Healthcare reimbursement for physicians and hospitals is evolving rapidly in the United States. In 2015, Congress replaced the broken SGR reimbursement system with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) to reward healthcare quality and lower costs while at the same time, migrating away from traditional fee for service payment models. Hospitals have been waiting to hear how this will be implemented. In late April 2016, it was revealed that this will take the form of the Merit-Based Incentive Payment System (MIPS). This major overhaul details how hospitals and doctors will be paid by Medicare in the United States in the coming years. The program kicks in on January 1, 2017.

MIPS places an increased emphasis on quality outcomes and reduced costs rather than traditional fee for service, but in large part leaves it to hospitals to figure out how to make this happen. Hospitals and doctors will be scored on quality and costs, and the data will be publicly available. Scores will derive from measurements of:

• Quality
• Resource Use
• Clinical Practice Improvement
• Meaningful Use of Certified Electronic Health Records (EHR)

The program is a zero sum game when it comes to payments for services:  The points will create an upper quartile of hospitals that receive a bonus and a lower quartile of hospitals that are penalized. Transparency requirements mean this data will be published on the web on pages like ProPublica for all to see.

Additionally, the system is migrating to Alternative Payment Models (APMs).  Care providers are encouraged to form groups, identify opportunities to improve care, implement new programs and analyze the benefits. Lump sum payments will be available for successful projects. Heart surgery is a prime target for APMs.

There is a potential 18% impact on the bottom line. These penalties may be enough to make or break some hospitals that already rely on thin margins to stay open. These penalties will directly impact the take-home pay of many physicians.  On the other hand, this will reward hospitals and doctors with the highest quality at the lowest cost.

ClearFlow has co-developed specific continuous quality improvement programs with top hospitals to help heart surgery programs implement programs that can reduce costs and improve outcomes in a measurable way – a strong start to the new payment models. Developed in a lean six sigma framework, the ClearFlow CQI is applicable to all patients undergoing heart surgery who require a chest tube, and thus is easily and widely applicable. It’s based on the principle that there is an absolute requirement to drain all shed blood, but that chest tubes frequently clog. Few programs have protocols to effectively address this very common problem. The CQI has been shown to reduce complications in cardiac surgery, and is currently being implemented at the Mayo Clinic. This simple program could be a huge boost to cardiac surgery MIPS and APM scores.

The time to start is now. 2019 payments will be based on 2017 data. Contact us for more information.