Five weeks ago, Eric Cragun and Rivka Friedman of The Advisory Board Company authored a very insightful and useful analysis of the proposed rule issued on April 27 by the Department of Health and Human Services (HHS)/Centers for Medicare & Medicaid Services (CMS) recently around physician payment under MACRA/MIPS (the Medicare Access and CHIP Reauthorization Act/the Merit-based Incentive Payment Program).
As Cragun and Friedman noted in their analysis, “The law will fundamentally change how Medicare pays physicians and other clinicians who participate in the program. It will establish a two-track system for Medicare reimbursement: one, called MIPS, for providers who are reimbursed largely through fee-for-service, and an alternative payment model (APM) track for physicians who take on a significant portfolio of APMs.”
The consultants made ten key points, with much analysis and annotation of them. Here are the ten:
> The rule underscores the complexity of MACRA.
> CMS has heard the call to streamline this rule and minimize the burden on participants.
> MIPS will push medical groups of all sizes to invest in reporting and tracking performance on PQRS.
> CMS set a high bar on requirements for APM track.
> CMS expects most eligible clinicians to be in MIPS
> Most clinicians qualifying for the APM track will do so as a group.”
> The proposed rule reflects a belief and expectation that medical home models have potential to drive significant value for Medicare.
> Providers must decide whether to submit MIPS data before they know if they will quality for APM track.
> Performance periods are rapidly approaching.
> The rule’s complexity (and its high stake) are likely to elicit concern and comments from various stakeholders.
Point number one was an essential one to make, and it is gratifying that the authors made it in their analysis. MACRA is indeed complex, and even MIPS is complex. But what’s important is not so much the complexity itself as its implications for physicians. As I noted in a blog early last month, John Halamka, M.D., the CIO of Beth Israel Deaconess Hospital in Boston, and a respected industry leader, after reading and analyzing the April 27 Notice of Proposed Rulemaking (NPRM), wrote this: “After spending 20 hours reading the MACRA NPRM, I had one overwhelming thought. Sometimes when you remodel a house, there is a point when additional improvements are impossible and you need to start again with a new structure. The 962 pages of MACRA are so overwhelmingly complex,” Dr. Halamka wrote, “that no mere human will be able to understand them. Above, I have only covered the HIT related concepts, which are a small subset of all the changes to payment processes. This may sound cynical, but there are probably only two rational choices for clinicians going forward –become a salaried employee delivering clinical care or become a hospital-based clinician exempted from the madness.”
Dr. Halamka’s cri de coeur notwithstanding, the core concepts embedded in the MIPS physician quality program are relatively straightforward. As explained by Kyle Murphy, Ph.D., in EHR Intelligence, “MIPS comprises four performance categories used to score a MIPS-eligible clinician's quality, use of services, EHR use, and quality improvements to care coordination and delivery: quality (90 percent); resource use (10 percent); advancing care information (25 percent); clinical practice improvement activities (15 percent). Whether a MIPS-eligible clinician's composite performance score exceeds, meets, or falls short of the threshold set by CMS determines a positive, neutral, or negative payment adjustment in later years,” he explained. “Beginning in 2019, the payment adjustment is four percent, following five percent in 2020, seven percent in 2021, and nine percent in 2022 and beyond.”
Still, the reporting and quality requirements to appear to be relatively rigorous—and that is a good thing. Only time will tell whether the combination of various requirements, and their weighting, per what Dr. Murphy outlined, will be precisely the right combination and weighting. It is virtually certain that the entire set of MIPS requirements will be tweaked at least slightly over time—and that really is to be expected.
The fundamental reality is this: CMS officials have made it clear that all Medicare-participating physicians, whether they are participating in alternative payment models or not, will have no choice going forward about whether they participate in some form of accountable care delivery in the broadest sense of the term “accountable,” as all those Medicare-participating physicians not participation in APMs will be held accountable for outcomes and processes through the MIPS program.
