Monday, June 27, 2016

MACRA Solutions versus MACRA Rants

Today, ACP offered practical solutions to physicians’ concerns about Medicare’s proposal to implement the new payment system created by the Medicare Access and CHIP Reauthorization Act (MACRA). 

The College’s detailed recommendations, summarized here in a press statement that is linked to the comment letter itself, would replace CMS’s proposed and unnecessarily complex quality scoring system with a much simpler and understandable approach as developed by the College. We challenge CMS to completely revamp how health information technology is reported to make it less burdensome and more clinically relevant to clinicians.  We advocate that CMS create safe harbors from payment reductions for smaller practices of 9 or fewer clinicians until a “virtual reporting” system is established.  We propose expanded choices and opportunities for physician-led models to qualify for higher payments as “alternative Advanced Payment Models”—including three new APM pathways for Patient-Centered Medical Home Practices, including two that would not require physicians in such practices to bear financial risk.  And we proposed many, many more ways that CMS can simplify implementation, ensure that only reliable and clinical relevant quality measures are used, and create more choices, more opportunities, and more flexibility for physicians in all specialties and types of practices to be successful by recognizing their ongoing commitment to improving care for their patients. 

Among the detailed suggestions that the letter offers to CMS:

  • For the Merit-Based Incentive Payment System, the College proposed a distinctive alternative scoring methodology, developed by ACP, which combines, simplifies, aligns and reduces the complexity of the four reporting categories that will qualify physicians for FFS payment adjustments in 2019.  The scoring approach included in the proposed rule had different points systems and scales for each of the four reporting categories, making it unnecessarily complicated; ACP’s alternative would put the points all on the same scale, combining them into one simplified and harmonized program as Congress intended.
  • The College proposed specific alternatives to CMS’s Advancing Care Information program that is to replace the current Meaningful Use program.  The ACP alternative would make it easier for physicians to report on and be successful in this category, in line with Administrator Slavitt’s promise to revamp the program to simplify reporting and make it more meaningful for clinicians.
  • ACP proposed additional improvements to simplify the reporting requirements for the Quality, Advancing Care Information and Clinical Practice Improvement categories.  The College’s suggested changes to the Resource Use category also included suggestions to reduce unintended adverse impacts on physicians and their practices.
  • ACP urged CMS to immediately create virtual reporting options and to create safe harbors for smaller practices until such options are available.  The College recommended that practices with 9 or fewer clinicians, should be held harmless from payment reductions that would otherwise occur until the virtual reporting option is available.  ACP also suggested that a virtual reporting option could be based on linking primary care Patient-Centered Medical Homes with Patient-Centered Specialty Homes, a concept long championed by ACP.
  • The letter also proposed more options and flexibility, instead of a one-size fits all approach, for practices to be certified as Patient-Centered Medical Homes or Patient-Centered Medical Home specialty practices, qualifying them for the highest possible score for the Clinical Practice Improvement Activity reporting category.
  • The College recommended that the initial reporting period for the quality payment program be pushed back to July 1, 2017, rather than starting on January 1 as CMS proposed.  This would give physicians and their practices the time needed to make the preparations required to be successful.
  • ACP proposed four different options for Medical Home practices to qualify as advanced Alternative Payment Models, instead of the single option proposed by CMS, including options to allow PCMHs to qualify without taking financial risk.  These additional options would potentially allow many thousands more practices to qualify and earn the 5 percent bonus on FFS payments 
  • The letter suggested other changes that would make more advanced Alternative Payment Models available for physicians in all specialties, especially including those in internal medicine and its subspecialties. 

The College’s approach of offering real solutions to real problems with CMS’s proposed rule will serve internists much better than ranting about MACRA—which regrettably characterizes much of the commentary about MACRA on social media.   While physicians’ concerns about MACRA are understandable and must be addressed by CMS, I stand by my view, as expressed in a previous blog post, that MACRA’s overall framework is far better for physicians than the current flawed Medicare reporting programs—offering them opportunities to receive positive updates rather than just avoiding cuts, giving them credit for their own quality improvement activities, exposing them to less financial risk through 2021 than under the current penalties for not being able to successfully report, providing opportunities for thousands of practices that are Patient-Centered Medical Homes to qualify for higher payments.  While I have had plenty of people express disagreement with that post, not a single one has been able to factually counter the specific improvements that MACRA makes over the status quo.  They can’t—because they are baked into the law itself.

