At the Health IT Summit in Philadelphia, sponsored by Healthcare Informatics and being held at the Warwick Hotel in central Philadelphia, a panel of industry leaders engaged in a bracingly candid discussion of the challenges that providers are facing under the requirements of the MACRA (Medicare Access and CHIP Reauthorization Act) law, including its MIPS (Merit-based Incentive Payment System) and APM (advanced payment model) components.
The panel discussion, entitled “MACRA and Bundled Payments Update—Staying Compliant and Keeping Aware of Policy Changes Affecting Your Organization,” was led by Mark Stevens of ARRAHealth Consulting, Inc. (Philadelphia). Steven was joined by Katherine Schneider, CEO of the Delaware Valley Accountable Care Organization (DVACO-Philadelphia), Anne Docimo, M.D., CMO of Jefferson Health System (Philadelphia), and Sriram (Sri) Bharadwaj, chief information security officer and director, UC Irvine Health (Irvine, Calif.).
The panelists plunged headlong into a discussion of the complexities and challenges of the MACRA law, including physician engagement, measurement issues, and overarching issues around policy and regulatory attention overload.
To begin with, Stevens asked Schneider to provide the audience with a very brief overview of where things stand with MACRA right now, including around clinician understanding of the law. “I’ve spent the last two years telling physicians that this is the biggest change in our lifetimes since Medicare, to physician practice,” Schneider noted. “And I’ve usually been met with blank stares. Remember, this law was passed two years ago, with broad bipartisan support; yet as recently as last fall, 50 percent of physicians couldn’t even tell you what it is; and only a small percentage could explain it. And, working in an ACO, particularly with small, independent practices, they cannot get their heads out of water long enough to study up on this. And there’s a lot of burnout, and people are overwhelmed.”
As a result, Schneider noted, at Delaware Valley ACO, “We have a team of practice support people to help our physicians develop patient-centered medical homes, and to do what they need to do in terms of what has been meaningful use and is now MACRA.” Going on to describe the choices facing providers, she noted that, “Potentially, there are large advantages in moving into the APM programs” under MACRA, “but there is substantial downside risk” in the regular APM track and in the advanced APM track, under the law. “If physicians take one of those alternatives, they don’t have to do the MIPS reporting. They don’t get a fee schedule adjustment at all, but a 5-percent bonus in their fee schedule every year. So potentially, there are large advantages, but taking risk is no small risk involved.” Meanwhile, on a very basic level, she noted, “Especially in terms of the independent practices, the end of meaningful use made headlines everywhere, so we had to counter the soundbite that ‘meaningful use was going away,’” even though in fact, the requirements under meaningful use simply became subsumed into requirements under MACRA/MIPS.
The reality, Schneider emphasized, is that the requirements under the MACRA program will be very demanding for physicians. “I don’t see how a small practice can achieve any of this, unless they’re tied to an ACO [accountable care organization] or some type of organization. And the vendors can help with some of it; but it is a heavy lift,” she said. “And what’s changed over time is this: MIPS is winners-pay-losers [system]. There’s a 4-percent penalty that funds a 4-percent bonus. So that’s an 8-percent spread, with a real potential impact. But in this first year, they’ve made it incredibly easy to avoid the penalty. Basically, if a practice reports anything, they will avoid the penalty. But the upside potential bonus has become much smaller. So now, suddenly, a lot of folks are looking at that 5 percent for APM participation, and saying, perhaps that might be a better deal?”
“Managing downside risk is a significant undertaking,” Dr. Docimo confirmed. “Those of you from Philadelphia might realize that the Jefferson of now is much different from the Jefferson of three years ago; we will have gone from a $1.8 billion delivery system to a $5 billion delivery system in just three years, through acquisition. And Jefferson has a clinically integrated network that’s a member of the DVACO. We have 1,300 physicians in our CIN, and about 700 are employed. There are a lot of independent physicians who have joined our network to be a part of the DVACO.” Importantly, with regard to fulfilling the requirements under the MACRA law, she said, “If you’re a practice of one, two, three, four, five physicians, the amount of time and energy you’d have to spend on this would be enormous. And so, the consequence of MACRA is that the people who did realize what was involved, looked to invest. And for those who decide they want to go at risk, they’re not going to do so as an independent practice, so it will be an interesting journey over the next five years.”
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