Identify Capabilities

With over 100 years of providing physicians leadership and guidance, the California Medical Association, the Texas Medical Association and the Florida Medical Association bring you experience to help navigate the new MACRA requirements including an easy-to-use Action Plan.

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Identify Capabilities

General Overview

The MIPS and Advanced Alternative Payment Model (Advanced APM) rewards clinicians for delivering high-quality and cost-efficient care. Successfully delivering on quality and cost goals require practices to develop and strengthen competencies and capabilities vastly different from those that drive success under today’s fee-for-service (FFS) model. This requires investment in new capabilities within the practice including analytics, performance management, risk management, patient engagement and technology.

The investment in these capabilities can be a significant challenge for independent clinicians and small practices.  CMS has offered limited financial support to help practices make up-front investments in capabilities – the ACO Investment Model (AIM) launched in 2012 offers direct federal financial support for rural practices but requires payment of the investment from any shared savings achieved by the practice. 

There are multiple strategies clinicians can use to develop or acquire the capabilities.

Assess Capabilities

Clinicians focused on success under MACRA require a level of integration and efficiency that would allow them to become high performers in the Quality, Advancing Care Information and Improvement Activities performance measures.  Providers must be able to monitor progress, evaluate performance against targets and take appropriate actions to stay on track to receive performance adjustments and shared savings.

This assessment is intended to assist the practice in a self-evaluation of the current capabilities.  The assessment is structure based on eight competencies with the goal of outlining a practice's capabilities, strengths and weaknesses.  

Capabilities Assessment

Capabilities Defined

There are eight key competencies that are important for success under MACRA, and in particular Advanced APM models.  Each of the competencies are equally important and can be implemented over time based on the pace of the practice's transition to be a high performer in both the MIPS and Advanced APM program.


Performance Management

Practices will need the ability to measure provider performance in two different ways – MIPS versus APM. For MIPS, the organization must understand the four different MIPS performance categories that will be weighted and used to calculate a final score. The final score is then compared nationally to all peers to determine whether the provider or practice is above or below the relative midpoint to determine the fee schedule adjustment. For MIPS, CMS has allocated millions of dollars to reward high performing providers who land above performance thresholds, so aiming high can result in additional performance payments.

Participation in an Advanced APM requires use of certified EHR technology (CEHRT) and bases payment incentives on performance in cost/utilization and quality measures comparable to those in the MIPS quality performance category. MACRA does not change how any particular APM functions or rewards value but instead creates extra incentives for APM participation.  The specific metrics required for Advanced APMs will be defined by the particular program.

Monitoring a practice’s financial, clinical/quality and contract performance on both a group and an individual level is imperative as every point matters.   By understanding and monitoring performance it enables proactive measurement surveillance to improve outcomes and facilitate targeted improvement.  When identifying focus areas for improvement, practices should be able to model the impact (i.e., quality and/or cost improvements) an opportunity might have to determine which changes will yield the greatest benefit.

Clinical Performance Management

Capabilities focused on improving the quality performance measures from a clinical process and out comes perspective. Capabilities include:

  • Logical and National Benchmarking
  • Group, Practice, Location and Physician Level Analysis
  • Evidence-based Protocols Adherence
  • Quality Performance Modeling

Financial Performance Management

Managing the financial health of a practice moving to value-based care requires an understanding of both upside and downside risk.  (Is there information on upside and downside).  Financial performance management is based on managing the volume and services of a population with the goal of lowering costs through improved wellness, care coordination and care management services. Capabilities include:

  • Financial Modeling
  • Resource Use and Cost Management
  • Cost/Efficacy Comparison of Treatment Alternatives

Contract Performance Management

Contract Performance Management solutions allow the practices to create "what if" scenarios to better understand how various contract terms impact payments for the services provided and accordingly reprice the contract.

