Tag: MACRA

A Letter from CMS to Clinicians in the Quality Payment Program: We Heard You and Will Continue Listening

Oct 14, 2016• 21

By ANDY SLAVITT

screen-shot-2016-10-14-at-8-43-48-am Today, we are finalizing policies to implement the new Medicare Quality Payment Program. Part of the bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Quality Payment Program aims to create a more modern, patient-centered Medicare program by promoting quality patient care while controlling escalating costs through the Merit-Based Incentive Payment System (MIPS) and incentive payments for Advanced Alternative Payment Models (Advanced APMs).

After issuing our proposal for how to implement the new program earlier this spring, we held a listening tour across the country to hear your thoughts and concerns first-hand about the Quality Payment Program. Whether you formally submitted one of the over 4,000 comments we received, or were one of the nearly 100,000 attendees at our outreach sessions, there have been record levels of clinician engagement. The interactions reflect the importance you place on serving the more than 55 million individuals that have Medicare coverage.

We found an eagerness to help the Medicare program improve and an interest in being engaged in how we address the challenges and opportunities ahead. We also heard concerns, which is not surprising, given the challenge of changing something as large and important as the Medicare program. But, we found that there is near-universal support for moving towards a future focused on patient care that pays for what works, reduces clinician burden, and better supports and engages the medical community.

Practicing Physicians and Healthcare Reform: Population Health vs. Compensation Wealth

Sep 25, 2016• 1

By NATHAN KAUFMAN

In her August 14^th 2016 interview with the LA Times regarding the ACA and value-based reimbursement, HHS Secretary Sylvia Burwell stated, …”and medical providers want this.¹” After reading this article, I wondered for a moment if I am working in the same healthcare system as the Secretary. Having spent a significant part of my 36-year career negotiating financial transactions with and/or on behalf of practicing physicians, I can unequivocally state that, unlike healthcare thought -leaders and policy wonks, a scant few practicing physicians are on board with population health management, value-based care and the “triple aim.”

It is essential to significantly improve the value of healthcare and it will require a lot of work by all. Given the disconnect between the policy makers/‘thought- leaders’ and the nation’s practicing physicians, I am pretty sure we are not going to get very far. Most practicing physicians consider the current movement to value based care/population health to be ineffective, expensive, bureaucratic interference with the practice of medicine.

MACRA Comment: CMS + MIPS/APM = Death of the Private Practice Physician

Jul 5, 2016• 5

By NIRAN AL-AGBA, MD

flying cadeucii Small, independent private practices are closing, increasing numbers of physicians are retiring early, and fewer medical school graduates are choosing primary care. The old-fashioned practice my father and I have built is a dying entity. Parents say coming to see us for an appointment feels more like a visit with a friend than a medical encounter. I am fighting for the subsistence of rural primary care practices. Most will not survive MACRA proposed changes to the reimbursement structure.

Seven days ago, I attended an “informational listening session,” sponsored by the Center for Medicare and Medicaid Services (CMS) for rural physicians to learn more about the new MACRA proposal known as MIPS/APM (Merit-Based Incentive Payment System/Alternative Payment Model.) This new plan will penalize 7 out of 10 small practices with 1-2 physicians in this country. Why? Because they will be overwhelmed complying with fruitless statistical reporting demands that do nothing to enhance the quality of care, instead of spending precious time seeing patients.

Sloppy Risk Adjustment and Attribution Guarantee MACRA Won’t Work

Jun 5, 2016• 6

By KIP SULLIVAN

flying cadeucii I just finished reading the 962-page MACRA rule CMS released late in April. I was prepared for the mind-numbing complexity of the document. What I was not prepared for was CMS’s glib treatment of two fundamental issues: The woeful inaccuracy of the scores CMS will use to punish and reward doctors, and the cost to doctors of participating in ACOs, “medical homes” and other “alternative payment models” (APMs)

These are not peripheral issues. If CMS dishes out financial rewards and punishments based on inaccurate data, MACRA will, at best, have no impact on cost and quality and may well have a negative effect. The second problem – the high cost of setting up and running APMs – may not be as lethal as the inaccurate-data problem, but at minimum it will reduce physician participation in APMs and, therefore, the already slim probability that APMs will reduce Medicare costs and improve quality.

