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.”
Too many reporting systems?
Looking broadly at some of the policy crosscurrents affecting providers in different states, Bharadwaj noted that “It’s interesting what’s happening here in Massachusetts versus in California. We went through PRIME,” he said, referring to the Public Hospital Redesign & Incentives Program. “Now we’re looking at the next level of DSRIP”—the Delivery System Reform Incentive Payment program. “The confusion,” he went on to say, “is that you’ve got DISRIP, MIPS, PQRS [the Physician Quality Reporting System], and the other reporting mechanisms we do, such as immunization tracking, etc. It’s a nightmare. If you ask the physician what he’s doing, he doesn’t know. And he hates the EMR. So my job primarily is to make sure that the EMR sucks less!” he said to audience chuckles.
“So we look at how to help the physicians manage this quantity of stuff happening out there. So I decided that we have to change this in Washington,” Bharadwaj said, referring to his participation in a provider advocacy group around MACRA. I can’t be the lone guy out in California trying to change this. So I threw my name into the hat to sit on the Public Policy Committee at HIMSS [the Chicago-based Healthcare Information & Management Systems Society], and got on. There was the issue of meaningful use reporting, with the requirement of a yearlong reporting period. And we said, you just cannot do this, and the reporting period changed to 90 days. So I think we as providers have to speak out,” he said, and urged other patient care organization leaders to become involved in advocacy work as the spirit moved them.
Meanwhile, Bharadwaj noted, the perspective of practicing physicians on MACRA is inevitably different from that of health system executives. “And when I look at this from the physician practice level, it’s a totally different situation. And it’s taking time for us to figure out what it all means. And everyone has this idea that if there’s a new rule out there, technology should be able to fix it. I can provide fields for them, but already the physicians are talking about ‘death by clicking.’ From a technology platform perspective, I think it’s more desirable to have something to help physicians communicate better with patients, because that’s the crux of what we’re trying to achieve—improving care and improving access to care. If the physicians are not given easy-to-use tools—already, they struggle with their EMRs. We have a program called Bring the Physicians Home for Dinner”—trying to improve the physician documentation environment so that physicians don’t end up spending endless hours completing their charting every workday evening.
“And it’s not your fault, as an IT person, about all the clicking,” Docimo told Bharadwaj. “You have to collect all the data being required to be collected. And there’s only so far we’ll get in terms of using IT. But I am hoping that somewhere there exists an electronic data warehouse that doesn’t end up requiring patients to fill out forms many times.”
Clinician engagement—when will it accelerate?
Later, the discussion shifted towards the question of how physicians and other clinicians could be engaged positively around MACRA’s requirements. “I think that as we get more towards risk, there will be a lot more skin in the game,” Schneider said. Right now, she said, “It is tough to make the argument that we’ll get a 2-percent bump as an organization, after doing all this work, and yet it might not mean anything for the physicians themselves.” On a broad level, she said, a key policy imperative will be moving towards reducing the number of outcomes measurement regimens that physicians have to participate in, across the healthcare industry. “We need to try to standardize towards a single set of measures; you have to do all these things for MIPS, and for Blue Cross and Aetna. And things are measured differently; and that’s what drives the doctors crazy. So having a common regulatory set would be great. Meanwhile,” she added, “there’s something about MIPS that’s similar to what happened under PQRS—at this stage, physicians can pick their own quality measures; but that game will end pretty soon, I suspect, because CMS [the Centers for Medicare and Medicaid Services] and MedPAC [the Medicare Payment Advisory Commission] are already onto the game; because which measures will providers choose? The easiest ones to fulfill.”
“Sri, you talked in your initial remarks about people needing to be engaged in process,” Stevens said. “And so far, we’ve established on this panel that EMRs suck. And MACRA sucks, too. How are we going to get MACRA to suck less? Comments are due to CMS by August 23, so this is a very timely discussion.”