The question then is whether CMS’s proposed implementation would accomplish the statute’s and Congress’s objectives to simplify and harmonize quality reporting and to create opportunities for physician-led delivery models to qualify for higher payments.  In ACP’s view, the proposed rule did have positive elements to move payments in the desired direction, such as reducing the number of required quality measures, but it fell far short in many other respects.  Keep in mind that it is a proposed rule—the very reason it was out for public comment was so that CMS could hear from doctors and others what it got right and what it got wrong, and even more importantly, what alternatives they would recommend to make it better.  Comments that just attacked the proposed rule, or the MACRA law itself, will accomplish nothing: only Congress (not CMS) can amend MACRA, and CMS can’t improve the proposed rule unless those offering comments can give them specific ideas on what they should do differently.  Solutions, not rants, are what will bring about the needed changes.

That is what ACP did today, offer solutions that would, in the words of Dr. Robert McLean, chair of ACP’s Medical Practice and Quality Committee, "simplify the quality reporting program, reduce the burden on physicians and especially smaller practices, and propose more options and flexibility for physicians to qualify for higher payments by recognizing their ongoing efforts to improve care to their patients.  With these improvements, implementation of the new payment systems would go a long way to achieving Congress’ goal of aligning payments with quality without imposing more unnecessary administrative burden on physicians.”

Today’s question: What do you think of ACP’s recommendations to CMS to simplify reporting and scoring, create safe harbors for smaller practices, revamp the Meaningful Use program, and provide more opportunities for physician-led Alternative Payment Models to qualify for higher payments?

Wednesday, June 8, 2016

Tolerating the Intolerable

Sarah Kliff is a highly respected healthcare journalist, now with and before that, the Washington Post. 

Sarah Kliff is also a patient.  

You might think that Sarah’s understanding of healthcare policy would have made her well prepared to navigate the complexities of our healthcare system. 

Think again.

In a fascinating first-person account of her experiences as a patient undergoing treatment for a chronic foot problem, Sarah observes that writing about American healthcare didn’t at all prepare her for the maddening work involved in coordinating her own care:
“I write a lot about health care for my job here at Vox, and have spent the past seven years covering and explaining the American health care system. But there was something I didn't understand about American health care until this experience.  It is the considerable burden our fragmented system puts on patients to coordinate their own care.”
She continues:
“Every three months, I just know I'm going to lose a few days of my life. I'm not talking about the work of managing one's health, the work that diabetics do to monitor their blood sugar or the healthy eating choices a doctor might recommend for an overweight patient. This can be a significant burden in its own right. 
What I didn't understand was the burden patients face in managing the health care system: a massive web of doctors, insurers, pharmacies, and other siloed actors that seem intent on not talking with one another. That unenviable task gets left to the patient, the secret glue that holds the system together. 
For me, this feels like a part-time job where the pay is lousy, the hours inconvenient, and the stakes incredibly high. It's up to me to ferry medical records between different providers, to track down a pharmacy that can fill my prescription, and to talk to my insurance when a treatment gets denied to find out why.” 
Something that should have been as simple as getting a prescription filled turned out to be anything but:
“The doctor handed me the prescription on a purple slip. It was for a topical anti-inflammatory medication that my doctor hoped would fix my problem by reducing swelling in a joint.
 I wanted to fill it promptly because my doctor said I'd need to bring the medicine with me to my first physical therapy appointment — the sooner I could get the medication, the sooner I could start treatment and (fingers crossed) the sooner I could return to running. 
I biked to the nearest pharmacy, a large CVS. A technician there informed me that that branch didn't carry this medication. I tried a larger CVS a mile away; no luck. I was late to dinner. 
I woke up the next morning. I called Walgreens, which did not carry the medication. I checked my insurance plan online, where I learned that they don't cover this medication so I couldn't use the mail-order pharmacy. 
I emailed my doctor's medical assistant at 8:28 am to ask what I should do. I searched for the medication online; the one place that appeared willing to sell it to me was an equine pharmacy in Iowa. I did not need a horse-size dosage. 
I sat at my kitchen table crying out of frustration. I cried because I was trying my best, and I really wanted to run again, but I felt like the health care system had bested me. I cried because nobody else — not my doctors, not the pharmacists — really seemed to care. 
It was 9:14 am, and I was late to work. 
I got an email from a medical assistant in my doctor's office at 5:05 pm. The doctor never should have given me the prescription in the first place. The medication I needed would have to be ordered by their office through a specialty pharmacy. I should expect to hear from them in a few days. 
‘I'm sorry this was not explained at the appointment,’ the email said. 
But then I got another email, from a different medical assistant. She didn't mention anything about the specialty pharmacy but asked if I wanted help filling the prescription. I sent her two emails back. She never responded. 
The issue was resolved three days later when I got a call from the specialty pharmacy, asking where to ship the medication. 
On its own, this is a relatively small inconvenience. Just writing out the details feels silly, almost self-indulgent. 
At the same time, it took about an hour out of my workday. When I didn't know how I'd get the medication, I was stressed and unable to focus. I felt like nobody else really cared about whether I got the prescribed treatment.” 
Sarah’s experience rings true for me, as I have had similar experiences trying to help a close family member get her prescriptions filled for an ongoing medical condition.  She too has had to go through the burden of obtaining pre-authorizations for her medications and then being bounced around from pharmacy-to-pharmacy trying to find someone who would be able to fill it.  I expect this experience rings true for many who read this blog.