As the market moves to performance based outcomes the comparison of alternative contractual terms on an apple-to-apple basis allows health systems to negotiate better contracts and drive revenues by optimizing financial performance. Capabilities include:

In addition, contract reconciliation from both a payer perspective and physician practice perspective is required to reconcile the practices performance.

  • Contract Modeling
  • Fee-for-Value Contract Reconciliation
  • Reimbursement Adjustments

There are new healthcare performance management tools emerging that offer an integrated platforms with a range of capabilities, including real-time integration of information and workflow to close performance opportunities.


Population Health Management

Population health management capabilities include risk stratification, care coordination and chronic and complex care management across a group of patients. It is built on a coordinated clinical team model that is directed by the physician and includes nurse care managers, social workers, behavioral counselors and community resources. 


Evidence-Based Care Delivery


Evidence-based protocols (EBP)

Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. Evidence-based protocols (EBP) are available for a number of conditions such as asthma, heart failure, and diabetes.

Incorporating evidence-based medicine into the practice is important under MACRA as this model of care offers clinicians a way to improve quality, reduce costs and engage patients.   Evidence-based medicine is not just about using evidence in treating a patient; it encourages open communication between patients and clinicians, so patients are engaged in making the decision that align with their values and preferences. 

As a practice matures, physicians will be measured and ultimately reimbursed on clinical protocol adherence, including the linkage to clinical outcomes.

Continuity of Care: Transitions in Care

Poor communication, incomplete transfer of information, inadequate education of patients and their family caregivers, limited access to essential services, and the absence of a single point person to ensure continuity of care all contribute to a lack of coordination when transitioning from one care setting to another.

Transitions in care encompass all the services, facilities and clinicians to promote the safe and timely transition of patients between levels of health care and across the care setting.  It targets coordinating patient hand-offs and the sharing of patient medical information across clinicians and care settings to reduce adverse events that include - inpatient readmissions and emergency room visits. As MACRA shifts focus to quality and cost, highly integrated transitions in care will be imperative to a practice's success in both MIPS and Advanced APM models.    


Care Management and Complex Case Management

Care management is a team-based, patient-centered approach designed to assist patients and their support systems in managing medical conditions more effectively. It encompasses care coordination activities such as medication reconciliation needed to help manage chronic illness.

Case management and Complex Case Management programs connect people who have complex health conditions and social needs to clinicians who coordinate and track their care over time. If successful, case management programs hold the potential for reducing visits to emergency rooms and hospital stays by making sure that people receive condition focused treatment in the community. The quality and effectiveness of case management programs varies, so there is a need for independent assessment of capabilities to demonstrate that case management has the key program elements in place to deliver the highest quality care.



Clinical Performance Improvement

Clinical performance improvement is a systematic approach to the analysis of practice and clinician performance; and the efforts to improve clinical, financial and quality performance.  It ensures clinical excellence through performance improvement, best practices, standardized processes, and use of tools to support workflow.

Under the MIPS program, the Improvement Activities require practices to select areas of improvement and to attest to improve the overall practice.   Examples include ongoing care coordination, clinician and patient shared decision making, regular implementation of patient safety practices, and expanding practice access.

It doesn’t just end with focusing on the MIPS improvement activities; both MIPS and Advanced APM models place an emphasis on quality performance.  For example, there are over 34 quality measures ACOs must report on before they are eligible for shared savings.

A variety of approaches exist to help you collect and analyze data, prioritize opportunities, implement changes and measure results. 



  • Model for Improvement: The Institute for Healthcare Improvement’s Model for Improvement combines two popular Quality Improvement (QI) models: Total Quality Management (TQM) and Rapid-Cycle Improvement (RCI). The result is a framework that uses PDSA (Plane, Do, Study, Act) cycles to test interventions on a small scale.
  • Lean Six Sigma ( Lean Six Sigma combines two popular QI models: Lean and Six Sigma. The result is a framework that provides a means for assessing value of potential QI efforts and an approach to executing QI projects, referred to as DMAIC, or Define, Measure, Analyze, Improve, and Control.


