Tag: MACRA

For US Healthcare Providers, Hope for Rescue From Shrinking Margins Lies in ‘People, Process, Technology’—But With Bolder and Smarter Partnerships This Time: Everest Group | Press Release

Everest Group offers solutions to help healthcare providers combat margin-crushing regulations, expenses, and risks in turbulent marketplace

A majority of healthcare providers in the United States suffered financial decline in 2017 amid the industry shift toward a value-based care system. Although many healthcare providers espouse a sound and logical strategy that focuses on people, process, and technology, few have been singing that song correctly, according to Everest Group.

In Everest Group’s recently published report, “Healthcare Provider Market: Addressing Issues Beyond Value-Based Care | What Healthcare Providers Need to Do to Address Myriad of Challenges,” the firm presents the challenges faced by healthcare providers in the market today and explains how most healthcare providers’ efforts to overcome those challenges have fallen short.

The key challenges facing healthcare providers include the following:

  • Not only Obama-era regulations, such as MACRA, but also some GOP-proposed / -passed regulations such as Tax Cuts and Jobs Act (TCJA) are putting pressure on hospital margins. MACRA alone is likely to cause a decline in hospital Medicare reimbursement by at least US$250 billion by 2030.
  • Massive investments into extremely expensive electronic health record (EHR) systems with little or no preparedness and vision have led to poor financial performance.
  • Continuing fraud, lack of education, and the inability of the Centers for Medicare & Medicaid Services (CMS) to address these issues have resulted in doubling of improper payments in the past five years, with improper payments in 2016 reaching approximately US$102 billion.
  • Claims denials totaled more than US$250 billion in 2016, highlighting the significance of payment risk for hospitals.
  • Talent shortages, escalating training costs and a lack of collaboration are also among the key issues affecting health systems’ workforces.

To engineer a turnaround in this bleak trend, U.S. healthcare providers still need to focus their investments on people management, process improvement and technology enhancement—but in smarter ways than ever before, according to Everest Group. In particular, healthcare providers need to be more targeted in their digital transformation investments and bolder in their ecosystem development endeavors, relying heavily on partnerships to effect greater change.

“One very real and pressing concern of many providers is the large investment they have already made in large-scale EHR implementations and the limited resources remaining for new investments,” said Manu Aggarwal, practice director at Everest Group. “To identify the path forward, providers need to outline a targeted set of investments instead of another round of large ones. Specifically, investments in automation and analytics can yield solid, quick wins and pave the way for future engagements without the need for high capital outlay.”

“Another ‘must’ for providers is ushering in a much more collaborative culture,” added Aggarwal. “For example, providers need real-time data sharing with payers in order to provide enhanced patient experience. Providers also need strong partnerships with technology vendors and business process service providers to deliver the modern, technology-driven services that patients demand. And, finally, broader collaboration among the health network is required for improving patient outcomes and maximizing reimbursements.”

Additional examples of the solutions recommended by Everest Group in the report include the following:

  • To address the talent shortage, hospitals should hire visiting physicians and nurses, link incentives with performance, and collaborate with specialists for training purposes to enhance people management.
  • Technology investment is a must; however, hospitals also need to sort out issues regarding technology illiteracy and improper implementation in order to achieve a positive return on investment.
  • Digital transformation does not end with EHR implementation; rather it involves continuous investments in other systems such as revenue cycle management (RCM) as well as tools for analytics and automation. Providers should set their sights on the ultimate objective: interoperable systems with end-to-end patient engagement.
  • The uninsured population is expected to increase with the removal of the Individual Mandate; hence, healthcare providers need to strengthen front-end processes such as eligibility verification and pre-authorization to avoid claims denial at later stages.

 ***Download a complimentary abstract of the report. ***

Healthcare Providers Will More Than Double Their Spending on IT Services in 2017, Says Everest Group | Press Release

New MACRA policies will stimulate IT investments as healthcare providers seek to document quality of care and ramp up patient engagement under new Medicare reimbursement model.

By 2020, healthcare providers will more than double their spending on technology services, which represents an incremental opportunity of over US$9 billion dollars for the healthcare IT outsourcing (ITO) market, according to Everest Group, a consulting and research firm focused on strategic IT, business services and sourcing. The healthcare provider segment is poised to be one of the fastest growing segments in the healthcare IT services market in coming years.

