Balanced Incentives and Healthcare Reimbursement

Healthcare payment reform is shifting again. At the rate of tectonic plates over the last 60 years, there have been several milestones that have utterly transformed the face of reimbursement. Diagnosis related Group (DRG) reimbursement, Managed Care capitation, and now the Medicare Access & CHIP Reauthorization Act (MACRA). MACRA will be a tsunami for Medicare reimbursement. With the Alternative Payment Model (APM) or the Merit based Incentive Program System (MIPS), reimbursement will be a synthesis of quality, technology, practice improvement, and cost reduction.

What will MACRA accomplish?

As with other historical reimbursement transformations, as Centers for Medicare & Medicaid (CMS) changes, commercial payers follow. For the MIPS alone, CMS will tie 30 percent (%) of their payments to performance outcomes by 2016, 50percdent (% ) by 2018, and commercial payers are targeting 75percent (%) of their payments by 2020. “Outcomes” involve a combination of clinical quality, resource use “cost”, health IT meaningful use, and clinical practice improvement activities (CPIA).

MIMPS is the balanced approach. Currently 50 percent (%) of the performance weighted is based on quality and PQRS reporting. By 2021, the balance will be 30 percent (%) quality, 30 percent (%) cost reduction, 25 percent (%) technology usage, and 15% practice improvement. The goal is to ensure that participating providers are working collaboratively to transform the delivery of healthcare. CMS is using payment disincentives for those providers not able to meet these outcomes. With the macro level, CMS plan to have a net neutral impact for all Medicare providers on incentives; some will receive bonuses, some will not.

Technology should always serve the healthcare provider, at the analytical level. MACRA is an organizational and multi-domain approach to transforming the reimbursement of care provided to those eligible for Medicare. This transcends to commercial payers and all patients due to process changes.

How Technology and MACRA Will Transform the Industry

Successful delivery of the MIPS activities above will be the synthesis of people, process, and technology: People to deliver the care, analyze patterns and establish quality improvement, care coordination and open access for those in the community, with technology as the critical infrastructure below both people and process. Actionable analytics and precise measurement to support reimbursement and margin analytics can only be attained if the full 360 degree view of the patient is available, consumed, de-duplicated, aggregated and delivered with the minimum amount of latency to the administrators, executives, and the care provider.

Technology is necessary to support the business, with the right balance of infrastructure and “at the glass” costing and margin analytics, intersected with clinical and quality outcomes. Oracle and its partners are recognized for the right blend of technology and service offerings that deliver world class data aggregation and top in KLAS population health solutions for MACRA, delivery reform, and value based purchasing.

Oracle Healthcare’s Offering

Oracle’s Health Sciences has a staff of over 2500 professionals including physicians, PhDs, nurses, and clinical informaticists who guide the technical development and product offering for the healthcare market. Its Oracle Healthcare Foundation (OHF) is a unified healthcare analytics platform for data integration and warehousing providing clinical, financial, administrative, and omics modules. Building upon OHF, healthcare organizations can deploy pre-built business intelligence, analytic, data mining, and performance management applications from Oracle and its partners. These organizations can also leverage OHF’s out-of–the-box, self-service, analytics tools to build customized analytics applications.Currently OHF is implemented in such prestigious health systems as Los Angeles County Health Department, Penn Medicine, and Adventist Health System with 43 locations, and hundreds of individual hospitals participating.

Oracle Healthcare Partners

Oracle’s HSGBU has an active and expanding partner ecosystem that encourages pre-integration with top in KLAS population health vendors and Big 4 Healthcare advisory service providers. The partner ecosystem is active and mirrors the population health market to fulfill current and emerging business needs and include the full range of population health, evidence-based medicine, risk modeling, ACO, alternative reimbursement models, and value base contracting models (including MACRA).

The following are two of the HSGBU’s partners that offer knowledge leadership and successful accomplishment in the MACRA and delivery reform space:


Deloitte is a Diamond-level partner and has been awarded Oracle’s highest honors for the past six years in a row. Additionally, Deloitte is the largest health care consultancy in the marketplace and a national and global leader when it comes to serving complex, multifaceted organizations. Analysts, including IDC, Gartner and Forrester, have both ranked Deloitte as a leader in EPM and Finance Transformation.

Oracle and Deloitte have developed a “Triple Aim in the Box” solution in response to MACRA reform. Triple Aim in a Box combines Oracle’s packaged software applications providing a flexible, scalable platform and leading practice accelerators, with Deloitte’s implementation and integration services. Together, these apps and services enable clients to customize and configure a healthcare solution for their specific needs. This solution has a “start anywhere” approach that gives healthcare organizations the flexibility to advance their analytic capabilities across all three Triple Aim pillars, while prioritizing components that are critical to them.

SCIO Health Analytics – Medicare Claim Analytics

SCIO Health Analytics is one of the fastest growing technology companies in the US, having featured for four consecutive years on the INC5000 list and twice on the Deloitte Technology Fast500 list. In 2015, SCIO Health Analytics® Ranked as Major Player in IDC Health Insights’ 2015 Payer Analytics Marketscape Report. SCIO has been recognized by CMS with several CMS innovation awards focused on Medicaid members. Recently, SCIO was awarded the CMS Centennial Award for its relationship with the State of New Mexico.

Learn more via our on demand webcast, MACRA, Analytics, and the Move from Volume to Value.

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