The Medicare Access and CHIP Reauthorization Act (MACRA) appears to be a reporting challenge for many healthcare provider systems with few resources for managing the menagerie of measures. Indeed, with more than 270 measures in play, many systems have yet to jump in, but the deadline is inevitable. A plan of action is possible by recognizing and acting on these eight challenge areas: Challenge #1: High-level performance insight Challenge #2: Defining measure specifications Challenge #3: Data quality reporting requirements Challenge #4: Benchmarking data Challenge #5: Proactively increasing measures surveillance to enhance outcomes Challenge #6: Strategically aligning measures on which to base risk Challenge #7: Identifying measures with the largest financial impact Challenge #8: Taking risk in multi-year, value-based contracts Mid-to-large size provider groups need a strategy around MACRA quality measures and a tool to help them make sense of all the reporting requirements.

1. Tackle These 8 Challenges of
MACRA Quality Measures
̶ Dorian DiNardo
Maggie O'Keefe

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MACRA
The Medicare Access and CHIP
Reauthorization Act (MACRA) era is upon us.
Passed with overwhelming bipartisan support,
and addressing cost reduction and quality
improvement, MACRA is here to stay, regard-
less of the continued uncertainty surrounding
the future of the Affordable Care Act.
This seeming permanence means that Merit-
Based Incentive Payment System (MIPS)-
eligible provider organizations that have been
practicing watchful waiting from the sidelines
must now determine how to proceed.

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MACRA
While non-participation will result in a negative
four percent payment adjustment, submitting
something—one quality measure, one
improvement activity, or four to five required
advancing care information measures—will
prevent a downward adjustment.
Partial or full submission may result in a
positive adjustment, and for reporting year
2017, an organization can submit as few
as 90 days of quality reporting data, meaning
that capturing performance can begin as
late as October 2, 2017.

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MACRA
Uncertainty about program implementation
dates, permanence, and impact size, coupled
with the myriad competing priorities all health
systems face, has led some organizations
down a less resistant path.
The 2017 strategy may be to simply duplicate
prior Physician Quality Reporting System
measure strategies and apply this single set
across all physicians in the system.
As the financial impact rises, organizations
must craft a more nuanced, thoughtful
reporting strategy for 2018 and beyond.

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Plan a MACRA Strategy to Meet These Eight Challenges
Understanding the overall performance of a
health system across a variety of locations,
providers, and EMRs, to identify key areas
of focus can be difficult and time consuming.
Leveraging claims data can provide a
holistic view of the patient population and
its full continuum of care.
Measures with strong historical performance
can be identified as well as specific trends
on a system, department, location, or
provider level.
Challenge #1: High-level performance insight

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Plan a MACRA Strategy to Meet These Eight Challenges
While not perfect, this can provide important
input for determining which measures to go
at risk on, or focusing improvements for the
current performance year.
Organizations can maximize ROI by
targeting areas where success is most
plausible.
Challenge #1: High-level performance insight
Solution: MACRA Measures & Insights allows the user a
view into all the MACRA quality measure at the level of
groups, practices, and providers, to visualize relative
performance internally and across MACRA domains.

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Plan a MACRA Strategy to Meet These Eight Challenges
Each provider participating in MIPS must submit
sufficient data for six quality measures to achieve
the full performance score.
Success on any given measure comprises both
high quality care provision and high data quality.
Put another way, it is not enough to have every
eligible patient receive all the care she needs; this
care must be documented with the appropriate
codes or language to be counted as complete.
Challenge #2: Defining measure specifications

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Plan a MACRA Strategy to Meet These Eight Challenges
It is important to understand what CMS defines
as acceptance criteria to get a patient into both
the denominator and numerator of the
measures that will drive a performance score.
Challenge #2: Defining measure specifications
Solution: MACRA Measures & Insights has built-in CMS
measure specification logic to help organizations achieve
full quality performance scores.

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Plan a MACRA Strategy to Meet These Eight Challenges
Many MACRA measures require data elements or
codes infrequently captured in discreet fields or
imprecisely recorded.
A practice may be providing 100 percent of
needed depression screenings, but if this isn’t
visible in the data, then performance at the end of
the year will look inadequate, or possibly be
submitted only with a large amount of manual
chart extraction.
Given this process, there’s an ocean of data
points to consider.
Challenge #3: Data quality reporting requirements

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Plan a MACRA Strategy to Meet These Eight Challenges
With the chosen reporting mechanism, will
performance be better on foot exams or hemoglobin
A1c scores with diabetes patients? Childhood
immunizations or adolescent immunizations?
By integrating all these data points, a provider can
determine the high-performing measures, report on
those, and steer clear of measures that may have
data quality issues until those issues are resolved.
Challenge #3: Data quality reporting requirements
Solution: The Data Quality feature in MACRA Measures
& Insights illuminates those measures with criteria met,
source system issues, insufficient measure data, and
details the numerator and denominator.