Accelerated IT investments on the part of healthcare providers will be driven in large part by new reimbursement policies taking effect under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Under MACRA, providers will earn more or less depending on the quality and effectiveness of the care they provide. As a result, healthcare providers will continue investing heavily in technology that supports initiatives such as compliance, legacy modernization, electronic health records (EHR) and patient engagement.

“MACRA encourages ongoing technology adoption by US healthcare providers by mandating specific tech-related measures,” said Abhishek Singh, practice director of Information Technology Services at Everest Group. “This will translate directly into four IT investment trends we’ll see develop over the course of the next 24 months. First, performance improvement and cost takeout will be a strategic focus; both are critical for compliance and to raise capital from the market. Second, patient engagement will drive the differentiation strategy. Third, we’ll see a growing urgency for data security. And, finally, we’ll see a market crying out for interoperability, nimbleness and innovation with respect to EHR.”

These results and other findings are explored in a recently published Everest Group report: “IT Outsourcing in the Healthcare Provider Industry – Annual Report 2016: The Big Bang MACRA-economic Theory of Provider IT Transformation.”

The full report provides an overview of the ITO market for the healthcare provider industry, which comprises large health systems, stand-alone hospitals and clinics, pharmacists, physician practices and diagnostic laboratories. Everest Group analyzes the current trends and future outlook of large, multi-year ITO relationships in the provider market, covering market dynamics, the current state of the market, and the future state of the provider IT industry.

Other key findings:

  • The global healthcare (payer and provider combined) ITO market is expected to grow at 12 percent CAGR during 2014-2020, reaching US$68.3 billion in 2020.
  • Demand in the provider ITO market has been concentrated in the larger health systems.
  • Currently, application, development and maintenance (ADM), testing and network services rank highest among the IT services included in ITO deals within the provider segment.
  • Given the consolidation and convergence tailwinds in the market, systems integration (SI), testing and asset rationalization work streams are expected to get a boost in 2017.

MACRA Nails it as the Next Big Bang of Reforms in Healthcare | Sherpas in Blue Shirts

On Friday, October 14, the Centers for Medicare & Medicaid Services (CMS) in the United States released a humongous, 2398-page rule to implement new value-based payment programs under the Medicare Access and CHIP Reauthorization Act (MACRA).

This release is a significant step forward in streamlining Medicare payments, and establishing what “value” will mean in the much debated Value-Based Reimbursement (VBR) programs.

Here’s our initial take on this release, in order of what I liked most about the rules.

CMS is making the right noises: As the CMS acting administrator, Andy Slavitt, put it, “…..changes to the rule were to help physicians focus on delivering care and seeing patients instead of performing administrative tasks.” The term in bold represented the point of conflict between a right thinking, efficiency-focused regulator and unnecessarily overburdened physicians.

How is some of this getting addressed?

Reduces confusion over quality improvement: The new set of rules consolidates three existing quality reporting programs — Physician Quality Reporting System, Value-based Payment Modifier, and Meaningful Use (MU))– and a new performance category into a single system through Merit-based Incentive Payment System (MIPS.) The definition of “merit” or value was never clearer. Here is a snapshot of the scoring model that defines the four performance categories and their weights:

MACRA Healthcare

Pick Your Pace (PYP): In order to make the above operational, CMS is allowing providers to pick their own pace, (see Andy Slavitt’s blog for more details), and choose from three data submission options or join an advanced Alternative Payment Model (APM):

  • Test the program
  • Submit 90 days of data
  • Submit a full year of data

Enabling consortiums: CMS now allows MIPS reporting as a group, enabling smaller providers to get a better deal. What this means is that a group of clinicians sharing a common Tax Identification Number (irrespective of specialty or practice site) can group together to receive payments based on the group’s performance. This will foster necessary consolidation in the ambulatory space.

Relaxes exclusion norms through APMs: Providers not eligible for MIPS can still receive a bonus payment for meeting performance criteria through qualifying APMs. The inclusion criteria are clearer than before, and the nervousness caused by stringent exclusion norms is largely addressed.

Last, but not least, provides a further fillip to IT: While use of certified EHR technology will continue to give providers brownie points for performance, the following five required measures that CMS has mandated for providers will further boost technology adoption:

  • Security risk analysis
  • E-prescribing
  • Provide patient access
  • Sending summary of care
  • Request/accept summary of care

Net-net, this new rules release is a great move forward toward settling the debate on “value,” and will energize the healthcare industry to spend more on technology. As you wade through the 2398 pages, watch this space for more of our explanations and perspectives on this topic.

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