The unnecessary and excessive burden our healthcare system imposes on patients is the flip side of the unnecessary and excessive burden it imposes on physicians.  One study found that 4 hours of professional time per physician and 5 hours of practice support staff time – could be saved each week if billing was streamlined.  Another found that cost of the hours per year that physicians spend on interacting with health plans is approximately $68,000.  Many other studies have reported the same: physicians are spending more and more of their time on administrative tasks that they find to be of little value to them or their patients—one of the drivers of the documented increase in reported  “burn-out” among front-line physicians.

Yet for some reason, both patients and physicians put up with all of this—or perhaps more accurately, feel powerless to stop it.  Maybe because it seems like the entire system is set up to ensure that no one is held accountable.

Physicians blame the insurance companies for requiring pre-authorization for needed drugs or procedures, insurance companies blame the physicians for ordering too many unneeded drugs or procedures, pharmacies blame the pharmacy benefit managers for making it difficult to fill prescriptions, pharmacy benefit managers blame the drug manufacturers for pricing the drugs too high—and everyone, it seems, blames the electronic health record.  The result is unhappy patients and unhappy physicians, yet nothing seems to change.

But it has to change.  We should not be asking patients to spend hours of their time navigating our maddeningly complex healthcare system.  We should not be asking doctors and their staff to spend hours of their time filling out unnecessary paperwork in our maddeningly complex healthcare system.

Patients and doctors alike should no longer be required to tolerate the intolerable.  In my mind, there is no more urgent task than demanding simplification in American healthcare.

Today’s question: What do you think of Sarah Kliff’s experience and what should be done about it?

Thursday, May 19, 2016

Relax, it’s only MACRA

Over the past three weeks, I’ve had the chance to present the changes being brought by the Medicare Access and CHIP Reauthorization Act (MACRA) to audiences of hundreds of physicians—at ACP’s Leadership Day on Capitol Hill, ACP’s Board of Governors and Board of Regents meetings, several educational sessions and a news briefing at the College’s Internal Medicine 2016 Scientific Meeting, and on Saturday, to the California Medical Association’s Leadership Academy.  I’ve also had chats with dozens of physicians outside of these formal presentations.

Here’s what I have learned: most physicians look at the “value-based” payment reforms being brought by MACRA with a degree of trepidation: they aren’t sure how to proceed, what measures will be used, whether they will be unfairly penalized for things outside of their control, and worried it will result in more administrative “hassles.”  It is certainly true that MACRA will make significant changes in the way physicians are reimbursed by Medicare, and ACP is addressing such concerns, through our advocacy with CMS and Congress, by educating our members about MACRA and by helping them be prepared.  For instance, ACP has developed a two-page explanation  of the law, recommended 10 steps physicians can take right now, and developed implementation tools to help them.

Understandable anxiety and trepidation is one thing, but what worries me is that there is a growing undercurrent (just Google “MACRA will destroy private practice”) that implementation of the law will be a “sky-is-falling, end-of-medicine-as-we-know-it” type of disruption.

Frankly, this is nonsense, because MACRA offers physicians far more flexibility and choices than what that they currently have to put up with.   

Remember, MACRA didn’t create the idea of linking Medicare payments to measure of value, physicians have had to report on quality measures for years, with their payments being adjusted upward (and increasingly downward) if they don’t report successfully.  So the real question is, is MACRA better than what doctors currently have to put up with PQRS, Meaningful Use, and Value-Modifier programs?