In this comment and two more to come, I will review both of these problems and CMS’s what-me-worry attitude toward them. I begin with a jaw-dropping example of CMS’s reckless indifference to its inability to measure physician “merit” accurately.

Rethinking MACRA Part II

May 15, 2016• 10

By JOHN HALAMKA

John Halamka In my blog posts, I speak from the heart without a specific political or economic motivation. Although I’ve not written about highly controversial subjects such as religion, gun control, or reproductive policy, some of the topics in my posts can be polarizing. Such as was the case with MACRA.

Some agreed with my initial analysis that clinicians will have a hard time translating complex MACRA payment processes into altered clinical behavior. Others felt I was overharsh, negative and inappropriate. It’s never my intent to criticize people, instead I want encourage dialog about ideas. In that spirit, here’s my opinion on how we should evolve from fee for service to pay for value/outcomes.

1. Humans can never really focus on more than 3 things at a time. Although we sometimes believe multi-tasking is efficient, in reality we do work faster with less quality. Instead of 6 or 8 dimensions of Meaningful Use performance combined with a large number of quality indicators, why not delegate each medical specialty the task of choosing 3 highly desirable outcomes to focus on each year, then reward those outcomes? For example, I have glaucoma. Asking my opthalmologist to record my smoking status or engage in secure messaging with me is probably less important than ensuring my intraocular pressures are measured, appropriate medications are given, and my visual field does not significantly worsen. The cost to society of my blindness would be significant. Keeping my sight intact represents value. Care Management software could ensure I’m scheduled for pressure check appointments, given medications, and have my visual field checked once per year. Some percentage of reimbursement could be withheld until those outcomes are achieved. How software does that is not important and innovative workflow would be left to the marketplace where clinicians will choose applications based on usability, cost, and time savings instead of regulatory oversight.

Independent Decision Support at the Point-of-Care for Both Patients and Physicians

May 13, 2016• 9

By ADRIAN GROPPER, MD

flying cadeucii “We did not spend $35 Billion to create 5 data silos.” This was said by Vice President Biden at the beginning of Datapalooza on Monday and repeated by CMS’s Andy Slavitt on Tuesday. On Wednesday, at the Privacy and Security Datapalooza at HHS, I proposed a very simple definition of electronic health record (EHR) interoperability as the ability for patients and physicians to access independent decision support at the point of care regardless of what EHR system was being used.

Over the three days of Datapalooza, I talked to both advocates and officials about data blocking. In my opinion, current work on FHIR and HEART is not going to make a big dent in data blocking and would not enable independent decision support at the point of care. The reasons are:

ACO 101: Koka Completely Misses The Mark on Medicare ACOs

May 3, 2016• 9

By LISA BARI

Recently, Anish Koka, MD, a Cardiologist from Pennsylvania, posted his anti-Accountable Care Organization (ACO) manifesto here on The Health Care Blog. [1] Koka argues that ACOs don’t work and are doomed to fail because they were designed by non-practicing physician policymakers and academics in ivory towers. He appears to be basing his judgment on a commercial ACO contract that only pays him $4 per month extra for care coordination and requires that he meet specific quality measures. He is also conflating his experience in a commercial ACO with Medicare ACOs, and interprets the initial results of one Medicare ACO program to mean that all ACOs are a failure. Finally, he relays an anecdote of caring for one of his patients, Mrs. K, a patient with chronic illness who doesn’t want to take her medication.

In his post, Dr. Koka calls out “well-meaning, hard-working folks that own a Harvard Crimson sweater…[whose] intent is to fundamentally change how health care is provided.” As luck would have it, I do own a Harvard Crimson sweater, and I’d like to respond.

The Affordable Care Act (ACA) of 2010 gave the Centers for Medicare & Medicaid Services (CMS) the authority to create ACOs in two forms. One, the Medicare Shared Savings Program (MSSP), is a large program that does exactly what its name says: it allows physicians and care organizations to share savings with CMS based on their previously-expected health care spending. The other was the Pioneer ACO model run by the CMS Innovation Center (CMMI). This five-year experiment was intended to test if physicians and care organizations could bear both upside and downside risk while still delivering high quality care. The Pioneer ACO program has ended as planned, and CMMI has incorporated its findings from the model thus far into the Next Generation ACO model. [2] Any other ACO program is a non-governmental agreement between a private insurer and group of health care providers that is neither designed nor controlled by CMS or any other part of the government.