“There are things that policy can drive, including better decision-making,” Bharadwaj said. “I sincerely believe that it can. MACRA as a program is great, from a vision perspective and policy perspective, at a high level. It’s definitely going to change the way we think about how we manage risk, including about how we improve care on a daily level. The concern is that it’s changed so much in such a short time. And that’s causing a level of concern among physicians. Sometimes, they just throw their hands up in the air, not wanting to do any of this stuff. Interestingly, I heard that from a health system CMO recently. He said, the work we need to do in terms of all of this reporting—collecting the data, making sure it’s correct, etc.—the entire process is too tedious. And the amount of effort we expend collecting the data and reporting on it, is not valuable. I am really concerned about the small physician practices. The small physician groups that struggle now—we need to help them. Making workflow changes, and collecting measures and improving performance based on measures, is a very big challenge. So yes, change is fine, but what are we trying to change? And are we throwing more into a system that’s already broken? That’s the question.”
“In terms of making MACRA suck less,” Docimo responded, “as Katherine pointed out, you can go down the APM paths, or MIPS. For Jefferson Health, honestly, starting down this path of ACO work, that practice transformation work, has been meaningful. And we get the credit for the quality and collecting data; and you can come up with methods to make it suck less. The employed physicians in an academic medical center assume that it’s someone else’s job to figure this out. And there will be one or two or five physicians, usually internists, who plunge into this, and everyone else just says, tell me what I have to do. As Katherine notes, among community physicians, there’s some level of engagement. The thing is, you can’t just go at risk without knowing who your patients are; you have to do some fundamental work first. So this could be like the school of getting ready, in terms of taking the fundamental steps you need to take. And if we can complete those steps, we can flip to the other side, on APMs. So the concept is very good. So I would work on individual practice levels to make those decisions.
“I’m the chair of the policy committee for the National Association of ACOs,” Schneider noted. ‘And if you’re not at the table, you’re lunch on the table. And I think the reason that MACRA sucks so much is that this is a brand-new thing, and we’re in an intense period of change in healthcare, and it’s very challenging. And the only person who likes change is a wet baby. And so who likes change? Change is hard. Transition is hard, and people are uncomfortable with it. But we can’t maintain the status quo, either. And it feels hard because I’m not sure that it feels like work that matters, for people. So that’s our motto at DVACO, work that matters. And there are a lot of physicians who are extremely skeptical that any of this will make any difference. And frankly, it was ludicrously watered down to help physicians to avoid penalties. So it sucks for those who don’t want to do anything, but it also sucks for those like us who have made major investments, to see how low the penalties are for not acting. But this is unquestionably, 100 percent, a move away from fee-for-service, and it has bipartisan support” on Capitol Hill.
“What are some of the successes you’ve all had so far?” Stevens asked. “Readmissions is one area,” Bharadwaj noted. “We were tracking readmissions, but weren’t tracking readmissions in the way that we should have, to compensate for risk. MACRA was one factor. And there were things we could have done in the transition to home—simply things, like making sure the patient understands what’s going on with his meds. And we pulled a program together, and it brought the physicians, clinicians, IT, and administration together, to really understand a little bit more about what it is we can do for the patient. So we starting collecting measures well ahead of MACRA. We realized there were things we could be doing. And it benefited us a lot in terms of improving care for the patients. And the patients started talking to us more, which was actually a phenomenal benefit.”
“Remember, we’re in August 2017, and only eight months in to the first reporting year of MACRA; it’s really new,” Schneider emphasized. “We won’t really have money impacts for another two years. But for us, we’ve seen this get the attention of a lot of independent physicians in our community, particularly the specialists. We’ve been a very primary care-centric organization, a lot of the primary care physicians have been very engaged in population health work, but the specialists not at all. And now the specialists are suddenly becoming very interested and getting engaged. And the fact that when you’re in an ACO and you’re all tied together under a single grade for MIPS, that’s incentivizing.”
“I agree,” Docimo said. “We’ve seen specialists coming to join the ACO with the reason of MACRA, to become employed. And so I think just the fact that we’re asking specialists to take a look at their process outcomes, etc., is a good thing. So what are the outcomes that would give me a higher grade? And if we can incent that kind of change, that’s a win.”