In the middle of the summer of 2017, many patient care leaders have understandably been focused on the June 20 release of the proposed rule for 2018 for the Quality Payment Program (QPP) under the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law, covering both the MIPS (Merit-based Incentive Payment System) program and the other side of the MACRA law, governing participation in advanced payment models (APMs). There is considerable complexity in the 1,058-page proposed rule; and much in the rule might change before it’s made final. But much of the discussion of the proposed rule, in the weeks following its release, was around the level of rigor and pace that should be embedded in forward progress around compelling physicians in practice more deeply into value-based healthcare payment.
Meanwhile, the leaders of more advanced medical groups say that the discussion around the details of MACRA’s requirements feels deeply secondary to the future they’re already building. Their organizations are already involved in taking on some level of financial risk in risk-based contracting, whether through federal accountable care organizations (ACOs) or ACOs sponsored by private health insurers, or through bundled-payment contracts (again, federal or private), or through any one or more of a broad range of population health-focused contracts of all kinds. And these medical group leaders have been spending the last few-to-several years learning how to collect and analyze data and use that data to feed continuous clinical and operational performance improvement, while at the same time building learning organizations, and transforming the physician cultures in their organizations. In other words, they’re already way ahead of the MACRA compliance game.
What’s exciting about that is that physician practice-based/clinic-based care remains at the core of the area of potential for change in healthcare, particularly when it comes to patients with chronic illnesses. Hospitals, health systems, health plans, employers, and governments all have a deep investment in efforts to improve patient outcomes and the patient experience, reduce costs and improve operational efficiencies; but it is in the physician practice setting that the most immediate interventions can be made—and the senior clinical and administrative leaders of the most advanced medical groups are making those interventions, and learning a great deal in the process.
One medical group leader whose attitude illustrates this perspective is Jeffrey LeBenger, M.D., chairman and CEO of the Berkeley Heights-based Summit Medical Group, a multispecialty physician group practice that covers a broad swath of northeastern New Jersey. Asked about the proposed 2018 rule for the QPP under MACRA, Dr. LeBenger quickly brushes the question aside. “I’m not concerned about that at all,” he says. “You’ve got to set up a model of care and make the economics work for you. If you can do that,” he says, there is a clear path to success. Indeed, he says, he and his colleagues have already zoomed past any of the core outcomes requirements mandated by the QPP.
Looking back at the last couple of years, LeBenger reports that “We’ve done very, very well in our population health process, meaning that we beat the market in PMPM [per member per month] costs in the state of New Jersey by almost 8 percent in the past year. What we found out” in terms of how to achieve success under risk-based contracts, “is that you must share data with your physicians, meaning that you have to scrub it, you have to fix it, and you have to work with financial and clinical data together. And it has to be timely data—you need timely data from the payers. And you have to put the right data into the right health information exchange. And you have to understand where your high-cost points are in your model of healthcare.”
Jeffrey LeBenger, M.D.
LeBenger further clarifies what he believes is and is not essential to medical group leaders wading into the ocean of risk-based contracting. “Everybody says it’s population health, population health,” he says. “To be honest, I think that’s a bit wrong. You have to look at your model of healthcare. We’re getting very close to 800 providers; we’re in seven counties. And what we’ve done is that we’ve created high-acuity urgent care centers with imaging and with specialists; and we’ve created high-risk clinics for our high-risk patients. We do transitions of care for our sickest 5 to 10 percent of patients. We have home healthcare. We have medical directors at 70 percent of the long-term facilities we’re in. We compensate based on outcomes. And we follow the patient-centered medical home concept; and we really manage the patients out of the hospitals. For us, a hospital is a center for tertiary or quaternary care. We look very closely at monitoring patients out of the hospital.” It’s all of those factors—essentially, creating a data-driven care management system around one’s covered populations, especially for all those patients with chronic illnesses—that is at the heart of success in this emerging world, he emphasizes.
LeBenger’s perspective is shared with all of those interviewed for this story, who agree that: