Erica Sprey

 shows that few doctors are being compensated for value-based care. Of 812 responding physicians, 67.6 percent say none of their compensation is tied to value-based care, and another 16 percent say it's less than 1 to 5 percent. Moreover, a clear majority or 72 percent say none of their compensation is tied to patient satisfaction metrics.

That will change, whether physicians like it or not. Medicare's new value-based reimbursement program is slated to begin in January 2017, with payment adjustments set to take place in 2019. CMS released its final ruling concerning the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) in mid-October 2016, which will compensate physicians for quality-based metrics and patient outcomes under the Merit-based Incentive Payment System (MIPS) or the Advanced Alternative Payment Model (APM) pathways. Yet, many industry experts say that a good number of physicians are not even sure what MACRA is, let alone willing to accept the paradigm shift that it requires.

Susanne Madden, founder and CEO of The Verden Group, a practice management consulting firm based in Nyack, N.Y., says physicians just don't understand the push to embrace value-based care. "When we talk about value, it's sort of 'value for who?'" she says. "Payers understand value because they are trying to get quality and outcomes for the amount of money that is being spent on healthcare. Physicians don't see it in the same way."

While it is easy to speak about bringing value, controlling cost, and improving quality of care for populations of patients, physicians are more intimately concerned with caring for each patient individually. This can set up an adversarial relationship with policy makers, economists, and even payers who are looking at healthcare more in terms of dollars and cents.

"The value is very cognitive, for most physicians, because it is about the relationship with the patient," says Madden. "So we are really talking about two radically different things from the perspective of each of the key players in this … [Physicians] are very physical, very tangible, not very economically focused and driven in the way that payers are," she says.

Why are physicians resistant to value-based care? 

In our survey, only 30 percent of respondents say they expect their compensation will be lower in 2019 because of the changes that MACRA will bring, and 60 percent say they are not sure how MACRA will affect their practice revenue. While the government has essentially eliminated the negative payment adjustment in the first year that Medicare uses its new compensation formula (as long as physicians report a small amount of data in 2017), that will not be the case in subsequent years.

Ellis "Mac" Knight, senior vice president and chief medical officer for Coker Group, a consulting firm based in Alpharetta, Ga., says physician resistance to MACRA may stem from an intrinsic view of medicine and patient care that is still firmly rooted in a fee-for-service (FFS) model. During the many years that Knight was a practicing internist and hospitalist, he says he foresaw "changes coming down the pike" stemming from healthcare reform and the movement to value-based reimbursement.

In his last role with Palmetto Health system in Columbia, S.C., he helped develop a Clinically Integrated Network (CIN) composed of the health system and roughly 600 community physicians, because he says he believed that the current system was not providing high-value care for patients or positioning physicians to thrive in a value-based environment. He admits that his position is not popular with the majority of physicians because, "Most physicians are so close to and so accustomed to practicing in a [FSS] environment, that they can't really see the perversities, if you will, that this payment model has caused," he says. "All healthcare providers, I would have to say, are fairly myopic in terms of their vision of the industry as a whole. They see themselves very interested in quality, they see themselves as very cost efficient, and they really don't see the broader picture that those two things aren't really true." 

What does MACRA mean for small, independent practices?

The value-based payment programs created under MACRA are designed to be budget neutral, meaning there is essentially a fixed pot of money for Medicare reimbursements beginning in 2019. In other words, if some physicians receive bonus money, others will receive a negative payment adjustment. According to the 

Quality Payment Program Overview Fact Sheet

 released by CMS, if a physician decides to participate in MIPS, then he will see either a positive, neutral, or negative payment adjustment of up to 4 percent of his Medicare payments (based on 2017 performance) in 2019, depending on the amount of quality-based data he provides.

There are exceptions to this provision: if a provider has fewer than 100 Medicare patients, or bills less than or equal to $30,000 in Medicare charges, then he is exempt from participation in MIPS.

Due to physician concerns during the final rule comment period, CMS has provided for a "transition year" starting Jan. 1, 2017, that eases reporting requirements and allows physicians to "pick their pace of participation." For instance, if a physician simply desires to avoid a negative payment adjustment in year one, she can start collecting performance data by Oct. 2, 2017 and submit a minimal amount of data to Medicare by March 31, 2018 - e.g., one quality measure or one improvement activity.

However, the reporting requirements will increase in year two, so doing the bare minimum is simply kicking the can down the road. Madden suggests that physicians use the transition year to familiarize themselves with new reporting requirements and quality metrics. "Don't wait, because you can take baby steps, January through October, and then test it out and see what that looks like for you in terms of monitoring your care and reporting on some of these categories," she says.

KrisEmily McCrory, is an employed, family-medicine physician based in Schenectady, N.Y. As a board member for her state chapter of the American Academy of Family Physicians, she also advocates for physician political activism especially when it comes to concerns over changing government regulations and practice conditions for physicians and their patients. She has expressed grave concerns about the challenges and burdens that MACRA will place on smaller physician practices.

After Medicare makes the first payments under MIPS, McCrory asks, "How many people are going to drop Medicare at that very moment? That, I think, is going to be very telling. You are going to find out in 2018 if you are going to have a negative payment adjustment. And if you are going to have a negative adjustment, is it worth taking Medicare patients anymore? We are not going to know that unintended consequence until we get through the first year."

Small practices have fewer resources than larger groups - staff, technology, and financial reserves - to help them address new reporting measures and needed changes to clinical work flows to support participation with MIPS, says Knight. If practices do try to go it alone, he says, they must first ask themselves, "What type of IT infrastructure am I going to need? What data systems am I going to need to report all these performance metrics? What billing systems am I going to need to put that into place, or get someone to outsource for me, so that I can get adequately reimbursed for value-based care?"

What specific steps should practices take to prepare for MACRA?

Many physicians are already participating in federal programs that are now part of MIPS; they've just been given new names. The EHR Incentive Program, or Meaningful Use, has been renamed the Advancing Care Information performance category under MIPS, which counts for 25 percent of the category weight in 2017. Most physicians will need to fulfill five measures in this category for at least 90 days (if they have chosen to report data for a full year in 2017): security risk analysis, e-prescribing, provide patient access, send summary of care, and request/accept summary of care.     

"If practices, particularly independent practices, have already started doing Meaningful Use, if they've already started taking steps to become a certified Patient-Centered Medical Home (PCMH), they're in the best shape," says McCrory. "People who have somehow managed to not get an EHR are in really tough shape."

Another consideration is the requirement that physicians must use an approved EHR that has been certified in 2014 for first year MIPS reporting, which could necessitate a significant investment in funds to upgrade or replace old technology. Madden says now is the time for practices to assess their current technology and ask if it is capable of reporting the data and quality measures required for MIPS. If not, practices should not wait on making new IT investments. It can take up to six months to thoroughly research, vet, and choose a new EHR system, she says.

Practices that are currently - or have taken steps to gain accreditation as - a PCMH are in a much better position in terms of demonstrating quality measures for MIPS, says McCrory. They are also more at home using technology for reporting purposes. "Participants in certified Patient-Centered Medical Homes, comparable specialty practices, or an APM designated as a medical home model, will automatically earn full credit" for the new Improvement Activities performance category, according to CMS. For practices that are not medical homes, Madden recommends they focus their energy on learning about Improvement Activities so that they can familiarize themselves with the new category, since it counts for 15 percent of the category weight in 2017.

The Physician Quality Reporting System (PQRS) program has been replaced by the Quality performance category under MIPS, which accounts for 60 percent of the category weight in 2017. When it comes to quality, "most Medicare providers have been reporting through Medicare's (PQRS)," says Madden. "They are fairly familiar with what the quality measures are and how they need to report on them." McCrory recommends that practices review the PQRS report from 2014 (the 2015 report will come out soon) so that they are aware how well they are doing on quality measures like patient HbA1Cs, compared to national standards.   

The final performance category, Cost, replaces the Value-Based Modifier and will not be counted into the final score for MIPS until 2018. For this measure, practices will not be required to submit data. It will be calculated from adjudicated claims data.

What are some other actions physicians can take?

Aside from becoming employed or dropping Medicare altogether, a third option for physicians is to join forces with other practices via Accountable Care Organizations (ACOs) or a CIN, says Knight. These types of structures can allow practices to operate independently, yet still benefit from economies of scale when it comes to administration, reporting, technology, contracting, and billing.

A strong advantage of joining a CIN is that the organization is already structured to focus on improving quality of care and decreasing cost via measuring outcomes and using them in data driven process improvement.