So what does this mean for hospitals, integrated health systems, and large medical groups, and for their leaders, including their physician leaders and their IT leaders? A lot. Practicing physicians are going to be clamoring for help in their practices with managing this new welter of different sets of requirements, and the only entities that will be able to help them, apart from individual consultants, will be the large medical groups, hospitals, and integrated health systems with whom the practicing physicians are affiliated or by whom they’re salaried.
On the one hand, I do not believe that large numbers of 40-something and 50-something practicing physicians are simply going to leave medicine altogether, as Dr. Halamka grimly hints might be possible. They simply have too much at stake to make such a grave decision. On the other hand, what I do believe is that, within the next year or so, we will be at a true inflection point in the history of the practice of medicine in the United States, as the historical fee-for-service practice of medicine is about to change fundamentally because of the steps being taken by federal healthcare officials to rein in costs and force measured accountability from practicing physicians. And most doctors simply won’t have the wherewithal—or the desire, frankly—to manage all the new requirements for Medicare participation, in the so-called “onesie-twosie” practices that have historically been the norm in so many healthcare markets until relatively recently (and which remain the norm in small towns and rural areas and in many specialties, even now).
So there are two developments that I believe to be certain, as all of this evolves forward. The first is that the shift that has already been underway for several years now of physicians flocking to employment by large medical groups, by hospitals, and by integrated health systems, is only going to accelerate tremendously now, as it becomes more and more difficult to stay in solo or small practice. Until now, one of the main challenges was purely economic—making a practice work from a business standpoint, at a time when solo and very-small-practice physicians were increasingly becoming disadvantaged compared to their brethren in larger group-practice settings. Now, with these changes to the core terms of physician participation in the Medicare program, the day-to-day operational challenges are going to intensify to the point at which most private-practice doctors will simply not want to practice any longer in very small practices. What’s more, related to this first core development, the ongoing consolidation of physician practices into ever-larger groups will also inevitably accelerate.
The second development that I believe to be certain will be that of physicians in practice turning more and more intensively to the healthcare IT leaders in their large medical groups and in the hospitals and health systems that either own those medical groups or are their business partners, for help around all things IT. Let’s face it: both the outcomes measures reporting aspects, and the core electronic health record (EHR)/clinical information systems aspects, of medical practice, are simply becoming too complex now for most practicing physicians. And they lack the time and the patience, in any case.
And where all of the proverbial rubber really, really meets the road around all this is in the small physician practices, where a few nurses and a handful of non-clinical staff have to manage pretty much everything that isn’t direct physician interaction with patients or other physicians or direct physician documentation. How many of us, when visiting a solo practitioner in his office (if it is a male primary care physician), have asked who his IT staff is, and had that doctor turn to the woman behind the front desk and say, “Here she is, my CIO—my wife Doris!”—or something to that effect? And as terrific as Doris was and is, there is simply no way that she will be able to manage the wave of new CMS-driven requirements. (And yes, we could easily transpose genders, with Dr. Jennifer Jones and her brother Sam, the “tech guy” for her one-doc family practice.)
And think about what happens when all the major private health insurers follow CMS’s lead and impose their own versions of MIPS. You know it’s going to happen.
So this will be both a humongous challenge, and a major opportunity, for healthcare IT leaders in the next few years. As always, the potential “win” here is essentially one involving the building of engagement and loyalty on the part of practicing physicians towards the large medical groups, hospitals, and health systems whose IT leaders are willing to support them technologically.
And, the fact that all of this is unfolding in a very time-sensitive context, adds to its significance, too. This is all very, very important.
So healthcare IT leaders can either take an ostrich-head-in-sand approach to all this and allow waves of policy and payment change to wash over them like payer tsunamis—or they can keep sharply abreast of current developments, while optimizing all of their key systems—EHRs, analytics and reporting systems, clinical decision support systems, quality/performance improvement/dashboard solutions, revenue cycle management systems, and all the other systems linked to these changes—to help them help their affiliated and salaried physicians to be successful in the emerging U.S. healthcare world. There really aren’t a lot of other options. And, to add yet another metaphor here, the sands are already sifting down through the hourglass.