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Healthcare Industry Leaders React to Quality Payment Program Final Rule for 2018

November 3, 2017
by Heather Landi
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One day after CMS released its final rule for 2018 requirements under MACRA’s Quality Payment Program, industry leaders express a spectrum of reactions
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The day after the federal Centers for Medicare and Medicaid Services (CMS) released the final rule making changes in the second year of the Quality Payment Program (QPP) under the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law, healthcare industry leaders are voicing mixed reactions, but do seem satisfied with some of the increased flexibilities that were maintained from the proposed rule, and intended to provide clinicians with a smoother transition to the Quality Payment Program.

Late in the afternoon on Thursday, Nov. 2, CMS published the 1,653-page calendar-year 2018 QPP final rule, under the MACRA law, affecting Medicare-participating physicians covered either under the MIPS (Merit-based Incentive Payment System) program, or participating in APMs (advanced payment models). It’s clear that easing provider burden in complying with MACRA was a priority for CMS officials in keeping with many of the proposals in the proposed rule.

In a press release announcing the final rule, CMS officials stated, “While part of CMS’s broader strategy to relieve regulatory burdens for providers, these rules also reflect the agency’s efforts to promote innovation in healthcare delivery aimed at lowering prices, increasing competition and strengthening the relationship between patients and their doctors.”

“During my visits with clinicians across the country, I’ve heard many concerns about the impact burdensome regulations have on their ability to care for patients,” Seema Verma, CMS Administrator said in a statement. “These rules move the agency in a new direction and begin to ease that burden by strengthening the patient-doctor relationship, empowering patients to realize the value of their care over volume of tests, and encouraging innovation and competition within the American healthcare system.”

Some of the key changes in the final rule include raising the MIPS performance threshold to 15 points in year 2, from 3 points in the transition year, and the final rule allows the use of 2014 edition and/or 2015-certified electronic health record technology (CEHRT) in year 2 for the Advancing Care Information performance category, and gives a bonus for using only 2015 CEHRT. For the 2018 MIPS performance year final score, the performance category weights will be: quality, 50 percent; cost, 10 percent; improvement activities, 15 percent; and Advancing Care Information, 25 percent. A 26-page fact sheet summarizing the final rule can be found here.

Some healthcare industry leaders have expressed concerns about CMS’s decision to require a full-year reporting period for the cost and quality performance category, rather than a 90-day reporting period.

Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association (MGMA), said in a statement, “MGMA is very disappointed that CMS quadrupled the length of the quality reporting period under MIPS from the current 90 days to 365 days in 2018. This fourfold increase to the quality reporting requirements is in stark contrast to the Agency’s statements today that the final rule reduces regulatory burdens. CMS is in effect prioritizing quantity over quality and giving physicians less than 60 days to prepare for the 2018 MIPS requirements.”

It should be noted that the final rule sets a 90-day reporting period in both 2018 and 2019 for Advancing Care Information and Improvement Activities performance categories.

According to CMS, the final rule includes a number of policies designed to provide clinicians with a smoother transition to the Quality Payment Program. “The QPP final rule includes policies that reduce burden and support clinicians in small and rural practices to successfully participate in this program. CMS is decreasing the number of clinicians required to participate,” CMS stated in the press release.

“There weren’t a whole lot of surprises” with the final rule,” notes Jeff Smith, vice president of public policy at the American Medical Informatics Association (AMIA). “When you focus on the quality payment program in MIPS, I think CMS telegraphed that they want to provide much more flexibility and are looking for ways to make the program more feasible for docs, and I think the final rule really does follow through with that intention.”

Adaeze Enekwechi, Ph.D., vice president of McDermott + Consulting, a Washington, D.C.-based healthcare consulting firm, who previously worked at the White House Office of Management and Budget (OMB) under the Obama Administration as the associate director for health programs, contends that CMS designed year 2 of the MACRA QPP as a gradual ramp up to full implementation in 2020.

Sharing her initial takeaways on the 2018 MACRA QPP final rule, Enekwechi, who also previously served as a senior analyst with the Medicare Payment Advisory Commission, and at the Congressional Budget Office, says, “What the Administration is doing is really making an effort to continue to ease the burden of implementation of MACRA this second year, but, at the same time, they recognize that full implementation will begin in the third year, so they don’t want to leave clinicians completely unprepared. You see evidence of a little bit of a ramp up, when you look at the MIPS scoring, whereas before you needed a minimum of 3 points and now it’s 15. And, cost is now weighted at 10 percent in the second year as opposed to zero in the first year,” she says, adding, “To me, it read very much like a real effort to get folks ready for 2020.”