Dr. Koka’s main point of criticism appears to be with the terms of a commercial, non-Medicare, non government ACO with which he contracts. Commercial ACOs tend to have stricter, less-generous terms for physicians; a 2014 study in the American Journal of Managed Care found that commercial ACO contracts were more likely to include both downside risk and upfront payments. [3] CMS cannot be held responsible for the terms of an ACO contract between Dr. Koka and a private insurer, but I’ll leave that aside for now.

Dr. Koka cites a recent Harvard study on the first year and a half of results from the MSSP as evidence for the failure of ACOs. [4] This study looked at Medicare claims data for two cohorts of practices–one starting mid-year in 2012 and one starting on January 1, 2013, through the end of 2013. In short, the mid-year 2012 cohort delivered a small amount of savings per beneficiary, and the 2013 cohort achieved a negligible amount of savings. Additionally, some quality measures showed improved performance, while others were the same as the control group. I do not interpret these results as a “failure” at all. These are early results from a generous program that is easing physicians and care organizations into accountable care by limiting the amount of risk that they must take on at first. Equivalent or better-quality care was delivered, along with small savings.

Leavitt Partners, a health care consulting firm, has been tracking and reporting on Medicare and commercial ACOs since 2010. In their recent report on the early takeaways from the MSSP results, they highlighted that physician group-led ACOs tended to do a better job than hospital-only ACOs, and that ACOs residing in high-cost markets were more likely to generate shared savings. [5] Based on all of these findings, I cannot agree with Dr. Koka that Medicare ACOs are a failure, and I certainly cannot extrapolate from commercial ACOs to Medicare.

The evidence is widespread and irrefutable that our current payment and delivery system has resulted in the highest health care costs in the world, along with some of the lowest-quality care. [6] We simply cannot continue to pay doctors and hospitals on an unrestricted fee-for-service basis. ACOs are the beginning of a massive shift in how we deliver, pay for, and measure health care in order to address these cost and quality issues.

Dr. Koka also fails to acknowledge a critical point about ACOs: they are generally designed with the Primary Care Physician (PCP) as the central care coordinator versus a specialist. PCPs are best situated to coordinate care for their patients and manage preventive care and population health measures. A more expensive specialist like Dr. Koka should not be the physician responsible for coordinating patient care in an ACO–it makes little sense. One reference point comes from The Accountable Care Guide for Cardiologists from the Toward Accountable Care Consortium. They highlight PCPs and good teamwork as critical central elements in any ACO. [7]

He also does not acknowledge that it takes time to get accountable care and care coordination right. A PCP or primary care organization is not going to have the tools they need or the right contracts in place with specialists and hospitals on day one. The processes and technology for effectively managing an ACO take time. The initial results from the MSSP prove this out.

Let’s say we assume for the sake of argument that Dr. Koka is right; that ACOs don’t work, and they are a colossal waste of time. Even then, his proposed solution is more than a bit ham-handed. There is no agreement among either the American public or the health care system that we should directly ration care. I suggest that we start by making PCPs the gatekeepers to specialists like Dr. Koka rather than asking him to spend many hours coaxing a patient to take her medications. Undoubtedly, this is what his commercial ACO intended. We need to do a better job of delivering the right care at the right time, from the right physician, nurse, or other provider–yes, this is care coordination.

And if all else fails, well, there is one easy, proven way to slow the growth of health care costs: making a blunt cut in reimbursement rates to providers, as we saw in the Budget Control Act of 2011. I am almost certain that Dr. Koka would not welcome another cut like this. [8]

If Dr. Koka would like to avoid this last-ditch option, perhaps it is time to partner with primary care organizations and see how he can help them to be a successful ACO…and allow Mrs. K’s PCP and case manager or health coach to field those Saturday calls.

As avid followers of federal health policy will know, this week CMS released the notice of proposed rulemaking for the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. The MACRA encompasses a massive shift in Medicare physician payment. The bad news for Dr. Koka? Accountable, value-based care is not going away anytime soon. The good news is that the proposed payment and delivery system models include more flexibility for physicians and will better reward them for high quality care.

