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An HIT Expert Dives into the Details of CMS’ Proposed Hospital Payment Rule

April 30, 2018
by Heather Landi
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On April 24, the Centers for Medicare & Medicaid Services (CMS) released an 1,883-page proposed rule on meaningful use rebranding with new emphasis on interoperability and burden reduction, along with indications that the agency may be raising the interoperability stakes.

The meaningful use (Medicare and Medicaid EHR Incentive Programs) program has been around since 2011 with the intent to encourage eligible providers to demonstrate meaningful use of certified EHR (electronic health record) technology. CMS is now proposing a shakeup of the initiative with a rethinking of industry priorities. In a press release, the federal agency said that it will be proposing to re-name the meaningful use program to “Promoting Interoperability.” CMS said the goals of the new program will be to: make it more flexible and less burdensome; emphasize measures that require the exchange of health information between providers and patients, and incentivize providers to make it easier for patients to obtain their medical records electronically.  According to CMS, the rule applies to about 3,300 acute care hospitals and 420 long-term care hospitals, and would take effect Oct. 1.

Since the rule dropped, there has been ongoing discussion about the changes in the proposed rule and if the government will be forcing providers to participate in health information exchange activities, and you can read some of that reaction in this article posted last week. For that article, Healthcare Informatics Associate Editor Heather Landi spoke with Jeff Smith, vice president of public policy at AMIA (the American Medical Informatics Association) about CMS raising the interoperability stakes. Below are excerpts from that interview.

What are your initial takeaways of this proposed rule?

This is the first rulemaking cycle that the new Administration has the ability to put its fingerprints on. The thing I’m struck most with is the fact that they have been talking about the need to reduce reporting burden and the need to improve interoperability, particularly patient data access. I do think those themes come through pretty loud and clear with these proposals. Now, one quibble is whether or not the total effort is reduced by how many measures they removed. CMS states that they have reduced total measures and objectives from 16 down to six. The question is, is it three times easier to do? The answer is, probably not. But, certainly, there is in these proposals an attempt to try to align meaningful use (MU) more with what I presume will be the strategy for MIPS [Merit-based Incentive Payment System) and Advancing Care Information (ACI). Now, we have to wait for that rule to come out. I think if the goal here is to reduce the reporting burden, align MU with MIPS and to try to make progress on interoperability and patient data access, I think these proposals, in total, at least on paper, are pointed in the right direction.

In this proposed rule, CMS is proposing a new scoring methodology. What is your perspective on the scoring methodology?

I think that they’re taking a page out of the MIPS and ACI playbook. It will be interesting to see what the reaction is. I think clearly what they are trying to do is create the opportunity for more flexibility and the preamble does reference the Bipartisan Budget Act of 2018, that was just passed at the beginning of the year. That legislation has allowed CMS to propose policies that are not intrinsically more difficult over time by eliminating the provision requiring more stringent measures of meaningful use. And, you can see that by how CMS is giving people the ability to submit data on fewer measures and by setting the overall composite score at 50 [points needed to avoid Medicare payment adjustments]. So, again, it borrows from the MIPS playbook by recalibrating a composite score and I think this will be largely helpful for those who are worried about the all-or-nothing component of MU. How much extra work and headache it’s going to save, is still another question

CMS also changed the name of the meaningful use program to Promoting Interoperability. How do the changes to the scoring methodology and the metrics support that?

I think there’s nothing you could do within the measures and objectives themselves to improve interoperability in a meaningful way. What you have to do is look at the totality of the program and the requirements, and that is inclusive of a 90-day reporting period and inclusive of the need to adopt 2015 edition certified EHR technology. I think the other thing that we have to keep in mind here is that it will probably take more policy levers than just these measures and objectives to improve interoperability.

Having said that, I do think there are some areas worth exploring a little more closely, and that includes the health information exchange objective. One of the important changes about this is that you no longer have to send the full suite of information and data in the C-CDA (consolidated clinical document architecture). Without getting too technical, what the proposal would allow is for clinicians to send component pieces of the C-CDA, depending on the situation. There’s a common complaint around sending these C-CDAs, that there’s a lot of information in there, mountains of information that are not helpful. What they are proposing is to allow providers to constrain the information in the summary of care record to support the transition of care. That will be interesting to see what the spillover effect is.