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Plan a MACRA Strategy to Meet These Eight Challenges
While higher scores on any measure will always
be better, rates across measures do not provide
the most meaningful insights into where strengths
or weaknesses may lay.
Having 90 percent of patients with HbA1c under
control is notably more impressive than having 91
percent of patients with a BMI documented.
Success in quality measures is partially based on
moving targets—benchmarks established by the
results of provider peers, which CMS calculates
and provides only after the performance year is
complete.
Challenge #4: Benchmarking data

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Plan a MACRA Strategy to Meet These Eight Challenges
Organizations need a tool that does more than
help choose measures on which they are
successful as compared to benchmark.
It is even better if they understand where the
benchmark may shift, to know the standard to
which this year’s performance will be held.
Challenge #4: Benchmarking data
Solution: MACRA Measures & Insights displays performance
on each measure relative to national benchmarks, as well as
user-specified benchmarks or targets.

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Plan a MACRA Strategy to Meet These Eight Challenges
Too often, provider organizations don’t know
where they stand on any measure until the
performance period is over.
Not only does this not allow for any sort of
course correction that could change the
financial impact of the performance, but by
the time a provider sees where the care
gaps existed, it is often too late for them to
impact patient care.
Challenge #5: Proactively increasing measures surveillance to enhance outcomes

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Plan a MACRA Strategy to Meet These Eight Challenges
Integrating data (EMR, ambulatory, lab, claims,
etc.) into a single repository, such as a data
warehouse, and providing dashboards or portals
for providers to be proactive, understand where
to intervene, and setup improvements for
individual success, will enable the entire
organization to proactively improve patient care
and achieve a higher quality score.
Challenge #5: Proactively increasing measures surveillance to enhance outcomes
Solution: The Performance Details feature of MACRA Measures & Insights
can filter measures by data source, payor, provider, provider group, MACRA
domain, cross-cutting area, and other categories to visualize your data in a
proactive and responsive manner.

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Plan a MACRA Strategy to Meet These Eight Challenges
MACRA was passed as part of the growing
national urgency to bend the cost curve of
providing healthcare, while ensuring quality is
maintained or improved.
The quality measures that are part of the
program were not created in a vacuum.
For nearly all providers, other contracts exist
with their own associated quality measures.
Challenge #6: Strategically aligning measures on which to base risk

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Plan a MACRA Strategy to Meet These Eight Challenges
When thinking through MACRA strategy, ensure
insight into other applicable commercial value-
based payment contracts, CMS initiatives and
local and regional market pressures.
Oftentimes, there may be significant areas of
overlap where focusing on improvement may
help maximize the ROI of any investment in
quality measure performance.
Challenge #6: Strategically aligning measures on which to base risk
Solution: The Measure Alignment feature in MACRA Measures & Insights
allows the user to add more than just MACRA measures, including additional
contracts and financial arrangements. This cross-cutting view of organizational
priorities helps identify areas of overlap they may want to target.

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Plan a MACRA Strategy to Meet These Eight Challenges
Although the measures chosen to submit under
MIPS are each worth the same number of
maximum points, alignment is more powerful
when the relative financial impact of each
targeted area is understood.
For example, perhaps both diabetic foot exams
and breast cancer screenings are present in a
commercial payer contract.
Intervening in either of these areas might make
more sense than for a measure that exists in
MACRA alone.
Challenge #7: Identifying measures with the largest financial impact

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Plan a MACRA Strategy to Meet These Eight Challenges
However, if the commercial contract containing foot
exams is worth a fraction of the potential quality
dollars as compared to those available from the
payor measuring breast cancer screenings, then it
may be more prudent to target the latter.
Silos often exist between commercial and
government contracting groups, or between quality
and financial groups within a healthcare system.
Challenge #7: Identifying measures with the largest financial impact

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Plan a MACRA Strategy to Meet These Eight Challenges
User-supplied financial details must be aggregated
for unencumbered analysis to understand the full
financial impact of quality measures.
Challenge #7: Identifying measures with the largest financial impact
Solution: MACRA Measures & Insights gives users a more
holistic view by allowing them to combine and analyze their
information in new ways through aggregating financial, quality,
and contracting data.

