During a House Energy & Commerce Subcommittee on Health hearing on April 19, various physician leaders gave their thoughts on the key elements needed for a smooth transition into the upcoming Medicare Access and CHIP Reauthorization Act (MACRA).
The subcommittee heard from Patrick Conway, M.D., deputy administrator for innovation and quality at the Centers for Medicare and Medicaid Services (CMS), last month, during a hearing that focused largely on current capabilities of the industry to measure value and outcomes in the fashion that will be necessary for participation in Merit-based Incentive Payment System (MIPS) or an alternative payment model (APM). During that hearing, Conway alluded to forthcoming coming flexibility under the meaningful use program, which becomes one of four performance categories for those physicians participating in MIPS. Beginning in 2019, payment adjustments will begin for physicians as they choose between the new MIPS or participate in a qualifying APM. But, those adjustments will be based on previously reported data starting in 2017.
It has been a year after the MACRA bill was signed into law, but as reported by Healthcare Informatics in one of its Top Ten Tech Trends of 2016, physician leaders find themselves in quite the precarious position, as even as the first program year of the law is scheduled to start in less than 12 months, there is little awareness about the health IT provisions of MACRA amongst the provider community. The White House’s Office of Management and Budget (OMB) is currently reviewing a proposed rule that it got last month that will implement MACRA, and industry insiders estimate that for a rule this size, publication should be expected later this spring. The final rule is expected to be completed this fall.
On Tuesday April 19, the Subcommittee on Health held its second hearing on MACRA, with several physicians present to give witness statements and answer questions, including: Jeffery W. Bailet M.D., executive vice president Aurora Health Care, co-president Aurora Health Care Medical Group; Barbara L. McAneny, M.D., on behalf of the American Medical Association (AMA); Robert McLean, M.D., on behalf of American College of Physicians (ACP); and Robert Wergin, M.D., board chair, American Academy of Family Physicians (AAFP).
Congressman Joe Pitts (R-PA) chairs the Subcommittee on Health and opened the hearing by advising physicians to participate in current value-based programs to act as springboard for MACRA. He said they should also start evaluating options available to them regarding whether MIPS or an APM is right for them for the future of their practice. Congressman Gene Green (D-TX) added that the physician stakeholder community has provided extensive feedback regarding the legislation and is continuing to work with this subcommittee and with CMS to make sure this legislation works, noting that Congress’ intent is for quality measures to be tailored to specific specialties.
Meanwhile, Congressman Michael Burgess (R-TX) said that MACRA, with the repeal of the Sustainable Growth Rate (SGR) formula, signals a five-year cessation of hostilities between Congress, federal agencies, and physicians. “We need to make certain that we get it right and put the power back in the hands of those who provide care so that doctors, not agencies, will help shape the programs of the future,” Burgess said.
Docs Continue to Wait
Broadly, the AMA, ACP and AAFP all expressed support for MACRA in their witness statements, referencing the broken system of reimbursement patches under the SGR formula, and the need to align and simplify quality reporting programs. “The legislation will truly reward those who have made investments or evolved into advanced practice structures like patient-centered medical homes (PCMHs) or other alternative delivery models where data and clinical metrics are used to improve population health and healthcare delivery,” according to an ACP statement given by McLean.
That being said, there is a burning desire among the physician community to know more about the law and also ensure that successful implementation of MACRA does indeed occur. According to AMA, success will be the result of CMS requiring rulemaking that will constructively 1) consolidate performance reporting; 2) broaden participation in APMs; and 3) improve measurement to reflect differences across medical practices. ACP also noted a fourth necessity—reducing physician burnout. “Hence the Triple Aim is now becoming the ‘Quadruple Aim’ with a fourth goal of ‘improving the work life of healthcare clinicians and their staff,’” according to an ACP statement. AMA’s McAneny added, “People know that MACRA is there but not how it will apply to them yet.”
ACP’s McLean additionally noted that MACRA gives physicians more individual control over Medicare pay, since it is based on quality. He said, regarding MACRA, he is most excited about the idea that physicians can take a lot of data floating around and make it actionable and incentivized. “There is also a lot out there on clinical guidelines and measures, so how do we use them? Those [elements], if they can be put into a situation where physicians can be incentivized to use this data well, then we can make that a part of our daily flow leading to better, safer, and more reliable care, and happier doctors since they won’t be checking boxes just because CMS told them too,” McLean said.
Aurora Health Care’s Bailet noted that physicians are in varying stages of readiness for value-based payment, and there will be a significant learning curve for taking on financial risk. Still, he said, "With MACRA, physicians are preparing for a payment system away from an unsustainable fee-for-service model." When asked what physicians can do now to better position themselves for MACRA, he said that it is simply not enough to purchase an electronic health record (EHR) system, as the data collected by these systems must be analyzed and interpreted in ways that, when reflected back to physicians and their care teams, it’s meaningful and actionable allowing care teams to deliver the highest quality of appropriate care that delivers the most value to patients. This also ensures best practices, once identified, can be disseminated across the entire healthcare system through shared learning and collaboration, Bailet said in his statement.
He then gave an example of how Aurora launched two predictive analytic pilots focused on preventing hospital admissions and readmissions for two patient cohorts, one with congestive heart failure (HF) and the second with chronic obstructive pulmonary disease (COPD). Using a predictive analytics tool, Aurora was able to identify and stratify a population of HF patients who had an 80 percent or higher likelihood of needing to be hospitalized as a result of their disease within the upcoming six-month period. “We then redesigned our care approach to this cohort of patients using health coaches, frequent proactive outreach and engaging patients to take active ownership of their treatment and health status. A similar approach was utilized for the COPD patient cohort. This effort helped Aurora reduce our congestive heart failure related admissions by 60 percent in a two-year period, and a 20 percent reduction in COPD related admissions for the COPD cohort,” Bailet said, adding that the infrastructure needed for this type of care delivery is not something that can happen overnight. “It will take time to build; we cannot move too quickly,” he warned.
Meanwhile, AAFP’s Wergin noted the need for physicians to currently “recognize and report to quality measures, and be a meaningful use EHR provider,” telling a story how his own practice was able to attest on the 90th and final day of the reporting period by having to get patients to call the practice in the waning hours so that a program threshold would be met. “Also, you should move towards a PCMH model, and even under MIPS, you will get credit for that. It’s a better delivery of care,” Wergin said.
When asked about CMS working as a partner with physicians within the legislation, the witnesses wholeheartedly agreed that CMS has been open and responsive to stakeholder input on MACRA. “They are listening, and we are asking them more than anything else to keep it simple and reduce the physician burden,” Wergin said. Added McLean: “From the get go, there has been ongoing dialogue between our organization and CMS, and we are very anxious about seeing the final rule. It won’t be perfect, but [CMS is] proving to be a willing partner and participant in conversations.”