OP-ED

Plans For the Quality Payment Program in 2017: Pick Your Track

Screen Shot 2016-07-07 at 2.30.28 PMAs the baby boom generation ages, 10,000 people enter the Medicare program each day. Facing that demand, it is essential that Medicare continues to support physicians in delivering high-quality patient care. This includes increasing its focus on patient outcomes and reducing the obstacles that make it harder for physicians to practice good care.

The bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) offers the opportunity to advance these goals and put Medicare on surer footing. Among other policies, it repeals the Sustainable Growth Rate formula and its annual payment cliffs, streamlines the existing patchwork of Medicare reporting programs, and provides opportunities for physicians and other clinicians to earn more by focusing on quality patient care. We are referring to these provisions of MACRA collectively as the Quality Payment Program.

We received feedback on our April proposal for implementing the Quality Payment Program, both in writing and as we talked to thousands of physicians and other clinicians across the country. Universally, the clinician community wants a system that begins and ends with what’s right for the patient. We heard from physicians and other clinicians on how technology can help with patient care and how excessive reporting can distract from patient care; how new programs like medical homes can be encouraged; and the unique issues facing small and rural non-hospital-based physicians. We will address these areas and the many other comments we received when we release the final rule by November 1, 2016.

But, with the Quality Payment Program set to begin on January 1, 2017, we wanted to share our plans for the timing of reporting for the first year of the program. In recognition of the wide diversity of physician practices, we intend for the Quality Payment Program to allow physicians to pick their pace of participation for the first performance period that begins January 1, 2017. During 2017, eligible physicians and other clinicians will have multiple options for participation. Choosing one of these options would ensure you do not receive a negative payment adjustment in 2019. These options and other supporting details will be described fully in the final rule.

First Option: Test the Quality Payment Program.

With this option, as long as you submit some data to the Quality Payment Program, including data from after January 1, 2017, you will avoid a negative payment adjustment. This first option is designed to ensure that your system is working and that you are prepared for broader participation in 2018 and 2019 as you learn more.

Second Option: Participate for part of the calendar year.

You may choose to submit Quality Payment Program information for a reduced number of days. This means your first performance period could begin later than January 1, 2017 and your practice could still qualify for a small positive payment adjustment. For example, if you submit information for part of the calendar year for quality measures, how your practice uses technology, and what improvement activities your practice is undertaking, you could qualify for a small positive payment adjustment. You could select from the list of quality measures and improvement activities available under the Quality Payment Program.

Third Option: Participate for the full calendar year.

For practices that are ready to go on January 1, 2017, you may choose to submit Quality Payment Program information for a full calendar year. This means your first performance period would begin on January 1, 2017. For example, if you submit information for the entire year on quality measures, how your practice uses technology, and what improvement activities your practice is undertaking, you could qualify for a modest positive payment adjustment. We’ve seen physician practices of all sizes successfully submit a full year’s quality data, and expect many will be ready to do so.

Fourth Option: Participate in an Advanced Alternative Payment Model in 2017.

Instead of reporting quality data and other information, the law allows you to participate in the Quality Payment Program by joining an Advanced Alternative Payment Model, such as Medicare Shared Savings Track 2 or 3 in 2017. If you receive enough of your Medicare payments or see enough of your Medicare patients through the Advanced Alternative Payment Model in 2017, then you would qualify for a 5 percent incentive payment in 2019.

However, you choose to participate in 2017, we will have resources available to assist you and walk you through what needs to be done. And however you choose to participate, your feedback will be invaluable to building this program for the long term to achieve outcomes that matter to your patients.

We appreciate the sincere and constructive participation in the feedback process to date and look forward to advancing step-by-step in that same spirit. We look forward to releasing the final details about the program this fall. Most importantly, we look forward to further engagement with physicians and other clinicians toward our shared goal of the highest quality of care and best outcomes for patients.

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10 replies »

  1. Respectfully, I’m sensing “Hmm, would you like a crap sandwich, or a sandwich of crap?”

    Physicians and “providers” are completely exhausted and done done done with EHR and government mandates that have us spinning around and then lead us nowhere. You (plural, encompassing government appointees and politicians) as bureaucrats do not see the impact your Kafkaesque-policies have had on the destruction of ambulatory primary care. You do not implement policy out of a sound knowledge on the sociology of medicine. It’s all about the favors that have been owed, and the pork that needs to be doled out. To suggest that you know the way that we all need to go and we must swallow MACRA whole in order to preserve a 5% out of the Medicare allowed amount? Watch Medicare sink, and watch the angry seniors in your halls.

    Medicare insureds (over age 65) are not the persons on whom one should conduct governmental experiments on random measures and endpoints that do not take into account, ever, a lifetime of bad, or good habits, habits that that come reaping dividends or bad things during old age. You cannot expect grand results or making healthcare U-turns in an septuagenarian alive today via pacemaker, anticoagulants, and smoking cessation. In fact by government standards, over 65’s should be dead, as at inception that was the lifespan of the average American. MACRA will make it so. Realize that Medicare has cost billions because Americans’ lifespan has been extended by about 20 years, and you’re all trying to figure out how to reduce the sizes of the pie slices given to those as compensation for delivering added life via excellence, time intensive dedication and plain old hard work.

