ve selected the right patient records and be confident in an intermediary’s ability to locate the right patient’s additional information and transmit it. Yet, while this may seem like an easy data management task, matching patient data that is constantly changing, and captured and stored inconsistently, can be a daunting task. In fact, even large, sophisticated health systems can struggle with interoperability, as evidenced by the rate of fragmented or duplicated medical records uncovered by providers. Updated and robust patient data sets will aid patient matching for those striving for interoperability outside of their homogenous EHR environments.
Lastly, care coordination, which is also linked to interoperability, presents a related data management challenge in knowing which practitioners to coordinate with. Patient care teams are burdened with situations that lead to inefficient use of their time. For example, they are asked for information like the correct phone number for a patient’s primary care physician, the address of a skilled nursing facility where a patient was discharged, the names of local psychiatrists to call for a patient evaluation so that an appropriate discharge location can be selected, and the address of a specific emergency department or urgent care center where the patient can be directed to once they are phone-triaged. All of these scenarios require accurate demographic profiles on individual practitioners and care settings that are easily available to help ensure practitioners are consulted and the most appropriate and convenient care settings for the patient are selected.
Combining the President-Elect, new healthcare appointees to the new administration, and the bi-partisan nature of MACRA’s legislative approval, no one knows exactly what will change in MACRA, if anything. Even so, complete, current, and comprehensive patient and practitioner data sets can help providers and their health IT vendors avoid creating additional work for clinical and administrative teams, safety issues for patients, and workflow inefficiencies that could jeopardize the intended benefits of the program.