In the proposed rule, plans from CMS signaled that many more clinicians will be exempt from MIPS once again, like they were in year one of the QPP, which began in January. In keeping with the proposed rule, the final rule will increase clinicians’ low-volume threshold from $30,000 or less in Medicare Part B allowed charges or less than 100 Medicare patients to $90,000 in Part B allowed charges or less than 200 Medicare patients.

There has been some debate about whether excusing more clinicians from MIPS for another year is beneficial in the long-term. Enekwechi notes that one potential impact of increasing the low-volume threshold is a growing chasm between physicians currently participating in MIPS and those who are exempt.

“You have some clinicians who are participating in MIPS and going through the rigorous effort of measuring quality, reporting, and for all intents and purposes, marching toward higher risk payment models, and just getting more involved in advanced APMs (alternative payment models). And then, on the other side, you have a whole set of clinicians who are not going to be exercised in that way and will not adjust to these new payment models that are coming out, not just from Medicare but from the commercial side. I do think, if we continue down this path where the majority are not participating in MIPS or APMs, I think we’re going to start to see differences between those two classes of clinicians,” she says.

To this point, the National Committee for Quality Assurance (NCQA) said in a statement that it is grateful that the rule lets small practices form virtual groups in 2018. It said, “Virtual groups can help small practices join together to have enough patients for robust measurement and prepare for APMs. Unfortunately, the rule prevents the smallest practices from joining virtual groups by defining low-volume practices as ineligible for MIPS. Low-volume practices—those with less than $90,000 in Medicare revenue or 200 Medicare patients—most need virtual groups so they can have reliable measurement and reap rewards for improvement. CMS could remedy this by amending its low-volume definition to say these practices are ineligible for MIPS ‘unless they join a virtual group.’”

Smith notes several positive developments in the final rule, such as giving providers the ability to use either 2014 Edition Certified Electronic Health Record Technology (CEHRT) or 2015 edition CEHRT, which was also in the proposed rule. “It was good to see that CMS is continuing to try to find ways to gently encourage people to adopt 2015 edition CEHRT as they maintained from the proposal to offer a bonus for using it,” Smith says, referring to the policy in the final rule that states providers can earn a 10 percent bonus if they only use 2015 edition CEHRT.

CMS also increased the number of improvement activities that are eligible for bonus credit under the Advancing Care Information category. As one example, CMS plans to give bonus credit to physicians who consult patient-generated health data from consumer wearables. Smith says, “I think that will be an important policy moving forward, for a host of reasons, not least of which is the fact that there are a growing number of consumer technologies that patients are showing up at their doctor’s office and saying, ‘here’s my data, this is keeping track of my weight or blood pressure and how do we make sense of that.’ If you look at the improvement activity piece of MIPS, they are trying to give credit to innovation and experimentation.”

He continues, “And, while it doesn’t account for a huge portion of the overall MIPS score, I think it’s an important policy lever. It will be interesting to see what additional kinds of issues arise out of this new proposal to pay physicians to take patient-generated health data and spend time with that data, but, I think, overall, that’s a positive aspect of the Improvement Activities.”

In the press release about the final rule, CMS noted that to further ease clinician burden, CMS is adding an option to help clinicians and small, rural practices join together and share the responsibility of participating in value-based payments in virutal groups. CMS is also adding a new hardship exception to assist small practices and clinicians impacted by hurricanes Harvey, Irma, and Maria. This change mitigates the absence of Electronic Health Records as a result of the natural disasters.

CMS also reports that it intends to develop a demonstration project testing the effects of counting as credit participation prior to 2019 and through 2024 in Medicare Advantage plans that meet certain criteria. In a statement released on Thursday, Blair Childs, senior vice president of public affairs at Charlotte-based Premier Inc., said he is encouraged that CMS plans to develop a demonstration project to examine how Medicare Advantage alternative payment models qualify for the threshold test and obtain the five percent MACRA bonus prior to 2021. Childs noted that nearly one-third of Medicare beneficiaries are enrolled in an MA plan. “Many MA plans have engaged providers in innovative value-based contracts that are benefiting patients and should count toward qualifying eligible professionals for the bonus in 2019. This policy would level the playing field for clinicians in areas with high MA penetration,” he said.