By allowing people to send a more constrained amount of information over, one could envision that information is more important and therefore, gets read more frequently, and needs to be integrated in a more workable way. An optimistic potential is that by allowing providers to send a more constrained amount of information, that will make that information more useable and actionable, and essentially, you’re going to have to have computers that can integrate and use this information. So, think of it as, if someone sends a whole bucketful of information, you’re not going to do anything with it. But if someone sends more finite, smaller pieces, then you might go out of your way to figure out how to use the information, and if you’re using an EHR, try to figure out how to incorporate that into your EHR. In terms of improving interoperability, you’re going to have to have a wider view of how this program sits within a larger portfolio of policy levers before we can say with any confidence that this has moved the needle.

Drilling down into the request for information (RFI) on Interoperability section of the proposed rule, what is your take on what CMS is considering?

I think last year you saw this Administration say ‘okay, we’re not making any changes, just do whatever you can and avoid a penalty.’ This year, you’re starting to see a little bit more fingerprint on the actual policy and there’s no better example than the request for information that is focused on the future directions. First, earlier in the rule, there is a table where it lists the measure proposals; some of the measures they are keeping the same, some of the measures they are dropping completely and some measures they are combining and renaming. If you look at the removed measures, they have removed view, download or transmit, they have removed patient generated health data and patient-specific education. What’s interesting about this is that CMS is doing away with one of the things that hospitals have complained a lot about, which is this notion of view, download or transmit. But, what this RFI seems to be signaling is that they are not saying it’s not important to allow patients to view, download and transmit their information; quite the opposite, they think it’s more important than participating in this little program that could cost you a percentage point or two in reimbursement. They think it’s so important that you don’t get to participate in Medicare. So again, on the one hand, they have tried to be responsive to the complaints and concerns about the burden that providers have discussed relative to view, download and transmit, but on the other hand, I couldn’t imagine many hospital executives who would trade MU Stage 3 patient data access measures and objectives, for conditions of participation. That raises the stakes significantly.

One of the really interesting things is that nestled away it says CMS may consider revising the current CMS Conditions of Participation for hospitals that would require them to transfer medically necessary information upon a patient discharge or transfer and to do so electronically, require hospitals to send discharge information to community provider via electronic means, if possible, and require hospitals to make information available to patients or a specific third- party application via electronic means, if requested.

My read on this is [about] participation in the TEFCA [the U.S. Department of Health and Human Services’ draft Trusted Exchange and Common Agreement]. Earlier in the same RFI, the same portion, they do talk about TEFCA and mentioned participation in TEFCA could count as the HIE measure and objective. One of the critiques of TEFCA is that it is voluntary and if you make it too hard, they won’t do it. I always thought that was flawed logic, because the ONC EHR certification program is voluntary, but nobody treats it like it’s voluntary if they want to be part of this world. I’d always assumed that TEFCA would be voluntary, sure, but the government would figure out a way to encourage participation. If you think about TEFCA as essentially requiring all these things, if they were to try to make Conditions of Participation align with the general outline of TEFCA, that would be a pretty strong motivation to participate. It sure seems to me that making information available to other facilities upon transfer or discharge and requiring discharge information go to community providers, and making sure that information is available to patients or third-party apps, pretty much is a large swath of what TEFCA is trying to accomplish.

The proposed rule also requires the adoption of 2015 edition certified electronic health record technology (CEHRT) in 2019. What is your perspective on this timeline?

The fact that they have proposed to move forward with the 2015 edition [CEHRT] in 2019 is really important. I think CMS did a good job of rationalizing it and looked at it pretty closely even last year. They said, the 2014 edition is out of date and insufficient for provider needs. From a purely logical mindset, if people don’t upgrade to the newest edition of the technology, then how do you expect for new standards and new functionalities to make their way out into the world, unless by virtue of some free market mechanism? I think we’re clearly at a point in time where policy has to be concerned with not just allowing or enabling innovation by ensuring that minimum standards are adhered to. I think the fact that they are putting a strong line in the sand that says, in 2019, you have to have 2015 technology, is good. We’re going to look at this proposal through the prism of, are the requirements meaningful within the context of what CMS can and can’t do? And, then we’re going to look at the things that they are dropping, and say, does this matter? The fact that view, download, or transmit is no longer required, I think that means, without much room for doubt, that the old way of viewing, downloading and transmitting information is going to change, and yes, I think patients will still to be able to access their information. I don’t see people rushing out to unhook their patient portals.

I’m hoping ONC gives us some time to get through this, before their rule drops, because I think that’s going to be an interesting piece to this puzzle; trying to understand how this relates to TEFCA is going to be an important thing to understand. And then understanding what comes after 2015. The 2015 edition CEHRT is going to be required in 2019, but it’s been five years since the last edition. So, is ONC going to continue with this edition construct? Is there going to be something else? There’s going to be a lot of additional interesting policies that will have a pretty big impact even on this.


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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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