Patient Engagement

Patient engagement capabilities require clinicians to better engage the patient throughout the care process, while providing the patient with greater control of their own health data.  CMS has added patient engagement and care coordination requirements to MIPS through Advancing Care Information; one of the four components contributing to the MIPS score. CMS also emphasizes patient-centered care through its APM incentive payments. Robust engagement is one of the driving factors toward APM success.  

To achieve the objectives of MACRA, patient engagement has to be more than just working with patients to achieve health goals; it is understanding the ways clinicians can interact and engage patients to encourage them to manage their health from office visits to text messages to patient portals.

The fundamentals of patient engagement include collaboration, coordination and connectivity.  At a minimum, clinicians need technology that would allow patients to communicate with their physician consistent with the Health Insurance Portability and Accountability Act (HIPAA).

An online patient portal allows patients to access up-to-date personal health information such as diagnoses, prescriptions, allergies, and vaccination schedules as well as other personal biometric data. Access to an online patient portal with individualized care plan available 24/7 via the internet is a valuable resource to patients and clinicians. Patients may be able to view, input, and modify their personal and demographic information in real-time. A patient may be able schedule an appointment online or request a prescription renewal without having to call the physician’s office.

Key capabilities of an online portal may include

  • Online and in-office electronic patient intake forms
  • Online and in-office health history submission
  • Appointment scheduling and reminders
  • Personal Health Record; including access to lab results
  • Online pharmacy refill requests
  • Online and text secure messaging
  • Online bill pay

Additional capabilities practices will need to evaluate are

  • Sharing clinical information with patient and clinician,
  • Telemedicine capabilities
  • Remote monitoring integration
  • Online care plans access

A secure, interactive portal can also provide a comprehensive library of consumer-friendly medical reference materials pertaining to medical conditions, discharge summaries, procedure recovery, and after-care instructions. These educational materials would be available for a patient’s reference at any time.



Data Aggregation

Many in the healthcare industry believe that the single most important element of value-based care is data.  More importantly, data aggregation and the comprehensive analytics it enables will determine success, not simply contribute to it. 

Capturing clinical and financial data from information systems remains a significant barrier for many practices, especially with the challenges of obtaining information from multiple clinicians.  Data that is structured, comparable and timely is required to support the delivery of care as well as improving quality and costs. 

The better your practice (or vendor) is at aggregating and normalizing your data, the more actionable and impactful the analytical solutions. Creating a unified view of clinical, financial and social demographic data will allow a practice to perform many of the needed functions including risk stratification, financial management and care management. 

The sources of the data include:

Claims Data / Clinical Date / Socio-Demographics / Care Management Data

  • Claims Data: Most often obtained from payers or medical or pharmacy benefit managers
  • Clinical Data: Found within electronic health records (EHR), biometric feeds, lab feeds, pharmacy feeds or health assessments (by either the patient or care manager)
  • Socio-Demographics Data: Found in the electronic health record and the care management platform, including race, education, family status, income, occupation, all have an impact on health
  • Care Management Data: Found in the care management tool identifying the plan of care



Fundamental to success in MIPS and Advanced APM models is the adoption of a comprehensive analytics platform. Healthcare generates plenty of data, but actionable analytics are necessary to help interpret and apply data to managing populations and to improving quality.

There are several analytical functions focused on population management that can help clinicians assess population risk, stratify their patients based on risks identified, identify gaps in care, engage patients based on need, and close gaps in care and improve quality.

Risk stratification tools stratify, identify and prioritize individuals in need of support.  Risk stratification is performed at a population level (identify the disease states common to the practice) and an individual level (identify the riskiest patients, currently and in the future).   As individuals are identified as high-risk, the care team can support the patient through care management programs that are built on standard evidence-based protocols.

In addition, population management analytics are utilized to identify patients that are out of compliance with the standard of care for a specific condition.  By informing the clinical team of the patients with gaps in care, they can proactively take action; ultimately improving quality and patient satisfaction. 