Regarding CMS’s efforts to reduce provider burden, Enekwechi says, “I think they’ve leaned as far as they can, while still maintaining implementation. I think that the slow ramp up in terms of scoring, basically they went from 3 points to 15 points, that’s still pretty low. I think 10 percent weight applied to the cost category is better than 0, and not as terrifying as 30 percent for MIPS eligible clinicians. They have also created multiple ways to submit data and information; you can do it through registries, you can do it through their website. This agency is doing as much as it can to try to ease burden with respect to implementation.”

 


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CMS’ MSSP Proposed Changes Slammed by Leading ACO Organization

August 10, 2018
by Rajiv Leventhal
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Industry stakeholders fear that ACOs will drop out, while CMS doesn’t seem to mind if upside-only ACOs that are costing the government money leave the program if they aren’t willing to take on more risk

The National Association of ACOs (NAACOS) called CMS’ (the Center for Medicare & Medicaid Services) proposals to redo the Medicare Shared Savings Program (MSSP) “misguided,” noting that the changes, if finalized, “will upend the ACO movement by creating havoc with a significant overhaul introducing many untested and troubling policies.”

Late yesterday evening, CMS proposed a rule that included major changes to the existing MSSP ACO (accountable care organization) program. As Healthcare Informatics reported last night, referred to as “Pathways to Success,” CMS’ proposal, which has been expected for a few months, looks to redesign the program’s participation options by removing the traditional three tracks in the MSSP model and replacing them with two tracks that eligible ACOs would enter into for an agreement period of no less than five years: the BASIC track and the ENHANCED track.

Much of the discussion following the rule’s release will likely center around the BASIC track, which essentially limits ACOs to stay in “upside-only” risk models for just two years, compared to the existing allowance of six years. What’s more, those ACOs in an MSSP Track 1 upside-only model would only be able to get 25 percent of any savings they take in, compared to 50 percent, which is the current max.

When ACOs are in a one-sided risk model, they do not share losses with the government when they overspend past their benchmarks, but they do share in the gains. As such, in these one-sided risk models, CMS is on the hook for any losses all on its own.

Indeed, CMS has a clear goal to move ACOs more quickly into two-sided-risk models as the agency has noted that upside-only ACOs are not reducing costs and are costing Medicare money. “We project these changes will result in $2.24 billion in savings to Medicare program over next 10 years,” CMS Administrator Seema Verma stated yesterday.

Stakeholders Show Concern

As expected, NAACOS—a coalition whose members include more than 300 ACOs—had plenty of gripes with CMS’ proposals. Previously, following a survey of its members, NAACOS urged CMS to refrain from mandating ACOs to assume more risk. The organization, earlier this year, specifically reached out to Track 1 ACOs that were about to enter the final agreement period in 2019 before moving into two-sided risk models. The results of their survey showed that 71 percent of ACO respondents indicated they would likely leave the MSSP as a result of having to assume risk.

In a statement released last night, NAACOS President and CEO Clif Gaus noted, “The administration’s proposed changes to the ACO program will halt transformation to a higher quality, more affordable, patient-centered healthcare industry, stunting efforts to improve and coordinate care for millions of Medicare beneficiaries.”

According to Gaus, “The downside financial risk for patient care would be on top of the significant financial investments ACOs already make, jeopardizing years of effort and investment to improve care coordination and slow cost growth.” He continued, “CMS discusses creating stability for ACOs by moving to five-year agreements, but they are pulling the rug out from ACOs by redoing the program in a short timeframe with untested and troubling polices.”

In the proposal, CMS itself is predicting that more than 100 of the 561 MSSP ACOs will drop out of the program in the next 10 years as a result of this rule. But Gaus said that the number of ACOs who will leave will be far greater than that, referencing NAACOS’ survey from earlier this year. “Given the proposals put forth today, 70 percent could be an underestimate, with even more ACOs leaving the program,” he said.

“It’s naïve to think that ACOs that aren’t ready can be forced to take on risk, given that the program is voluntary. The more likely outcome will be that many ACOs quit the program, divest their care coordination resources and return to payment models that emphasize volume over value,” Gaus said. “This would be a significant setback for Medicare payment reform efforts and would undermine implementation of the overwhelmingly bipartisan Medicare Access and CHIP Reauthorization Act (MACRA), which is designed to move providers into alternative payment models such as ACOs,” he added.

