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CloudView blog

Ideas and insights to help health care providers stay informed and profitable in today's challenging health care environment.

Which Guarantee Is Not Like the Others?

by Stephanie Zaremba, Director of Government and Regulatory Affairs

2016 has been a year of tremendous change in the way providers are paid under Medicare.  This spring, I told you that Meaningful Use (MU) was ending for some providers.  My colleague Greg Carey followed up with news of MACRA, the 2015 landmark legislation which established a new two-track Medicare physician payment system emphasizing value-based payment models—and replaces Meaningful Use, among other things.

MACRA is a new Medicare reimbursement scheme which replaces its deficit-inducing precursor, the Sustainable Growth Rate, and is designed to set health care reimbursement rates on a more stable, budget-neutral, and value-based trajectory.  It represents a significant opportunity for CMS to implement the changes necessary to achieve HHS’ laudable goal of tying 90% percent of Medicare fee-for-service payments to value or quality by 2018. But it also creates a whopper of an administrative technocracy.

The stakes really couldn’t be higher—and neither could the reward.  The Merit-Based Incentive Payment System, or MIPS, will replace other pay-for-performance programs under MACRA, and it follows the well-worn logic of government mandated programs.  Consider MU, which debuted with a traditional “carrot” incentive payment model.  Purchase a certified EHR, perform, attest, and receive incentive payments. That strategy slowly transitioned over time to become a double-edged sword.  Failure to attest evolved into a 1 percent penalty on Medicare reimbursements, increasing to 2 percent in 2016 and 3 percent in 2017. 


No surprise, then, that Congress has decided to take the same tact once again, wielding carrots but whacking with a stick along the way.  And this time, both the upside and downside is dramatic:  perform at or above the national average to receive a 4 percent upward payment adjustment in your Medicare reimbursement rates, or suffer a downward adjustment to the same degree. By the time the program is fully rolled out in 2022, that increases to a positive or negative adjustment of 9 percent.

This type of double-edged sword would be a bitter pill under almost any condition, but it is especially so given the byzantine box-checking and reporting it requires.  It’s not that MACRA creates hurdles that are too high. athenahealth clients are proof that clinicians can jump through the hoops erected by CMS to achieve Medicare payments. Our MU attestation rate is more than twice the national average, and almost 99 percent of our clients will avoid penalties under the Physician Quality Reporting System (PQRS) and Value-Based Modifier (VM) programs in 2016.

Do we think that these complex requirements and administrative burdens result in better care? Not necessarily. At athenahealth, we’re proud of our clients’ results with these programs but have been advocating from the start for less intrusive, burdensome programs that reward creating real value, not just checking boxes.

Clinicians could focus more on patients and providing value if they spent less time trying to understand the ever-changing rules of the reimbursement game. Unfortunately, in the spirit of giving clinicians flexibility and one purportedly “streamlined” value-based payment system, CMS has sadly created with MIPS a program more complex then the ones it replaces. 

Alas, the road to bloated, complex, and unpopular regulatory regimes is paved with good intentions. 

We expect CMS to share their final MACRA rule this November.  But certainty, as with most government mandates, remains elusive.  So, seeing another chance to provide clinicians with certainty when the government will not, athenahealth has already decided to demonstrate its commitment to steward providers through this next round of change.

Enter our MIPS Guarantee, unlike any that we’ve offered before.  Just as providers are being asked to put their finances at risk, so is athenahealth.  Like with our MU Guarantee and PQRS Guarantee, we guarantee to cover the penalties for clients who use our services and do what is asked of them, but fail to meet the government’s bar. But this Guarantee is also bolder, and braver.  As an industry, we still know quite little about what the final rendition of MIPS will look like, how it will impact quality reporting, and what it will do to reimbursement over time.  Heck, we don’t even have a firm implementation timeline!  Yet we are so confident in the power of our network to track providers’ progress, make adjustments as needed, and get participating providers across the MIPS finish line—wherever that ends up being—we’ve decided to guarantee it.

I believe in the potential of Triple Aim: improving care delivery and patient outcomes while increasing efficiency and reducing systemic costs.  MIPS, as currently written, falls short of that potential.  That, of course, isn’t providers fault.  At athenahealth, we will be ready to support our providers in whatever form MIPS finally takes.  It might not be everything, but it’s another piece of how we can ultimately unbreak healthcare.



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