PriceCheck: Health Department Challenges Providers To Improve Billing

In July, if you have health insurance and go to an in-network hospital but a doctor who is not in your insurance plan's network helps you, you aren't supposed to get a surprise bill. The law is designed to stop what's called balanced billing - the practice of charging a patient for medical care delivered by doctors outside their insurance network even when the the care was performed at an in-network facility.

It's a small effort toward more clarity for health-care prices. It's not exactly price transparency for health care, though. Health care is complex and pricing can be confusing and convoluted.

Co-pays, deductibles, in-network, out-of-network, co-insurance, patient responsibility, negotiated rates, negotiated discounts -- all these phrases describe some part of the price patients pay for health care in addition to their monthly premiums. For most Floridians, that means money out of their paycheck.

While Obamacare gets plenty of attention in Florida (and for good reason because Florida has the largest number of people of any state signing up for health insurance via Healthcare.gov), four out of 10 Floridians get their health-care coverage through an employer. That makes the employer-based health insurance market the largest in Florida. That's slightly larger than the percentage of the population covered by government-provided Medicare and Medicare, according todata from the Kaiser Family Foundation.

WLRN has launched a reporting project aiming to help better understand health-care prices called PriceCheck. It's a database of prices that health-care facilities shared with our partner - Clear Health Costs -- and costs contributed by you.

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PriceCheck is a tool that you'll be able to find on our website. It does two things: It lets you share your health-care costs with the community - the charges from the doctor or hospital, what you paid… and if you have insurance, what your insurance paid.

The second thing it does is it will let you see what other people paid.

The U.S. spends $1 out of every $6 on health care, according to the World Bank.

2. Medicare's new plan for paying doctors

CMS on Wednesday released its long-awaited proposed rule for new value-based payment programs under the Medicare Access and CHIP Reauthorization Act (MACRA).

The law will fundamentally change how Medicare pays physicians and other clinicians who participate in the program. It will establish a two-track system for Medicare reimbursement: one, called MIPS, for providers who are reimbursed largely through fee-for-service, and an alternative payment model (APM) track for physicians who take on a significant portfolio of APMs. The Advisory Board will have much more to say on the MACRA proposal (more on that below) as we digest the 962-page rule, but here are 10 early key takeaways.

1. The rule underscores the complexity of MACRA. While CMS has made a valiant effort to keep implementation streamlined, the sheer number of elements in MACRA requires lengthy, complex rules.

2. CMS has heard the call to streamline this rule and minimize the burden on participants. Despite MACRA's complexity, it is clear that is CMS making a concerted effort to preserve simplicity and flexibility for providers. For example: The MIPS quality category will require providers to report just 6 measures, fewer than required under the existing Physician Quality Reporting System (PQRS); The MIPS cost category measures come from claims data, allowing CMS to calculate performance independently; The EHR use category-now known as "Advancing Care Information"-moves away from an all-or-nothing approach, and promises more customizable measures; and CMS defines two approaches to meeting the alternative payment models (APMs) threshold-based on either revenue at risk or number of patients attributed under risk.

3. MIPS will push medical groups of all sizes to invest in reporting and tracking performance on PQRS. MIPS requres PQRS performance accountability for groups of all sizes. Previously, reporting alone would satisfy PQRS requirements and small groups were not subject to the value-based payment modifier program. For all providers, MIPS means more accountability for PQRS performance than they've had in the past.

4. CMS set a high bar on requirements for APM track. Under the agency's criteria for payment models to be eligible for the APM track-which CMS calls "Advanced APMs"-the Bundled Payments for Care Improvement (BPCI) Initiative, the Comprehensive Care for Joint Replacement (CJR) Model, and Track 1 of the Medicare Shared Savings Program (MSSP) all will not qualify. Meanwhile, MSSP Tracks 2 and 3, Next Generation, and Pioneer-which all require downside risk-will qualify.

Less surprisingly, CMS confirmed that only Part B (traditional) Medicare payments will count toward the Advanced APM threshold. Payments from Medicare Advantage plans can count toward the "Other Payer" threshold beginning in 2021, but only if those payments are made through models that meet Advanced APM requirements. Notably, the rule does not address whether CMS will allow Track 1 ACOs to switch MSSP tracks mid-participation agreement to join an Advanced APM.

The proposal applies only to clinicians who bill Medicare Part B. In future years, Medicaid Eligible Professionals (EPs) and all hospitals would continue to work within the existing MU program.

CMS would keep their "two-year lookback" policy. For example, performance in 2017 would determine payment adjustments in 2019.

Providers traditionally excluded from MU would not be scored on EHR use. This includes hospital-based providers, those facing an applicable hardship, and advanced practitioners-at least for the first performance year.

What would change?

MU would no longer be a standalone program. EHR use requirements-now referred to as Advancing Care Information (ACI)–would account for 25 percent of a provider's total MIPS composite performance score. That composite score, in turn, would be used to adjust a Medicare provider's payments upward or downward, or keep them flat. The total maximum downward adjustment for Year 1 would be negative 4 percent, and the maximum upward adjustment is 12 percent.

The proposal abandons MU's "all-or-nothing" approach. Currently, MU requires that providers meet all measure requirements, including specific performance thresholds. Under MACRA, CMS plans to reward providers for both participation and performance toward EHR use-even if they don't meet performance goals.

The participation component relates to a "base score" that awards providers 50 points of the total possible 100-point ACI category score. To receive the base score, providers would need to complete a security risk analysis, be in active engagement with an immunization registry (or qualify for an exclusion), and report a numerator (of at least one) and denominator for all remaining measures. Failure to report all base score requirements would result in a zero score. In that respect, this part of the proposal is "all or nothing."

The performance score consists of additional points awarded for certain objectives. No minimum threshold would be required for each individual measure. Rather, providers would receive up to 10 points for certain measures; in theory these measures could sum up to greater than 50 points, but CMS caps this part of the category's score at 50. CMS focuses the performance score on the Stage 3 Patient Electronic Access, Coordination of Care through Patient Engagement, and Health Information Exchange objectives (or their associated Modified Stage 2 measures in 2017). Additionally, providers can add up to one public health bonus point if they achieve Active Engagement with a public health registry (e.g., Syndromic Surveillance, or Specialized Registry).

Will MU be better under MACRA?

The proposal improves parts of MU for Medicare providers. It gets rid of the "all-or-nothing" approach, which often frustrated providers. The ACI scoring method would afford more flexibility, letting providers choose to target certain measures to boost their scores-even if they underperform on other metrics.

 
 
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President, IPOF