These value-based tenets will prepare physicians for participation in MIPS or APMs, according to Knight. "The roll out of MACRA is going to hasten … the interest of most independent providers to either become employed or to band together under APMs like CINs or ACOs, and offload or at least share the responsibility for this reporting burden and these change activities with a larger entity," he says.

"At the end of the day, you can run but you can't hide," Knight declares. "I think [physicians] are going to have to face up to the fact that a lot of what we do is waste and inefficient, and not necessarily value add … This is the whole purpose that CMS is trying to drive, [doctors] can look at their practice patterns and say, 'What can we do to reliably deliver measureable, high-quality outcomes, and do that in the most cost-efficient manner possible?'"

 She can be reached at editor@physicianspractice.com.

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Is your practice ready for the new Medicare payment systems coming in January 2017? Now is the time to develop a plan. 

The Race to MACRA and Value

Editor's note: We work hard to write about issues that will help physicians run their practices in a manner that is both prosperous and efficient, while still delivering quality patient care. And we are delighted when our readers let us know what they are thinking. This month we are excerpting an article by Laird Harrison on physician-manager partnerships and the annual physician compensation survey. The articles has been edited for space and are followed by comments made by readers at PhysiciansPractice.com.

Achieving Effective Physician-Manager Partnerships

Management of a medical practice often depends on the partnership of an administrator and a physician who share decision making and problem solving.

"I've taken the words 'command and control' out of my vocabulary for many, many years," said Bruce Bagley, a physician who once led a family practice and is now senior advisor to the American Medical Association (AMA) for professional satisfaction and practice sustainability. "It's all about influence and education."

Bagley teamed up with Allison Winkler, MPH, and a senior practice development specialist at the AMA to present strategies for improving teamwork at this year's medical group management association (MGMA) annual conference in San Francisco, California on Monday (Oct. 31).

The balance of power is shifting in medical practices because physicians no longer control all the information, Bagley said. The advent of smartphones and other handheld computers have allowed administrators quick and easy access to clinical data.

But many practices have not caught up to the new reality, he said. "We're still operating on the 'hero model' where the doctor is the source of all information." In this model, the physician's authorization is required for most orders, and the staff works to optimize the physician's work flow and throughput.

 Wow. This is spoken as a true hospital administrator. The doctors want to be team players, but, unfortunately, it is the administrators (both physicians and people who think that they know something) that make terrible decisions and don't allow enough input from the doctors they are trying to help. Ultimately, every decision weighs upon the physician running the team. You marginalize the physician's importance to the team and the role of the leader. I am disappointed in this line of thinking. But, I would expect nothing else from the AMA. Keep up the good work. Selling out doctors. Appreciate all you do to run doctors out of business.

 Unfortunately, I am typing this during a busy day at work. I need to make a correction - it is the administrators - both physicians and the non-medical or even [nurse] administrators that are getting input from money-making business models; either insurance companies or hospitals. This line of thinking is driving out the relationship that physicians build with patients and this is needed in medicine today. The team approach benefits big business. AMA helped push through the lovely ACA that has many doctors dreaming of retiring (causing burnout at dramatic levels; now called an epidemic) because of the bureaucracy involved. Not to mention all of the conflicts of interest that so many of the regulations forced upon us. The weight of the decisions "the team" makes fall only on the doctors. Dr. Bradley - this new model you propose for medicine is not the type of medicine many doctors or patients want. This is the type of medicine that would, however, benefit an ACO. Take out the middle men, please.

2016 Physician Compensation Survey Results

The cost of business is going up for physicians, according to this year's 

Last year, 32.4 percent of physicians estimated that overhead was 41 percent to 60 percent of their revenue. In this year's survey, which included 1,095 physician respondents across multiple specialties, that number shot up to 40.4 percent. The percent of those paying a low percentage of overhead (1 percent to20 percent) decreased from 24 percent last year to 16.6 percent this year. Furthermore, 32 percent said that the cost of overhead was greater for them than it was last year.

This rising financial burden may be a problem for many physicians, whose income has stagnated. Nearly 40 percent of respondents said their income was the same as last year, while 28.7 said it went down, and 31.8 percent said it went up. This has, of course, left many physicians disappointed (44.7 percent of respondents).