CMS, however, doesn’t seem to have a problem if upside-only ACOs that are costing the government money leave the program if they aren’t willing to take on more risk. Verma said yesterday on a press call that “[Upside-only] ACOs have no incentive, at all, to reduce healthcare costs while improving outcomes, as they were intended.”

On the contrary, NAACOS believes that “The best scientific evidence shows that the Medicare Track 1 ACOs overall are returning millions of dollars of savings to Medicare and improving the quality of care for millions of beneficiaries. To shrink and disable this leading alternative payment model in its early stages defies logic.”

Premier Inc., which has some hospital-led ACOs in its population health management collaborative, released a statement agreeing with NAACOS when it comes to forcing ACOs into more risk. Blair Childs, senior vice president of public affairs, Premier, said, “First, the level or investment and change required to move to two-sided risk is far greater than CMS clearly appreciates by providing only a two-year onramp of no risk for organizations newly entering into an ACO.  Forcing providers to accept risk too quickly will deter participation.”

Further, the American Hospital Association (AHA) also believes that CMS’ proposals are too aggressive. Tom Nickels, AHA’s executive vice president, noted that “drastically shortening the length of time in which ACOs can participate in an upside-only model ignores the reality that providers are starting at vastly different points and will have vastly different learning curves when moving toward value-based care.” He added, “The proposed rule fails to account for the fact that building a successful ACO, let alone one that is able to take on financial risk, is no small task; it requires significant investments of time, effort and finances… A more gradual pathway is critical for hospitals and health systems that are interested in participating in risk-bearing models – particularly those that are exploring such models for the first time.”

Some Show Positivity

It should be noted that not all of the reaction that has come in thus far has been negative. Leaders from Orange Care Group, a South Florida-based organization that owns and operates four independent, physician-led Medicare ACOs—including one of the first risk-based Track 3 ACOs—are pleased that CMS is “formally recognizing downside risk ACOs as the future of the model and evolving ACOs to better service Medicare and its patients,” according to Frank Exposito, Orange Care Group’s executive vice president of finance and strategy.

Exposito, in response to e-mailed questions from Healthcare Informatics, also agreed with Verma’s comments yesterday when she said upside-only ACOs have not lived up to the accountability part of their name. “ACOs, by definition, need to be accountable and ACOs who have continually failed to generate savings and improve quality are not contributing to the model and the industry at-large. With the entire market shifting to risk, the ACO model will gain strength in the communities they serve because all ACOs will be incentivized for moving the needle forward,” he said. Exposito further noted, “This will foster more innovation in the space as ACOs seek to mitigate their risk through novel partnerships with high-quality and high-performing acute and post-acute providers, while placing primary-care physicians at the center of their patients’ care. This will ultimately help extend the efforts of Medicare reform across the healthcare continuum.”

Overall, America’s Physician Groups (APG) also considers the proposed rule a very balanced approach to various stakeholders’ concerns as well as a positive step forward in the movement from volume to value, the organization said in a statement, also noting that physician-led ACOs that take on two-sided risk provide superior quality at a lower cost than other ACOs, while saving Medicare money.

Valinda Rutledge, vice president, federal affairs, APG, added that the CMS proposals build in a transitional pathway for those ACOs who are looking to take on more risk. “We know that many of today’s ACOs have experience in upside risk only. The proposed rule acknowledges this and provides for a transition period instead of forcing groups into downside risk right away. We believe that no group should be forced into risk; however, when groups decide to accept the opportunity for shared savings, we also believe that they then should take on the responsibility of saving money for our healthcare system and the people and communities they serve,” she said.

The Health Care Transformation Task Force, meanwhile, said it welcomes the release of CMS’ proposal. “This is an important step to promote value-based transformation and to push industry momentum forward. At first pass, the proposed rule presents novel ideas and careful thinking on how ACOs may better lower cost and improve patient outcomes,” said Jeff Micklos, the group’s executive director.

Official public comments on the rule are due Oct. 16.


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BREAKING: CMS Proposes Sweeping Changes to MSSP ACO Program

August 9, 2018
by Rajiv Leventhal and Heather Landi
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CMS is proposing to push ACOs into two-sided risk models by shortening the duration of one-sided risk model contracts

The Centers for Medicare & Medicaid Services (CMS) is proposing a new direction for ACOs (accountable care organizations) in the Medicare Shared Savings Program (MSSP), with the goal to push these organizations into two-sided risk models.

