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Adam J. Weinstein, MD, is vice president of medical affairs, clinical IT services for DaVita Kidney Care, a part-time nephrologist in Maryland and chair of the Renal Physicians Association's Quality Clinical Data Registry workgroup.
There's no one-size-fit all solution, but there are common strategies practices can take to adapt to value-based programs.
As we enter the second year of data collection for Medicare’s Quality Payment Program (QPP), it is worth thinking through some higher-level thoughts and strategic goals. Adapting to the increasing amounts of quality-based reimbursement requires practices and providers to undergo “practice transformation”-adopt population health tactics through process changes, expanded use of data and changes in the work performed by providers and staff.
Unfortunately, there are no recipes or easy answers. Each practice must identify the needed changes based on their local environment, opportunities, as well as their organizational capacity to evolve.
Practices attempting to participate in any value-based programs need an organization-specific operational definition of transformation.
In the context of the Medicare program, transformation means to adopt the necessary policies and tactics that allow for the identification of high-risk patients (outliers) and patients who are not receiving expected care (gaps). Beyond addressing the individual patients, a practice must bake in process improvement activities based on patterns gleaned from monitoring for high risk patients. While the QPP provides a framework for the end points of these changes, practices need to decide the “what” and the “why” of the transformation.
Will the QPP’s Merit Based Incentive Payment program (MIPS) be the immediate end goal or will working to participate in Advanced Payment Models (APMs), regional clinically integrated networks and/or private payer quality incentive programs make the most sense?
Who in the practice will be asked to do the work of population health activities or will new staff be hired?
How will short and long-term success be measured outside of quality-based payments?
What is the opportunity cost of transformation-i.e. at what promised penalty or reward is the time and effort worth the risk?
Irrespective of the answers to these questions, the first step is to simply identify the disease processes, patient subgroups or specific outcomes that reflect the care your practice delivers and begin the process of identifying patients who are furthest from meeting the goals.
The QPP requires that practices use certified electronic health record technology (CEHRT) in some capacity. However, EHRs are just one aspect of the tools necessary to perform population health activities. The most commonly used EHR features do not typically offer a robust set of population health tools. As such, practices taking steps to transform must make the necessary strategic investments in using analytics/population health tools. Though this functionality is increasingly common in some EHRs, the most common population health tools are used by payers and organizations that bear financial risk.
As such, many practices may find themselves having to invest in a broader set of EHR features or an entirely new software plus data connections to their EHR. Common features of these tools often include dashboards, learning aids, and lists of patients and specific clinical data points pertaining to measures and metrics the practice is interested in. Unfortunately, these programs often only contain a portion of a practice’s patients-the portion associated with the payer or program. Either way, it is critical to understand that implementing population health strategies requires more than just an EHR system.
These strategic investments must also include staff time to learn, understand and implement the use of these tools. When it comes to participating in the QPP, spending time, money or both must be considered investments with a long timeline to return on investment.
To this end, it is highly unlikely that the training and software will show significant financial returns in under 24 months. Even the two-year timelines established by the QPP (data reported this year will impact payment in 2020) only captures a small part of the time it takes to develop and integrate a population health program. As such, in addition to understanding the tools that are required for transformation, it is equally important to understand the financial impact.
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The move to a population health-focused practice takes investment and yields returns that may span multiple years and come in the form of avoided penalties and earned bonuses from a variety of payment sources. Truly a mind-boggling accounting endeavor.
The ultimate goal of all this change is to yield the sort of organization that layers thinking and action at two levels: the care of individual patients and for groups of patients. This requires staff in new or expended rolls to oversee the necessary granular steps for successful data capture, changes in care delivery based on insights from the analysis of that data and reporting the best of this data to CMS or other entities.
This notion spawns several questions:
• Who in the practice selects measures that are reflective of the work done by the clinicians?
• Who understands and can train others as to where in the workflow needed discrete data elements can be captured and where in the EHR those data are recorded?
• Who monitors the integrity of the captured data?
• Who institutes and monitors improvement programs when gaps in data integrity are identified?
• Who ensures there is accurate and timely transfer of data between the electronic health record and whatever analytics packages are being employed?
• Who monitors and reports insights from the analytics package that allows clinicians to be alerted to gaps in clinical performance before data is reported to the payers?
All of this, and more, are roles that are not typical in a traditional medical practice. Undoubtedly, the job descriptions of frontline nursing and office staff will need to be updated. But these kinds of skills may require new talent with a background in data management, IT systems integration and/or performance improvement. While it may not be possible to identify each person accountable for these answers on day one of QPP participation, the answers must be clear before the data is due.
Practice employment agreements must also be updated. No longer is it realistic to have providers compensated solely on relative value unit production. Given the offset between data submission and payment adjustments, there must be elements of provider compensation based on the more interim steps of quality data gathering, quality measure performance, in addition to any value-based program payment adjustments.
In addition, contracting should address concepts around the portability and ownership of physician-related quality data. This will become painfully relevant if a provider changes practices in the middle of a reporting year or is anticipating some sort of value-based payment after a job change. The goal must be to have compensation and work expectations calibrated to reflect the reality of revenue generation for the practice.
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The fact is, completing notes and bills, seeing enough patients per day and/or capturing hospital or nursing home charges may no longer be enough to be successful. There may very well be a point in the near future when a clinician who sees a high volume of patients, but does not capture the correct discrete data consistently, could earn less revenue than a data-oriented and pop-health focused clinician.
Seeing fewer patients, while capturing data conscientiously, dedicating time each week to population health activities and working toward avoiding ED visits and well-coordinated discharges from the hospital may be the new picture of success. Realistically, it will take several years to agree and enact such changes to the typical employment agreements in the typical practice. However, creating a chain of accountability from the exam room to the practice’s quality payments two years later requires such change.
Despite all this “good advice,” it may seem idealistic and obvious. The hardest part is the economics of this process. There is no easy way to align the costs of practice transformation with the stream of revenue, at least to the degree to which it is required. Investments in time, and energy often feel like expensive distractions from the day-to-day work of a high-volume, encounter-based practice.
To be sure, there are short-term lost revenue opportunities. The contracts and programs that would yield the financial return on investment for these kinds of changes are still nebulous and new. And yet, to demonstrate even a modicum of success in even the QPP, some minimum threshold of transformation is required. It is difficult to do only a “little bit” of population health.
Participation in QPP/MIPS or a well-managed advanced APM are good first steps. A thoughtful practice walking down either of these paths would be wise to aim for more than just the minimum work for the most immediate financial gains. Rather, understanding and implementing the larger lessons, tactics and strategies can be the initial momentum needed in getting closer to the loftier goals of practice transformation and population health. Ultimately, and irrespective of the short-term economics, the question is: How many of these changes can you afford to ignore?
Adam J. Weinstein, MD, is vice president of medical affairs, clinical IT services for DaVita Kidney Care, a part-time nephrologist in Maryland and chair of the Renal Physicians Association’s Quality Clinical Data Registry workgroup.