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New Medicare payment system still coming into focus, but practices should act now.
Reimbursement under Medicare is about to evolve yet again. While the rules are still being finalized, providers should be getting ready for their unveiling this fall.
The Centers for Medicare & Medicaid Services (CMS) recently announced its proposed rule for the Merit-based Incentive Payment System (MIPS), which will measure physician performance in four categories-resource use/cost, quality, advancing care information and clinical practice improvement activities-with bonuses or penalties that could eventually reach up to 9% of physicians’ Medicare reimbursements.
While the bonuses or penalties don’t start until 2019, physicians and practices must begin reporting their results in January, notes Robert Doherty, senior vice president, governmental affairs and public policy at the American College of Physicians (ACP). “There’s talk that it’s two years down the road,” he says, referring to the 2019 date. But it’s not if CMS start collecting data in 2017.
The first three categories essentially replace and consolidate parts of existing performance measurement systems, combining parts of the Value-based Payment Modifier, the Physician Quality Reporting System (PQRS) and the electronic health record (EHR) incentive program (Meaningful Use).
The fourth category-which will measure a practice’s performance in areas like care coordination, beneficiary engagement and patient safety-marks a new front in Medicare’s attempts to rate doctors and practices.
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Here’s how physicians can start preparing now to get their best scores in the four categories:
The quality measure, which will hold the most weight at the outset (50%), provides physicians with a menu of 200 sub-measures from which they must choose six that best accommodate their practice or specialty. One of those measures needs to be an outcome measure, and one needs to be “cross-cutting,” meaning that it’s applicable to all specialties.
This is somewhat streamlined from the nine measures required under PQRS and represents an improvement from the perspective of practices, says Owen Dahl, MBA, FACHE, a practice consultant. But what hasn’t changed for the better, Dahl says, is that CMS is still asking physicians for information and providing only modest feedback regarding long-term success and outcomes.
“Physicians are supplying data, but it stops there, other than some abstract reporting from CMS about how effective the treatment plans-data sent-have really been in improving patient care. This is a universal frustration for all offices I talk with,” he says. Still, Dahl sees the new format as more customizable, flexible and closely aligned with how practices actually measure themselves.
General quality measures include activities such as effective clinical care, patient safety, community/population health and communication and care coordination. Specific measures range from the percentage of the patient population between ages 50 and 75 who had colorectal cancer screenings, to percentage of patients 65 or older with a history of falls who had a risk assessment performed in the previous 12 months. The specialty-specific measures are subdivided into allergy/immunology/rheumatology, anesthesiology, cardiology and the like.
Eric Schneider, MD, senior vice president for research and evaluation at The Commonwealth Fund, says that the new rule addresses the problem under PQRS that primary care physicians were being judged on measures better suited to specialists, and vice versa.
Because physicians and practices are allowed to pick which measures to use, they should examine the menu and figure out where they might do well, suggests Cristina Boccuti, MA, MPP, associate director of the program on Medicare policy at the Kaiser Family Foundation. Ideally, those choices would be based on more than just strong hunches but instead be derived from data that physicians’ offices compile either from their EHR or through a simple spreadsheet program or other type of practice registry. But failing that, they will just have to go with their “best guess,” she says.
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Schneider suggests clinicians ask themselves, “‘What’s my current level of performance in each of the measures on the menu and how can I improve over time?’ The selection of measures where you’re already high-performing could be important, but also the selection of measures where there’s room for improvement over time.”
Doctors and practices also should select measures that reflect the types of clinical care they most commonly provide so they have sample sizes large enough to be statistically significant, Schneider says.
Harold Miller, president and chief executive officer of the Center for Healthcare Quality and Payment Reform, thinks the range of quality measures should be broader. The proposed list “doesn’t even come close to being able to address the various types of patient conditions and the different needs of patients,” he says. “You wind up with a lot of those measures being designed for patients with only one health problem and don’t work well for those with multiple health problems.”
Miller is also concerned that lower scores on quality measures sometimes occur because providers have taken on many patients with low incomes and/or who lack community or home supports. “There’s no change in the fundamental payment to address that. That could discourage physicians from taking on those patients,” he says. “If they have a patient population that may be sicker, or faces social challenges, physicians may be penalized for things that are out of their control.”
While in some senses CMS has streamlined the process for doctors, intensive compliance and reporting will not go away, Dahl says.
“The good news is, we don’t have three programs to monitor,” he says. “The bad news is, we still have programs to monitor and comply with.”
This replaces Meaningful Use, with physicians and practices choosing measures emphasizing information exchange as well as security and interoperability, i.e. how well their records communicate with those of other offices and stakeholders in the system, Boccuti says.
This includes tasks such as the ability to prescribe electronically, send messages securely and show that a practice has systematically analyzed security risks. No longer required will be measures of clinical decision support and computerized provider order entry, she says. To score well on this measure, Boccuti suggests ensuring that your EHR system communicates well with others and has appropriate security measures in place.
Schneider says the ACI score broadens and specifies what will be measured, while simplifying the process somewhat. “The use of electronic information under Meaningful Use is sort of a check-box, did you or didn’t you meet the standard?” he says. The ACI barometer “allows for progress on six dimensions: protecting health information, patient access to electronic records, patient engagement, coordination of care, electronic prescribing and health information exchange.”