In my opinion, the best news is that the MACRA provides a clear path for our public health care system to move away from fee-for-service once and for all. I hope that Dr. Koka can reconcile himself with a world where care providers, in partnership with patients, are asked to be more accountable for the high cost of health care. At a minimum, I hope that the difference between commercial and Medicare ACOs is now clear.

Lisa Bari is a Master of Public Health candidate at the Harvard T.H. Chan School of Public Health, and previously worked in health IT. She loves primary care health policy, health care payment reform, interoperability, and health data APIs. She never thought she’d own a Harvard sweatshirt. You can find her on Twitter @lisabari.

1 https://thehealthcareblog.com/blog/2016/04/25/the-aco-delusion/

2 http://www.brookings.edu/~/media/research/files/papers/2015/05/12-aco-paper/impact-of-accountable-careorigins-052015.pdf

3 http://www.ajmc.com/journals/issue/2014/2014-vol20-n12/aco-contracting-with-private-and-public-payers-a-baseline-comparative-analysis

4 http://www.nejm.org/doi/pdf/10.1056/NEJMsa1600142

5 http://leavittpartners.com/wp-content/uploads/2016/04/MSSP_ACOs_takeaways_whitepaper_final.pdf

6 http://www.commonwealthfund.org/publications/press-releases/2015/oct/us-spends-more-on-health-care-than-other-nations

7 http://www.ncmedsoc.org/wp-content/uploads/2014/06/ACO-Guide_Cardiologist_052814_reduced-file.pdf

8 http://www.cbpp.org/research/how-the-across-the-board-cuts-in-the-budget-control-act-will-work

9 http://www.politico.com/tipsheets/politico-pulse/2016/04/exclusive-andy-slavitt-on-macra-214014

The Angry Physician

May 1, 2016• 34

By ANISH KOKA, MD

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I think I speak for most physicians when I say that we did not choose to go into medicine to shape health care policy. Medicine is a calling, and I treated it as such. I immersed myself with taking care of patients, and keeping up with the ever changing knowledge landscape that is medicine. I left the policy making to the folks I voted for the last 8 years. These were the adults, the intellectuals – they would take care of the task of taking out the bad elements of our healthcare system and leaving the good. I truly believed. I eagerly began the ehr/meaningful use saga believing this would result in better care for patients.

It took me two years to realize the meaninglessness of meaningful use. I still can’t believe how long it took me to realize that creating a workflow in my office to print out and deliver clinical summaries to patients didn’t do anything other than fill the trashbin. I still held out hope. I thought – this was a first draft, improvements would come. What came instead were positively giddy announcements of the success of the meaningful use roll out. The administration was actually doubling down. There was no acknowledgment for the mess that had been created – onward and forward on the same road we must continue to march. Except the road would no longer be paved and we would be walking uphill.

You Won’t Believe What Medicare Just Did on Patient Engagement!

May 1, 2016• 8

By MICHAEL MILLENSON

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Sure, I’ve always wanted to write a clickbait headline that sounds like a promo for the bastard child of Buzzfeed and the Federal Register. But, seriously: you will not believe what Medicare just did about patient engagement in a draft new rule dramatically changing how doctors are paid.

And, depending upon the reaction of the patient community, you definitely won’t believe what happens next.

Preparing Your Organization for MACRA 1.0

Apr 20, 2016

By BOBBI BROWN

flying cadeucii What does the Medicare Access and CHIP Reauthorization Act (MACRA), signed into law in 2015, mean for healthcare organizations and providers? At HIMSS 2016, the CMS Center for Clinical Standards and Quality Director, Kate Goodrich, MD, stated MACRA’s goal: “to have a single, unified program with flexibility. The new Merit-Based Incentive Payment System (MIPS) will offer that flexibility and not be a one-size fits all program. The new rule will reimburse physicians based on four factors.”

Health systems are still waiting for additional details about the “four factors” Goodrich mentioned (listed in this article under “MIPS”) or how CMS will reward providers for delivering better care. We’re aware of MACRA’s general structure, but still waiting for clearly defined rules and regulations. Until then, it will be difficult to evaluate this new law.

Even though health systems are currently in a waiting period for clarifying details about the proposed MACRA regulations (with major impacts in 2019), MACRA’s base year will likely be 2017—and 2017 is just around the corner. This article provides an overview of MACRA and guidance about what health systems should do to prepare for MACRA now.