While most healthcare providers agree the move toward fee-for-value is a positive advance for the healthcare industry, this shift away from fee-for-service isn’t coming without its challenges.
That’s especially true for providers who serve patients in rural and underserved areas and now must implement changes dictated by the Medicare Access & CHIP Reauthorization Act of 2015, or MACRA.
“This is a thousand-page rule that rural and underserved areas are being asked to digest, and they have fewer resources to commit to changing what needs to be changed,” said Aaron Turner-Phifer, URAC’s director of government relations. “They’re asking themselves, ‘How is this going to impact my business, and how is this going to impact the way I deliver care to patients?’”
The move repeals the sustainable growth rate, or SGR, approach to physician reimbursement, replacing it with two payment options—Alternative Payment Models (APMs) and Merit-Based Incentive Payment Systems (MIPS). Of the options, Turner-Phifer says MIPS is the more complex, requiring reporting on measures of quality, resource use, clinical practice improvement and meaningful use of certified EHR technology. APMs are structured to provide lump-sum incentive payments.
Providers in metropolitan areas—particularly those associated with large integrated health systems—typically have more resources to weather these regulatory changes and are already integrating such concepts as Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes into their practices.
In rural areas, fewer providers cover large geographic areas, often in small practices that are less experienced with technologies like EHR. Their patient base tends to be older and lower-income, making them disproportionately reliant on Medicare and Medicaid. The challenges are similar in underserved low-income urban areas, which face a critical lack of primary care providers and where patients are more likely to suffer from long-term chronic conditions that have gone unaddressed due to lack of access or education. As a result, they tend to use the emergency room as a source of primary care.
“When you’re eating into the profit margins of rural and underserved providers, there’s a potential decrease in access for patients in those areas,” says Turner-Phifer. “It’s a public health concern if you’re in areas that have access issues already. If anything adds onto this, even incrementally, it’s really going to strain that delivery system.”
In addition to reduced access for patients, Turner-Phifer anticipates that MACRA’s impact on rural and underserved areas will include consolidation of practices in such areas or mergers with larger health systems and some may choose to stop accepting Medicare.
The trend toward consolidation is already evident; a recent study published in Health Affairs documented a drop in the proportion of physicians in groups under 10 from 40.1 percent in 2013 to 35.3 percent in 2015. Meanwhile, the proportion of those in groups of 100 or more grew from 29.6 percent to 35.1 percent in that same time period.
One thing that holds promise for easing that strain on providers in rural and underserved areas is telehealth. “It has the potential to improve access in a value-based world while allowing providers to get paid and keep their doors open,” he said. Telehealth is increasingly being recognized by CMS in fee schedules, but he says it will be a slow process of documenting the clinical data required for widespread use.
The good news is the CMS is recognizing the unique challenges facing providers in such areas, allocating additional funding to help with training and implementation. Meanwhile, organizations like URAC and local and state professional societies also are stepping up to educate and support the transformation of rural and underserved providers.
“Our certifications have taken the concepts of sustainability, flexibility and quality improvement and rolled them together to achieve a sustainable positive impact for patient and physician practices,” says Turner-Phifer. “We acknowledge that practices are going to begin the transformation process at different points, so we have to accommodate the readiness of practices.”
Readiness in a rural practice looks quite different than it does in a large integrated health system, so URAC’s standards provide a clear path to transformation based on sequential steps to improvement and milestones for putting knowledge into practice, with a focus on changes that are sustainable for that provider.
“We’re constantly focused on helping find a solution that makes sense from a patient perspective and a business perspective,” Turner-Phifer says.