Referred to as “Pathways to Success,” CMS’ proposal, which has been expected for a few months, looks to redesign the program’s participation options by removing the traditional three tracks in the MSSP model and replacing them with two tracks that eligible ACOs would enter into for an agreement period of no less than five years: the BASIC track, which would allow eligible ACOs to begin under a one-sided model and incrementally phase-in higher levels of risk; and the ENHANCED track, which is based on the program’s existing Track 3, providing additional tools and flexibility for ACOs that take on the highest level of risk and potential rewards. At the highest level, BASIC ACOs would qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program.

Currently, the MSSP model includes three tracks and is structured to allow ACOs to gain experience with the program before transitioning to performance-based risk. The vast majority of Shared Savings Program ACOs have chosen to enter and maximize the allowed time under Track 1, which is an “upside-only” risk model. MSSP Tracks 2 and 3 involve downside risk, but participation in these tracks has been limited thus far.

When ACOs are in a one-sided risk model, they do not share losses with the government when they overspend past their benchmarks, but they do share in the gains. As such, in these one-sided risk models, CMS is on the hook for any losses all on its own.

Broadly, CMS is now essentially proposing that the contract agreements of upside-only ACOs be two years, rather than allowing six years (two, three-year agreements) like the government has previously permitted. Overall, there are 561 MSSP ACOs out of 649 total Medicare ACOs, with 82 percent of those 561 MSSP ACOs taking on upside risk only.

While ACO contracts normally renew at the start of the year in January, CMS is giving ACOs whose contracts expire this December a one-time-only six-month extension, until July 2019, so they can apply for a new agreement beginning on July 1, 2019, if they so choose. Moving forward, CMS would resume the usual annual application cycle for the performance year starting on January 1, 2020 and subsequent years.

As the federal agency continues to steer ACOs away from upside-only models, CMS noted that some Track 1 ACOs are generating losses (and therefore increasing Medicare spending) while having access to waivers of certain federal requirements in connection with their participation in the program. These ACOs may be encouraging consolidation in the market place, reducing competition and choice for Medicare FFS beneficiaries, according to agency officials.

CMS Administrator Seema Verma previously has criticized upside-only ACOs, remarking that they have not generated enough results to date. And today, she hammered this point home on a press call. “[Upside-only] ACOs have no incentive, at all, to reduce healthcare costs while improving outcomes, as they were intended. Thus, the program has not lived up to the accountability part of their name,” Verma asserted.

Meanwhile, the ACOs in twosided risk models “have shown significant savings to the Medicare program and are improving quality,” CMS said in today’s announcement. As such, Verma said today that requiring ACOs to take on downside risk more quickly, matched with increased risk and flexibility, would reframe the Medicare Shared Savings Program to deliver value to the 10 million patients currently in ACOs, and taxpayers. “We project these changes will result in $2.24 billion in savings to Medicare program over next 10 years,” she stated.

How will Upside-Only ACOs Respond?

Indeed, as it stands today, MSSP Track 1 remains by far the most popular option for ACOs. Recently, the National Association of ACOs (NAACOS) surveyed Track 1 ACOs that were entering their third agreement period and found that 71 percent of ACO respondents indicated they are likely to leave the MSSP as a result of having to assume risk.

In CMS’ proposed rule, the agency internally estimates that more than 100 ACOs will drop out of the program over the next 10 years. CMS said in the rule that “The overall drop in expected participation is mainly due to the expectation that the program will be less likely to attract new ACO formation in future years as the number of risk-free years available to new ACOs would be reduced from six years (two, three-year agreement periods in current Track 1) to two years in the BASIC track, which also has reduced attractiveness with a lower 25 percent maximum sharing rate during the two risk-free years.”

Verma was asked on the press call about the expected drop in ACOs, to which she noted that since the two-sided risk ACOs are the ones who are generating savings, having organizations who are losing the government money eventually leave the program is not a bad thing. “We know that they are losing money when they are only taking on upside-only risk. So, we’re only allowing them to do that for the first two years of the program.”

Verma continued, “The other change we’re making is that for six years we’ve been allowing [ACOs] to only take upside risk while also take in 50 percent of the savings. Now, we’re saying you can only do this for two years and only get 25 percent of the savings. So, that’s why we’re mitigating the losses that we’re having in the program.”