 Get rid of [EHRs], and do not give state medical boards carte blanche to fine (steal from) doctors for simple mistakes. We are human, we make charting mistakes, we should not be written up for the purpose of embarrassment. The state medical boards should not able to take away a doctor's license until tried and proven guilty. The Texas board is the worst offender. The state medical boards should not be able to close down pain management clinics just because they don't like them. A lot of these patients have real legitimate pain and the only thing that works is a narcotic. … Narcotics may take lives accidentally but so do automobiles, and we don't take away car dealerships from the owners and force public transportation. Insurance companies should not be able to refuse payment of certain radiological studies nor medications, they are not doctors, and they promote real suffering for the ones that pay them. …

The EHR has cost us so much money, time and now knowledge. We used to spend our time reading articles and doing research but we have no time anymore. We are too busy tapping away our notes and trying to find the where the computer says what we know we want to say, but we are not allowed to free text. We should go back to paper t-sheets and if we can afford it hire transcriptions to enter it into an EHR, but the doctor should not be required to use it unless they want to, and they should not be required to buy an [EHR]. Once you buy one then they extort you with the maintenance fees - when in residency we bought our first EHR for $140,000.00. Now we could see only half the patients we saw before, the wait times went up to three and four hours …

… These are just some of the things I know that have increased the cost of medicine and increased the wait times and expense. And it's not the doctors getting the money. It's all the middlemen with all of their requirements. How did they get in between us and the patient and then start making requirements for us to meet or we can't work? Anyway when the expense goes up then patients stop coming, they sit at home suffering and we sit in our office suffering.

In our recurring blog "Inbox" we share comments from physicians and practice administrators telling us what keeps them awake at night.

Inbox: Physicians Lament Loss of Control

, our new weekly column exploring what's being covered in the larger world of healthcare. 

CMS has announced a co-venture with the State of Vermont called the Vermont All-Payer Accountable Care Organization (ACO) Model, 

  The statewide ACO aims to enroll all major state payers to include Medicare, Medicaid, and commercial health plans, to jointly incentivize quality patient care and outcomes for the state's medical providers. The new payment model will reimburse all participating providers under the same compensation structure. CMS is providing a $9.million grant to help Vermont physicians with care coordination and collaboration with community providers, and has extended Vermont's Medicaid Demonstration project for five years, so that Medicaid can be a full partner in the All-Payer ACO program. The Vermont Medicare ACO Initiative (part of the larger All-Payer ACO) will qualify as an Advanced Alternative Payment Model under the Medicare Access and CHIP Re-Authorization Act (MACRA).

What Every Small Practice Should Know About MACRA

Amid great anticipation, CMS has released its final rule for MACRA. At 2,400 pages, it is complex and not well-understood, especially by smaller practices, reports 

 While the legislation has softened first-year reporting requirements, giving physicians the option of "picking their own path" to compliance, there are still significant hurdles for smaller entities. Family physician John Meigs, Jr., president of the American Association of Family Physicians, feels data reporting will challenge small practices and regrets the delayed implementation of "virtual groups" that would allow them to join forces and combine data. Another sticking point is the technology specifications, which will necessitate practices use a 2015-certified EHR for reporting data starting in 2018.

Humana Medicare Advantage Providers Ace Value

Humana has just released the year-end performance results for its Medicare Advantage value-based reimbursement model, which indicates continued improvement in patient health, quality care, and cost controls, 

 Humana compared member data for Medicare Advantage patients who were treated by providers enrolled in value-based reimbursement programs, and those operating under standard reimbursement agreements. Key findings from 2015 data are:

• Providers in value-based agreements scored 19 percent higher on Healthcare Effectiveness Data and Information Set (HEDIS) than peers in traditional reimbursement agreements;

• Medicare Advantage members treated under value-based arrangements had 6 percent fewer emergency room visits than patients treated under traditional reimbursement agreements; and

• Humana had 20 percent lower overall costs for members treated under value-based arrangements vs. those treated in traditional fee-for-service Medicare programs.

Politics and Medicine - Strange Bedfellows

"While most physicians do an excellent job of focusing on patients and leaving personal opinion and biases aside, this neutrality can be hard to completely achieve. In this season of intense political debate and a particularly passionate upcoming presidential election, physicians may find it even harder to refrain from sharing their political opinions with others."

Final Rule concessions under MACRA may just delay implementation of new payment model, and together CMS and Vermont create single, state-wide ACO.  