Some of the features of an analytics platform include:

  • Benchmarking quality performance metrics;
  • Identifying areas of opportunity to improve quality performance;
  • Modeling of MACRA quality performance measures to determine optimal selection;
  • Stratifying patient risk to support predictive modeling;
  • Identifying gaps in care to support population and individual care management;
  • Supporting clinical decision making at the point of care;
  • Measuring clinical and financial performance on a population and physician level;
  • Managing outcomes to support contract management;
  • Delivering insights into patient behavior; and
  • Managing the performance of the practice.





Electronic Health Record (EHR)

Successful reporting on many of the performance measures under MACRA will require increasing the use of Certified Electronic Health Record Technology (CEHRT) over time. In 2017, a clinician can use the 2014 edition CEHRT, 2015 edition CEHRT, or a combination of the two. However, ALL clinicians must be on the 2015 edition of CEHRT beginning with the 2018 performance period.

Check you EMR for Certification

To support the Advancing Care Information requirements (ACI) of MIPS, a system will need to meet the following criteria:

Data Capture

Design and Performance




Quality and Safety

Finally, CEHRT must also be able to exchange key health data known as the Common Clinical Data Set using specified vocabulary standards when applicable. This will allow systems to “speak the same language” when sending and receiving patient data. All clinicians using a 2015 ONC edition CEHRT should be able to electronically send the following clinical information about a patient:

Common Clinical Data Set

  • Patient Name
  • DOB
  • Sex
  • Race
  • Ethnicity
  • Preferred language
  • Problems
  • Vitals
  • Smoking Status
  • Medications
  • Medication allergies
  • Lab tests and results
  • Procedures
  • Immunizations
  • Implantable Devices
  • Assessment and plan of treatment
  • Goals
  • Health concerns
  • Care team members


Care Management (Population Health Management)

Care management systems support care coordination, interventions and education for targeted patients (those identified as high-risk or those with a chronic condition). The system can be part of the EHR or can be a stand-alone system that integrates data with the EHR.    Traditional EHRs are not designed for care management purposes as they lack automated workflows that alert the care manager to follow-up on critical work items to support the patient.

Care management systems aggregate patient data across multiple health information technology resources, create a single patient record, identify opportunities for improved patient outreach and track the interventions.   The platform provides real-time insights to the care team to identify and address gaps in care within the patient population. 

Care management and care coordination systems support the care managers based on an Identify, Engage, Enroll and Monitor workflow model. 


Identify / Engage / Enroll / Monitor



Clinical and administrative leadership is key to moving from fee-for-service (FFS) to a value-based care payment model. While most practice leaders understand the basics, many are uncertain about how to guide their organizations through this transformation. Studies evaluating leadership in successful Advanced APMs identified several key factors.  

  • Consistent Communication

Consistent, proactive and transparent communication on all topics related to the change creates an atmosphere of trust and engagement across the clinicians, the clinical care team and the administrative team at all levels of the organization.

  • Seek Involvement and Input

Ensure clinicians and the care team have the critical information to drive ownership of the change throughout the transition.  Proactively answer the why, how and when of the change in a transparent and honest manner before those questions arise.

  • Adopt an Innovation Approach

Openness and adoption of a pro-innovation approach allows the practice to look at new ways of doing things.  This means encouraging new ways of thinking and executing. 

  • Fail Fast and Move On

When implementing new workflows or programs, the practice needs to be willing to take risks.  If the practice wants to be successful, then it must be willing to accept that mistakes will happen.  Instead of reacting negatively when something fails, understand the reasons for the failure and move on to the next opportunity to improve. 

  • Identify a Clinical Champion

The champion – a respected leader in the physician community - is a change catalyst with the ability to initiate, drive and manage the clinical and practice transformation across clinicians and the organization.   The champion develops and maintains relationships with all stakeholders to gain alignment and integration across the practice.