It remains to be seen how stakeholders will respond to CMS’ proposal today, but with the survey NAACOS administered in May, the organization stated that it encourages ACOs to prepare to move to risk and strongly supports ACOs that are ready to do so, but that it does not support forcing ACOs to assume risk if they are not ready.

Verma, when asked on the press call about the new proposals, said that it’s simply time for the program to evolve. “When we developed this program, we wanted to move the entire program towards providers taking more risk because we know that works. We want to work with ACOs that are serious about participating in the program and investing in the type of changes that are going to deliver value to patients,” she stated.

The CMS chief acknowledged on the press call that, “For some, change is always difficult, and we understand that there are those who say they haven’t had enough time to live up to their commitment to achieve value."

Proposal Specifics

In its proposal, CMS said that the BASIC track’s glide path would offer an incremental approach to transitioning eligible ACOs to higher levels of risk and potential reward. The glide path includes 5 levels: 

  • A one-sided model available only for the first two years to eligible ACOs (ACOs identified as having previously participated in the program under Track 1 would be restricted to a single year under a one-sided model);
  • And three levels of progressively higher risk and potential reward in years three through five of the agreement period. Under the one-sided model years of the glide path, an ACO’s maximum shared savings rate would be 25 percent based on quality performance, applicable to first dollar shared savings after the ACO meets the minimum savings rate. The glide path concludes with a maximum 50 percent sharing rate, based on quality performance, and a maximum level of risk which qualifies as an Advanced APM for purposes of the Quality Payment Program.  

ACOs in the BASIC track glide path would be automatically advanced at the start of each performance year along the progression of risk/reward levels, or could elect to move more quickly to a higher level of risk/reward, over the course of their agreement period.

In the end, ACOs entering the BASIC track’s glide path for an agreement period beginning on July 1, 2019, would have at most 2 ½ years under a one-sided model (with ACOs identified as having previously participated in the program under Track 1 restricted to 1 ½ years) and their first automatic advancement would occur at the start of performance year 2021, CMS explained.

What’s more, ACOs identified as “low revenue”—typically composed of physician practices and rural ACOs—could participate in the BASIC track for up to two agreement periods.  For instance, a low revenue ACO that participates in the BASIC track’s glide path could renew under the BASIC track, at the highest level of risk and reward, for a second agreement period. ACOs identified as “high revenue”—typically ACOs that include hospitals—would be required to transition to the ENHANCED track more quickly, after no more than a single agreement period under the BASIC track.

CMS has observed that low-revenue ACOs have outperformed high-revenue ACOs, but that some low-revenue ACOs lack a pathway to transition from a one-sided model to more modest levels of performance-based risk. Agency officials noted its Medicare Track 1+ ACO Model, a time-limited Center for Medicare and Medicaid Innovation (Innovation Center) model which began this past January, demonstrates that a lower-risk, two-sided model is an effective way to rapidly progress to performance-based risk. 


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A Pioneering M.D. Leader Shares Insights on Successfully Navigating the Massachusetts Healthcare Market

August 9, 2018
by Rajiv Leventhal
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Dr. Barbara Spivak details her organization’s long, but rewarding journey to value

On the ongoing journey to value-based care, provider organizations are all over the map when it comes to how advanced they are. Some are just starting out on that road while others are much further along.

In Massachusetts, the Mt. Auburn Cambridge Independent Practice Association (MACIPA), based in Brighton, includes 500 affiliated physicians and operates an ACO (accountable care organization) that is in Track 3 of the federal Medicare Shared Savings Program (MSSP) model—the track in which ACO participants take on the most risk for their patients. Indeed, the organization, headed by Barbara Spivak, M.D., CEO, has been engaged in risk-based contracting since the 1980s. Needless to say, MACIPA is on the advanced side of the road.

At the Boston Health IT Summit on August 8, Dr. Spivak joined Healthcare Informatics Editor-in-Chief Mark Hagland on stage to discuss MACIPA’s value-based care journey, the core health IT and policy-related issues physicians are facing these days, and much more as it relates to healthcare in the state.

