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Todd Shryock, contributing author
Come out swinging for patients.
If doctors want to continue providing the best care for their patients, they will need to fight through the challenges of data reporting and government mandates accompanying the transition to value-based care.
The biggest driver of the shift is the Medicare Access and CHIP Reauthorization Act (MACRA), but its data-reporting requirements have many doctors confused and concerned about implementation costs and their effect on practice finances. It’s all part of a broader government-mandated move away from fee-for-service medicine, and that’s not going to change.
“Everything down the road in reimbursement is going to be based on quality and outcomes,” says Joseph Schlecht, DO, a primary care physician in Jenks, Oklahoma, who has been tracking and reporting quality data for more than a decade. Practices cannot be run the way they are now, and if they fail to change, the doctors running them will be looking for a job in five to 10 years, he adds.
While physicians struggle to figure out the next steps for their practices, they need to keep in mind that the shift away from fee-for-service is not just about saving money for Medicare or increasing profits for insurance companies-patients benefit when value-based care is done correctly.
“Putting quality-based protocols in place allows a practice to get better outcomes and achieve better quality, and that’s what payers and the public want for the future,” says Schlecht.
For doctors to succeed in this new environment, they will need to understand the challenges of value-based care and embrace them, says Lerla Joseph, MD, a primary care physician in Richmond, Virginia.
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“I think the first step is to understand what [the Centers for Medicare & Medicaid Services (CMS)] is requiring and what other payers are requiring,” says Joseph, who formed an accountable care organization to join forces with other doctors to navigate the challenges of value-based care while maintaining her independence.
Members of the ACO work together to improve quality and help each other work through the best way to comply with
MACRA. “It can seem a bit daunting when you look at all the metrics, but value-based care requires you to look at a population and not just an individual patient,” she adds.
MACRA has two payment options: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). Most small practices will participate in MIPS, which calculates payment adjustments (bonuses and penalties) based on evidence-based and practice-specific quality data categories created by CMS.
APMs are payment models developed in partnership between CMS and the clinician community that provides added incentives to provide high-quality and cost-efficient care and may apply to a specific clinical condition, care episode or population.
Schlecht is in the Comprehensive Primary Care Plus program (CPC+), which is a form of a patient-centered medical home that qualifies as an APM. Before that, he was involved in other quality reporting initiatives, including some developed by his staff after he wanted to improve outcomes for his patients with diabetes.
Based on all this experience, he says doctors in MIPS need to know one thing: The only way to be successful in MIPS is to understand registries.
“Development of registries, severity indexing, [higher hepatocellular carcinoma] indexing-all will be critical for them to be successful down the road,” he says. “Identifying every diabetic in a practice and then putting protocols in place like three-month visits, foot exam every visit, eye exam once a year-all those need to be put in place.”
Registries will help a practice identify patients who require additional assistance and highlight where the practice is doing well and where it needs improvement when its numbers are compared to other practices. Both Schlecht and Joseph encourage physicians to check with whatever professional organizations they belong to for help with registries and getting started with value-based care and MIPS. “Look around and see what exists that matches your values and then go for it,” Joseph says.
This year, MACRA has a pick-your-pace option, meant to encourage physicians to try the program at their own speed, but some haven’t done anything yet. Experts say it’s not too late to get started.
“Don’t write off 2017 yet,” says Anders Gilberg, MGA, senior vice president of government affairs for the Medical Group Management Association. “The reporting periods are 90 days and you can still be eligible for the upside bonuses, even if you haven’t started. It’s good to report a few measures to protect yourself now while you continue to learn.”
Protection comes in the form of avoiding a 4% reduction in 2019 Medicare payments for not reporting anything under MACRA in 2017. “The worst thing you can do is take the 4% penalty,” says Gilberg. “It’s too easy to avoid. It would be a shame for physicians to not participate in the context of, ‘it’s too much for me.’”
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To avoid the penalty, physicians need to report only one quality measure or improvement activity, and can start collecting data as late as October, with data submission due March 2018.
Gilberg suggests practices look at the list of measures on the CMS website and search for things the practice is already doing. One possibility might be extended office hours. “Many practices have extended hours because of competition from urgent care centers and many primary care physicians have Saturday hours,” says Gilberg. “These are the types of things that are relatively easy to do, that you may already be doing and will help you be successful in avoiding a penalty.”