  • Yes, by combining reporting of quality data into one program instead of the three separate ones, MACRA can substantially ease the burden of reporting. Already, CMS has proposed a reduction in the number of measures that have to be reported under the quality program that will replace PQRS and improvements in the Advancing Care Information program that will replace the Meaningful Use program to make them less burdensome.  In addition, MACRA adds a new category for reporting on Clinical Practice Improvement Activities, with approximately 90 flexible options for physicians to get credit for many of the improvements they already are making in their practices. Further, CMS has emphasized its commitment to ensuring that smaller practices get the flexibility and support they need.  Although CMS’s proposed improvements don’t go far enough, ACP intends to hold the agency to its commitment to “streamlining and strengthening value and quality-based payments for all physicians; rewarding participation in Advanced Alternative Payment Models (APMs) that create the strongest incentives for high-quality, coordinated, and efficient care; and giving doctors and other clinicians flexibility regarding how they participate in the new payment system.”

  • Yes, because MACRA’s maximum potential penalties for failing to successfully report quality and cost data for the next four years are less than under the current reporting programs.  Under the current PQRS, Meaningful Use and Value-modifier programs, physicians in 2017 could get a maximum downward adjustment of up to 8 percent:  -2% from PQRS, -2% from Meaningful Use,  -2% from the Value Modifier Program (for physicians in groups of 2-7) or -4% (for groups of 8 or more).  Under MACRA, the maximum downward adjustment a physician could get in 2019 (which CMS is proposing will be based on data submitted in 2017) is -4 percent, -5% in 2020, and -7% in 2021.  Only in 2022 and subsequent years would MACRA’s downward adjustment of -9% be greater than the current maximum downward adjustment of up to -8% under the current programs.

  • Yes, because MACRA allows physicians to earn positive payment adjustments while the current PQRS and Meaningful Use programs only allow physicians to avoid penalties (no positive adjustments allowed). Under MACRA, physicians can earn positive payment adjustments each year for quality reporting of up to +4% in 2019, +5% in 2020, +7% in 2021, and +9% in 2022 (although the actual maximum positive adjustments each year could be less than this, depending on how many physicians fall above or below the threshold required to avoid downward adjustments), and top performers can earn up to 10% more each year.  Under the current PQRS and Meaningful Use programs, there are no positive upward adjustments available, only avoidance of penalties for failing to report successfully.

  • Yes, because under the current PQRS and Meaningful Use programs, Medicare keeps the money from negative adjustments to some physicians while MACRA keeps it in the physician payment pool. Under MACRA, any negative adjustments to physicians who fall below the scoring threshold needed to get positive adjustments are redistributed to physicians who score high enough to receive positive adjustments.  While such “budget neutral” redistribution creates challenges, it’s clearly better for physicians that MACRA allows the money to stay in the physician payment pool rather than letting Medicare keep it as it now does.

  • Yes, because MACRA allows the thousands of  physicians in certified Patient-Centered Medical Homes (or who decide to get certified) to get favorable scoring, helping them qualify for positive payment adjustments.  No such opportunity exists under the current reporting programs.  CMS is proposing a number of flexible options for practices to get certified as PCMHs.

  • Yes, because under MACRA, physicians in Advanced Alternative Payment Models can to earn 5% Medicare FFS bonus payments each year from 2019-24 (and more favorable updates afterwards), plus whatever payment incentives and additional revenue opportunities apply to their advanced APM. To illustrate, CMS has proposed that physicians participating in the new Comprehensive Primary Care Plus program, which I blogged  about last month, could qualify as Advanced APMs, meaning that they would get risk adjusted prospective payments averaging $15-27 each month per beneficiary, plus at risk incentive based monthly payments of $2.50-$4.00 per beneficiary per month (this portion would have to be paid back if savings weren’t achieved), plus their FFS billings, plus the 5% bonus on Medicare FFS payments available only to advanced APMs.

So yes, MACRA is a big deal, but not in the way many physicians think it is. Compared to what physicians are currently dealing with under the current Medicare reporting programs, MACRA offers more opportunities for physicians to earn positive adjustments, exposes physicians to less risk from negative adjustments through 2021, creates positive rewards for the thousands of physicians who are practicing in certified PCMHs or who choose to get such certification, keeps all of the money from downward adjustments in the physician payment pool rather than letting Medicare keep it, and creates very substantial payment rewards for physicians in advanced Alternative Payment Models.  These changes are all good for physicians, especially those in smaller practices.

And, don’t forget, because of MACRA, we no longer have to deal with the annual SGR cut and all of its associated baggage.   

Sure, MACRA remains a work-in-progress; more can and must be done to simplify reporting and create additional options and flexibility for physicians in all types and sizes of practice, and physicians will need help in making the necessary changes in their practices.  But even as it stands right now, MACRA clearly is a change for the better compared to what physicians currently have to deal with.

Today’s question: what do you think the impact of MACRA will be on your practice?