Massachusetts healthcare, said Spivak, a local practicing physician for the last 30 years, is unlike most U.S states in that nearly every doctor belongs to some type of health system. But the biggest issue doctors face today, she contended, is that when they belong to a network, they are supposed to keep business inside it. At the same time, the healthcare market is moving more into “open access,” she said. “Patients choose health plans [in which] they can go anywhere [for care]. And now, more patients are expecting that no matter where they go, their primary care physician and specialist should know what happened to them, even if they go to other physicians [in other systems],” she said. 

As such, preventing patient “leakage” out of the system has become an enormous pressure on physicians, Spivak attested. “We have talent in every system so it’s not like you will get good care in system A but bad care in system B. They are all great systems that will provide great care. So you can’t deny people based on quality because the quality is great everywhere,” she asserted.

Regarding health IT, Spivak noted that years ago, MACIPA was doing population health management even before the organization ever got an EHR (electronic health record). She said that when EHRs started to gain traction, MACIPA applied for a state grant to get the funding to implement one. And although MACIPA just missed out on that funding request, Spivak said by that time she had already convinced her colleagues to get the EHR anyway, so they did. “And over the years we have done more and more population health, using real clinical data, not just claims data. We were also one of the first Pioneer ACOs, and now we’re in MSSP Track 3 with significant upside/downside risk,” Spivak said, speaking to how far along MACIPA has come.

As such, Spivak said that when MACIPA was considering which ACO model to join, an endeavor that would involve taking on risk for Medicare fee-for-service patients, Mt. Auburn physicians were already accustomed to managing care for their patients via their Medicare Advantage contracts. “Those patients got a lot of support. They were provided social workers, health coaches, and had care managers,” Spivak recalled, noting the biggest complaint from physicians at that time was why MACIPA couldn’t do these things for their Medicare fee-for-service patients as well. “But we didn’t have the data on them and there was no risk involved,” she said.

Spotting Flaws in Quality Metrics

Spivak went on to note that for all of issues facing the healthcare industry, as physicians continue to manage populations of patients, they have to “staff up” and getting the data and documenting is quite challenging. “One of key factors in physician burnout, particularly in primary care, is the documentation required for all of the quality metrics,” she said.

Even though MACIPA is a small organization, its physicians are still held accountable for hundreds of quality metrics that differ across various health plans. But Spivak said her physicians are taught just one set of metrics. For example, if there are 50 diabetic quality metrics spanning across all MACIPA’s health plan contracts, Spivak and her team narrow those 50 down to eight and then teach the physicians just those eight.

Nonetheless, Spivak believes that there are some major flaws in how certain quality metrics are measured, offering CMS’ (the Centers for Medicare & Medicaid Services) measure for screening for future fall risk as an example. Originally, she explained, physicians had to simply ask at-risk patients if they had two or more falls in the past six months and if they were injured. But a new CMS proposal may make things more complicated than that, Spivak noted. If the proposal passes, starting in 2019, physicians will have to ask these patients many more questions, including finding out details about stairs in the patients’ home as well as their vision.

But there are timing issues, Spivak continued. The final rule on this proposal will come out in October and the mandated start date for complying would be in January 2019, meaning EHR systems will have to remove those two original questions and replace them with another seven or eight. “Once that happens, I have to go out and teach all of my doctors, nursing homes, advanced practitioners, and others that the old [method] is out while the new questions are in. And that takes three to four months. Think about health systems that have 1,500 doctors. It’s an impossible situation,” she attested.

What’s more, Spivak offered, there are plenty of quality metrics that don’t measure quality. She noted one measure that looks at whether or not the physician prescribed antibiotics for bronchitis. This, Spivak, asserted, is a “coding measure” and has nothing to do with the amount of antibiotics the physician gave, since it all depends on if that physician coded for viral bronchitis or bacterial, as it’s OK to give antibiotics out for the latter, but not for the former. “Am I a trained or untrained rat?” Spivak jokingly asked. “That’s what this measure is about.”

Indeed, Spivak advised providers to not to blindly listen to the EHR companies who say that quality metrics are imbedded inside their systems, and that physicians can document easily. “Everyone’s quality metrics are a little bit different across the U.S. and its important to work with clinicians on them,” Spivak offered. “One advantage for me is that I still see patients about one-third of the time and it’s not the healthy 20-year-olds who I am seeing. I see chronically ill patients who are tough to document for. So you have to run things by your clinicians, and ask them if the [EHRs] work for them as is or if they’re making documentation [harder].  Don’t just rely on what your vendor tells you.”


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