There are other easy wins, says Randy Buchnowski, MHA, FACHE, network executive for Halley Consulting Group, a practice consulting firm. He says that the clinical improvement activities category is a “slam dunk,” with 92 options to choose from. For example, if a physician provides timely notification of test results to patients-with the definition of “timely” left up to the physician-that’s a measure that can be attested to and is enough to avoid the 4% penalty.
Doctors can also report as a group, which may be less of a burden, because if one member reports, the entire group gets credit. Everyone in the group will receive the same score, so make sure performance measures are the best the group can deliver, Buchnowski says.
Another place to look for easy wins under MIPS is what a practice is already doing for Medicare quality and value reporting, says Buchnowski. Three of the four categories that make up MIPS-quality, advancing care information and cost-replace physician quality reporting system (PQRS), meaningful use and value-based modifier respectively, and there are a lot of similarities in reporting options.
“These are things that are probably already being done, so let’s not reinvent the wheel,” he adds. “Whatever you do, make sure it works for you in meeting the standards and that it adds real value to patients.”
For Joseph, chronic care management plays a big role in caring for patients and meeting the MIPS requirements. “Between annual wellness visits and chronic care management visits, you can meet two-thirds of MIPS metrics if you can get patients in for those,” says Joseph. Because she is reporting data to MIPS, Joseph will avoid the penalty and be eligible for a payment bonus, depending on how she performs relative to other practices.
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And MIPS isn’t a death knell for independent practices. There are ways to comply while retaining independence: Joseph is using her physician-led ACO to unite practices to work through the challenges as a group; Schlecht is participating in CPC+ to comply. Familiarity with legacy programs like PQRS will make it easier for smaller practices to understand and comply with MIPS.
“I don’t think MIPS will force an independent practice to join a larger health system,” says Buchnowski. “There may be other forces, like access to a better [electronic health record (EHR)] that a small practice can’t afford, but I don’t see anything in MIPS that will force a provider to become part of a larger system.”
Physicians next need to fully commit to value-based care. The penalties for not doing so will come not only from MIPS, but possibly from private payers.
The noncompliance penalty for MIPS increases to 9% by 2023-a substantial hit to any practice’s Medicare revenue. Private payers are likely to create their own incentives and bonuses, if they haven’t already, that may be based on the same quality measures, so a practice’s revenue might be reduced by penalties from them, says Robert Dean Jr., DO, a critical care physician and senior vice president for performance management at Vizient, a Dallas-based healthcare performance improvement company. “You really have to look at how much you might be sacrificing by not making this investment in value-based care,” Dean adds.
Investment can come in many forms, from having an EHR that’s certified to 2015 standards to population health tools or care coordinators who can help manage complex patients.
“Not only do they need to look at the chronic diseases, but some of the social determinants of health, which are really important in value-based care,” says Joseph. Social determinants are factors like access to safe housing, education and healthy foods, which can all have an effect on whether a patient adheres to treatment.
“Once you put the registries together, ID your complex patients, you’ll find all sorts of reasons why they aren’t keeping up, such as they don’t have transport or can’t afford their meds,” says Schlecht. “Then you can match them up with programs that are in place to get them to participate and help take care of themselves.” The result is better care for the patient and high quality numbers for the doctor.
Schlecht has seen his practice’s diabetes treatment rankings go from the bottom quartile to the top-and knows that patients are better cared for as a result. “The goal is better quality and costs, and we achieved that compared to where we were at the very beginning of the effort,” he says.
CMS’ stated goal is eventually to move all practices into APMs, but for most small practices, the only realistic path now is to start in MIPS and see what additional APMs are offered in the future, says Buchnowski. APMs are shared-risk models, and most small practices are not ready for that. Because many of the quality measures in APMs are the same as those in MIPS, moving forward with MIPS gets a practice ready for a future transition to an APM, he adds.
Gilberg says doctors that want to stay independent need to not only educate themselves about MIPS and APMs, but understand the capabilities of their EHR and practice management systems and how they can help capture the data for quality reporting that drives performance.
“Familiarize yourself with MIPS and have conversations with your vendors now on how they can help,” says Gilberg. “Take the basic steps to protect yourself and your practice while at the same time looking at the ways you can get some positive payment opportunities for things you may already be doing.”
Dean says that as doctors adopt value-based care protocols, the results will be positive for both them and their patients. “When they adopt some of these things, we see many clinicians feel like they are taking better care of their patients. We are seeing an increase in the improvement of burnout and more joy in their work. I think we need to get through this transition, but they are all things that will make patient care and the practice of medicine better.”