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The updated system focuses more heavily on information exchange and patient engagement, based on the hope that providers and patients are sharing more electronic information, Schneider says. “The notion they’re building on there is to promote care coordination by enabling information to flow,” he says. “It isn’t that you have a patient portal and ‘X’ percentage of patients use it. Instead, you’re graded on how much information is being shared.”
Eliminating the clinical decision support and computerized provider order entry measures reflects the fact that those have become standard in EHR products. Consequently, it’s probably more appropriate to grade vendors rather than the providers on the presence or absence of those features, Schneider adds.
Dahl has found that practices generally are either very proficient with EHRs or have avoided them entirely, with very few in between. At the outset of MIPS implementation, he suggests continuing to use the patient portal and other systems put in place under Meaningful Use. Those who have gone beyond that, as one might expect, will be able to respond better to the reformulated measures under ACI and perhaps be ahead of the curve, he says. CMS has proposed point systems to track compliance with the new measures that Dahl summarizes as, “If you comply with ’a,’ ‘b’ and ‘c,’ you’ll get more points than if you don’t comply.”
“I have suggested to practices … to not jump on the bandwagon and try to solve everything right now,” Dahl says. “My message is, ‘Be aware of it.’ We don’t know how it’s going to evolve.”
Physicians and practices will choose from among 90 activities designed to measure
capabilities in areas such as care coordination, beneficiary engagement and patient safety.
As listed in the proposed rule, these activities include measures such as improving hemoglobin A1c control for patients with diabetes, prevalence of strep testing for children with pharyngitis, and percentage of women ages 40 to 69 who have had mammograms.
Examples of activities under patient safety could include assessing medication adherence or ensuring proper reconciliation of medications from more than one pharmacy, Boccuti says.
These measures are based largely on the requirements for board certification of the various American Board of Medical Specialties (ABMS) subgroups, Schneider says. Practices can select activities similar to those that ABMS boards have begun adding in recent years in addition to their traditional focus on evaluation.
Physicians must choose at least one such activity, such as demonstrably improving care of patients with diabetes, and they can get credit for more than one. Schneider adds that primary care physicians are enthusiastic about the individualization of measure selections and points earned as a result.
Schneider says at this point there are no specialty-specific activities practices should hone in on because that focus will depend on several issues local to the practice, its capabilities and past performance. In short: Keep doing what you do best.
This component does not require reporting by physicians or practices. Instead, data are gleaned from claims sent to Medicare throughout the year, Boccuti says.
CMS has added more than 40 episode-specific measures to MIPS to address concerns from specialists that the legislation doesn’t include measures that accurately reflect the types of care they provide, Boccuti says.
In addition to using their resources more efficiently, practices should look at their most recently-used codes and ask patients to bring in their explanations of benefits, Dahl says. That way they can determine whether the hospital to which they might refer a patient provides the best value for the procedure the patient needs, he says. And if it doesn’t, they can look for alternatives.
Across all of these measures, Dahl suggests understanding the broad concepts laid out in the activities without getting too immersed in details that could still be changed before the rule becomes final this fall.
“Think about how you might deal with it and gather data,” he says. “What are you doing for patient engagement and patient satisfaction scores, and how is that looking? What are you doing for safety, and are you doing any kind of measurements and monitoring of safe and unsafe practices, even to the point of making sure water on the floor is cleaned up?”
The American Academy of Family Physicians declined comment about the changes under MACRA. The American College of Physicians (ACP) is urging its members to familiarize themselves with MACRA’s requirements, offering assistance through briefing sessions.
Although finding the legislation potentially problematic because it’s required to be budget-neutral-meaning there will be losers as well as winners-on balance the ACP supports MACRA because it streamlines and combines existing programs in a way that will simplify requirements at least somewhat, says the ACP’s Doherty.
“We’re advocating for core sets of meaningful measures for each specialty,” he says. “Just because it can be measured doesn’t mean it should be. And other qualities, like compassion and time spent, are harder to measure. Like any proposed rule it won’t be everything we wanted, but they are taking meaningful steps.”
Shari Erickson, MPH, ACP vice president of governmental affairs and medical practice, notes that setting those thresholds will be tricky during the first year, given that there won’t be previous data across the categories.
In thinking through how to implement the necessary changes, physicians and practices should take bite-sized steps and not try to do everything at once, tailoring their approach to the size and nature of their practices, she says.
Among Erickson’s recommendations:
make sure you understand the law;
test your Meaningful Use procedures in 2016 because many of its components will continue forward;
continue to participate in PQRS because it’s not going away all at once;
survey the 90 options to date for clinical practice improvement activities to see which ones would best fit your practice; and
use the to existing feedback reports to measure your performance.
Robert McLean, MD, chair of the ACP’s medical practice and quality committee, says that simplifying Meaningful Use will help practices such as his, Northeast Medical Group in New Haven, Connecticut. He has testified before Congress, expressing concerns about the paperwork he deals with while attempting to care for patients.
“I just don’t want to take time away from patients to deal with administrative issues on a daily basis,” McLean says. “It is pretty remarkable when you get notes from specialists with pages and pages of things completely unrelated [to medical care] because they have to check boxes related to Meaningful Use. It is getting increasingly difficult to garner meaningful information.”