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Plan a MACRA Strategy to Meet These Eight Challenges
Many health systems have the ability to
negotiate with commercial payers on the specific
measures they include in value-based contracts.
If organizations are aware of their existing
strengths and weaknesses in their data
and processes, as well as areas they must
focus on to be successful in existing contracts,
then this can be used to inform these contract
negotiations and to ensure selection of
measures with a likelihood for success.
Challenge #8: Taking risk in multi-year, value-based contracts

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Plan a MACRA Strategy to Meet These Eight Challenges
Challenge #8: Taking risk in multi-year, value-based contracts
Solution: MACRA Measures & Insights can ingest historical
measure performance data for comparing to established
benchmarks giving administrators the information they need on
which measures to include or exclude from at-risk contracts
and/or government reimbursement programs.

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There’s Help for Organizations Developing Their
MACRA Strategy
In addition to addressing the challenges listed
above, MACRA Measures & Insights can drill
down into provider practice performance
variation and integrate with other applications,
such as Community Care.
If a group decides to go at risk on a subset of
measures, these can flow into the Community
Care app, which tracks at provider and
patient levels.
Community Care can also display care gaps
in the EMR, notifying physicians of needed
interventions at the point of care.

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There’s Help for Organizations Developing Their
MACRA Strategy
MACRA Measures & Insights can analyze the
lack of compliance on, for example, depression
screenings, to help decide if there’s a data
capture issue or provisioning issue.
The product can stratify performance, enabling
an analyst to see problematic trends or areas of
excellence, allowing that to be applied to the
rest of the system.
For many provider organizations, MACRA’s
financial implications are large enough to make
a difference in their financial sustainability,
profitability, or margin.

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There’s Help for Organizations Developing Their
MACRA Strategy
Easing the Submissions Process
There are multiple reporting mechanisms
available depending on the MACRA reporting
model (e.g., the EMR, qualified clinical data
registry reporting mechanisms, or the Group
Practice Reporting Option).
While MACRA Measures & Insights is not a
certified submission product, Health Catalyst®
is exploring avenues, with CMS and other
vendors, to streamline data extraction and
make the submission process easier for
healthcare systems.

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MACRA Measures & Insights Relieves
Reporting Headaches
The prospect of reporting under MACRA
invites many complex and time-
consuming decision processes, as
provider practices consider the vast
matrix of measures and complex
reporting requirements.
MACRA Measures & Insights is a Swiss
Army Knife for measure managers.
The tool is a flexible framework that
tracks CMS and other payer measures to
give valuable performance insights for
provider organizations.

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MACRA Measures & Insights Relieves
Reporting Headaches
Multispecialty clinics can benefit by aligning
across common measures for their specialties
or tracking by individual provider within this
tool, thus easing the burden.
MACRA Measures & Insights integrates data
from multiple data sources—EMRs, claims,
and patient experience surveys, to name a
few—to break down silos between
departments so they can aggregate financial
details and paint a complete picture of the
MACRA landscape.

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For more information:
“This book is a fantastic piece of work”
– Robert Lindeman MD, FAAP, Chief Physician Quality Officer

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More about this topic
Link to original article for a more in-depth discussion.
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Preparing for MACRA: A Comprehensive FAQ for Physicians – Dr. Bryan Oshiro;
Bobbi Brown, Senior VP; Dorian DiNardo, VP of Operations and Performance Management
How Physicians Can Prepare for the Financial Impact of MACRA – Dr. Bryan Oshiro;
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Health Catalyst Success Story

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Dorian DiNardo joined Health Catalyst in July 2013. Prior to coming to Health Catalyst, Dorian
worked for PeaceHealth as a Senior Data Warehouse Developer. Dorian has a Bachelor of Science
Degree from Oregon State University and her PMP certification.
Other Clinical Quality Improvement Resources
Click to read additional information at www.healthcatalyst.com
Dorian DiNardo
Maggie O'Keefe joined Health Catalyst in July 2015 as Associate Director, Accountable Care. Prior
to coming to Health Catalyst, she worked for CCNC Services as a Clinical Data Analyst. Maggie
has a Master’s degree in Social and Behavioral Sciences from the Harvard School of Public Health
and a Bachelor’s degree in Religious Studies from Yale University.
Maggie O'Keefe