    Finally, a study measuring what is going on in physicians’ workday, and this is pre MACRA: http://annals.org/article.aspx?articleid=2546704

    “Conclusion: For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work”.

    This is directly attributable to the shoving down our throats of EHR’s that were beta tested on us, and mandates that have nothing to do with medical care or epidemiology even and everything to do with justifications to the government on what we do and why. You have probably millions of data points that you can glean from ICD 10 as well geographic and demographic data. Put the Public Health Service to work on it. We’re done being unpaid data entry clerks.

    Meanwhile Solyndra got half a billion dollars, no questions asked and everyone had fun posing for pictures, while it lasted. Then they pled the 5th and got away with it.

    We see this and seethe.

    Dysfunction, thy name is Washington DC.

  2. Anish, to quote the movie Step Brothers…”are we becoming best friends?”. You are right on the mark with this… recently Dartmouth has had to eat their “ACOs are great” shoe. They dropped out of the program because…wait for it….It costs money to setup and run AND they claim that they are so low cost already, that they cannot squeeze another drop of savings out, so they are somehow then penalized by CMS. Classic. Now they say, maybe “Sounds good” doesn’t work, that all these ACOs/APMs/fancy data entry heavy programs DON’T save money, even though they sound pretty good. Further, they announced they are laying off hundreds. I totally agree on these ‘so-called” quality measures and their nonsense. Are my patients going to get better if I have to report if I asked if they have a living will? Puhlease. We had a talk by a Premier leader the other day. What I learned…Apparently if you teach to the test, CMS loves it. Premier claims that that readmits have dropped a percent or two over the past 5 years from incentives. They conveniently forgot that I do not get an incentive for not readmitting and that the observation admit rates have gone way up, moving admits down. They sold CMS on this notion that readmits are down because of incentives, not because of observation use. I find it ironic that the highest quality care with the lowest cost comes from the small independent docs, that have NO access to improving the rules in their favor. Hence, give us the control group for MACRA, the “leave us alone” option and see how we do…

  3. Andy,

    For a Primary Physician, the long-standing, worsening reimbursement for Basic Healthcare Needs by CMS has led to a supremely under-capitalized segment of the healthcare industry: Primary Healthcare. The remote possibility of a 5% “bonus” is an insult. Furthermore, you haven’t commented on the accuracy of assigning a Medicare citizen’s PCP status. So, how can a Primary Physician learn anything from CMS when the data is likely to be seriously in error, especially a penalty rather than a bonus?

    The real issue facing the reform of our nation’s healthcare industry is the burgeoning increase in Medicare eligible citizens in the next ten years. Is there any reason to believe that our nation could afford to finance another round of hospital expansion to accommodate the future healthcare needs of this Medicare population? Albert Einstein said it well: “We cannot solve problems by using the same kind of thinking we used when we created them.” Using Medicare reimbursement systems to solve the problems created by this same system will never solve the excess cost of our nation’s healthcare industry. For 2015, the excess cost of our nation’s healthcare industry represented 60% of the Federal deficit and $2,700 per citizen.

  4. I agree with the previous comments, and especially with the notion about a control group. As clinicians, we don’t usually change our clinical behavior just because of “expert opinions”, and that is what you are basing your behavior on. Our stance is “show us the data” that proves this new drug or this new blood pressure target causes improved outcomes and/or lower cost to our patients. I think it is obvious that clinicians are suspicious of any imposed change in how we do things if there is no data to support it, or at least the promise that there will be a scientific analysis of the proposed new way as it compares with the old way. And if you read any medical literature at all, you must be aware that today’s quality is tomorrow’s fallacy. How can we be enthusiastic about putting our paycheck in jeopardy on the basis of substitute outcomes measures, which is all we have in many cases? And nobody is talking about our patients’ priorities. What about being patient centered and asking “what is your target number, Mrs. Jones”?

  5. I realize that the option to delay any reporting is meant to mollify the angry physician, but that isn’t what physicians were asking for. There was a time where idealistic young physicians (that would have been me) lapped up the reasonable sounding Obama/Andy speak. Who needs details? The big picture is what matters. Let’s give good quality care to our patients, and get paid more if we do, less if we don’t. Unfortunately, it is not enough to say the right things – you have to be able to implement. The current administration is very long on vision, and remarkably short on ability to deliver on promises. The ACA – set up to pool risk among the uninsured – a failure. The EMR rollout – meant to be a stimulus, simply became a give away to the tech world that has saddled us with clunky EMR’s that decrease productivity and do next to nothing to improve patient care.

    Look quality metrics are very hard. 10 cardiologists today would give you 10 different blood pressure targets. Its likely none of them are wrong. Even when we agree on a certain parameter, how do we account for the difference between the inner city population, well heeled suburban population, and a rural population? The wonks will show you a study that says populations can be risk adjusted – and I’ll tell you that everything can and will be gamed by the folks with resources to hire a performance improvement team. There was a time when I would have given the benefit of the doubt to seemingly bright, motivated policy foks – i really figured they would get it right in the end as long as they had the same big picture idea as I did. I was completely wrong. Details matter. For instance, how will all these small practices report? do we go to a cms website to report? will our emr’s be able to directly report this? They want to try and start in 2017 – 3months from now. I have been trying for over a year to report data into an acc registry – without success (perhaps subject of another blogpost). I want details. What is the exact mechanism, what are the exact measures, and how much extra time will it take? These seem like simple questions the behemoth that is CMS should handle with ease – but I wouldn’t be so sure..

  6. As someone who has never used an EMR, nor seen much less treated a patient, it is difficult for me to comment intelligently. Be that as it may, I look for themes or threads in things like Andy’s blog and the comments, and similar blogs and comments in the past. There seems to be significant physician disgust with EMRs of today which is exacerbated by what many of the commenters portray as largely useless and time consuming reporting, all for say 5% bonuses? I know I wouldn’t bust my back for 5%. I might, however, bust my back IF I were convinced my patients would receive better care, but most commenters claim to the contrary.

    Yet when you read Andy’s article and past articles, they make eminent sense. What am I missing here? Is the disconnect THAT huge? Is this physicians-opposing-any-change-leave-me-alone or is this government-regulation-run-amok? And if it’s somewhere in the middle, why isn’t dialogue more constructive?

    All I DO know is that our delivery of healthcare is suboptimal.

    Just askin’

  7. You are heading in the proper direction regarding the new option for flexibility. I agree, of course, with the other posters below. We need a control group aka “leave us alone” in this study of the Quality Payment Program. When there are multiple options for a new system, it should be compared to what we already have at this moment before simply assuming it is the correct path to take because it is new. I, for one, am happily volunteering to be part of the control group of physicians.
    If, after three years, my group is costing more money overall, then so be it, you have more ammunition to convince the country your way is better. However, if indeed, the “virtual group” of independent physicians who serve as your control group are less costly than your large conglomerate organizations, and better yet, the quality is equal to better, then changes should probably be made.

  8. Agree completely with the “leave us alone” path proposed here. At the very least, you will need control data to determine if all this quality interference is actually harming people instead of helping. There is already evidence that small indy practices have reduced hospitalizations, improved access and higher satisfaction. Been doing it without quality mongering programs.

  9. Welcome news overall, though realistically these are three new options, as A-APM has been on the table since the proposed rule. Also clear that potential relief for solo, rural, HRSA providers is embedded, meaning all practice types and sizes are offered the flexibility to level the playing field and make further good on earlier efforts to aid these provider types. Also looks like A-APMs won’t be expanded beyond the current six, but maybe we can hold out hope that the QP and partial QP thresholds may lessen to increase participation opportunity there, and no surprise the reporting options harken “back” to the oft-repeated 90-day back-offs of MU. What’s not explicit is the assumption that a full calendar year of reporting would translate to data from all four MIPS scoring pillars. And given the options, who would pick that? Maybe based on upcoming details around what the positive payment adjustments would exactly be. And given the letter to CMS from Ways and Means and Energy and Commerce just two days prior, CMS just may have won the news cycle, and salvaged this part of the Obama administration’s legacy.

  10. Pick your poison. Andy, with all due respect and I do think I would like you as a person, I think this we are going to beat you lightly this year and then club you with a bat next year and beyond is not going to fly. We do appreciate the one year reprieve, but full MACRA is a huge distraction to patient care, not to mention onerous, irrelevant, burdensome, expensive, etc etc. So to tell us to get used to the beatings for a bit but expect a full on smack down in a year means that you heard us, but are not fixing the problem. Maybe its your way out as the admin is changing in a few months, and this will get you out of a pinch until the new admin comes in. I understand you get many voices coming at you, but the AMA, ACP, Premier/ACOs that are pulling on your ears about MACRA are not representative of the front line MDs out here actually caring for your patients. I have a feeling this rules on rules thing you are putting out as pick your path, still will ring hollow with independent small practices. Again it appears we will be living this nightmare of EVERY year, more crazy rules about attesting, EHR, quality, etc. I have a suggestion. Try the “Leave them alone” path. Meaning, see how the resource use/readmit/quality (not self selected BS measures, but YOUR data entry people enter the data) do compared to all these crazy schemes you are dreaming up. DONT penalize the leave them alone path. I bet you will find the leave them alone path has better outcomes, less readmits, better quality, lower costs. Having MDs attest to self selected quality measures will NOT improve quality (did PQRS improve quality over all the years you received info? No). Did MU really improve EHRs and their use? No way. Will CPIA reporting really improve clinical practice? No way. Its all just a big waste of time and those of us left out here battling to care for patients need that time to do what our license lets us do. Care for patients. Not enter useless data. So I ask again, let us have a “Leave us alone” option, no EHR Cert, use any method you feel is best to care for your patients.

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