Practice Rounds: All Payer ACO Comes to Vermont

Editor's note: We work hard to write about issues that will help physicians run their practices in a manner that is both prosperous and efficient, while still delivering quality patient care. And we are delighted when our readers let us know what they are thinking. 

This month we are excerpting articles by managing editor Gabriel Perna on physicians' alternate careers, the burdens of MOC by primary-care physician KrisEmily McCrory, and why a 15-minute patient visit just doesn't cut it by primary-care physician Jennifer Frank. The articles has been edited for space and are followed by comments made by readers at PhysiciansPractice.com.

It's always fun to look back and see where your career could have gone if you had made a left turn instead of a right one. We asked members of our editorial advisory board to reveal what career path they would have gone on if they hadn't gone into medicine.

We are also interested in your thoughts on alternate career paths. What career would you choose if you hadn't gone into medicine? Share your thoughts in the comments section of the article or by tweeting us 

 Wall Street or pharma executive or research scientist.

 In the dark days of apartheid in South Africa, people of color had educational restrictions. For instance they were not granted admission for study in most faculties at the top universities. Exceptions included architecture and medicine, but even here their numbers were restricted to 10 percent of the student intake. And so I studied medicine which of course was not out of choice. In the absence of apartheid, [I would have studied] likely physics and/or aeronautics.

 Veterinarian or horse trainer/barrel racer; maybe country western singer.

 I would have been a Veterinarian maybe, but I put myself through college as a bartender at a live rock & roll bar. It was the best job I ever had. There were so many people out back then and so many people to meet. It was a magical time back then. I am the last year of the Baby Boomers and every place was packed with people where ever you went. I sometimes think I should open a live entertainment acoustic bar, just so I can experience those fun times of listening to live music and getting to know the people in an environment so opposite from a hospital.

The Unnecessary Burden of Maintenance of Certification

Approximately 10 years ago, the America Board of Medical Specialties decided that the system for physician certification was insufficient and the new era of maintenance of certification dawned. Since that time, physicians have struggled to keep track of often changing requirements, point systems, and looming recertification exams. Although an undercurrent of despair with this process has been present throughout the country, it is often overshadowed by other threats to physicians such as MACRA, MIPS, and APMs. Recently, however, some specialty societies have begun to speak out against the current system, including the American Medical Association, as have states like Michigan and Oklahoma which have recently seen legislation regarding mandatory board certification for hospital privileges and medical licensure.

Why should physicians stand by while a private credentialing company forces physicians to undergo unreasonable, costly, time consuming, and sometimes irrelevant modules and an exam in order to maintain board certification? ABMS claims that physician recertification shows a commitment to lifelong learning and better patient outcomes; however, evidence showing an association with positive and meaningful patient outcomes is far from absolute.

There is absolutely NO evidence that passing Board Exam equates to being a better doctor. How does one test a physician in being empathetic and skillful? Knowledge does not translate to being a better physician.
Is there any study that has shown that board certified physicians have had less law suits then those that have not?! How many times does one need to take Board certification to prove their competence?

 The board has empowered the insurance companies to find yet another reason to pay less for services of physicians who are not re- re- re-certified. The majority of physicians believe this is a system rigged to make money. Patients weed out bad physicians.

Quite right -nothing I have ever done in "review" for the test has ever added or changed anything toward my care of patients, but it has at times eaten up all of my CME time and money for that year. The test has very little to do general family medicine and review courses are geared to studying for the test, not actually learning anything. We should all remember the "zebras" from medical school, but this is not the most efficient way to do that. The costs have gotten exorbitant.

 The costs in time, money, and effort are all exorbitant for a process that has little to no evidence of improving meaningful patient outcomes.

 MOC is like being raped all over again. Patients think we are criminals. We can no longer practice independent medicine and earn a living. We get burned out practicing computer medicine. And no matter how hard you try, you can never document enough to please Medicare. We have little free time, and must spend it doing costly review that doesn't help with my area of practice. It should be criminal!

 Just another way for the tail to wag the dog.

Why the 15-Minute Doctor's Appointment Is Unrealistic

Our organization is undergoing primary-care redesign like many other health systems and practices across the country. As part of this process, we are looking at what are the key problems in the current delivery of primary care. One issue we’ve identified is that patients are more complex overall. Primary-care clinicians are not seeing the patients with strep throat, ring worm, UTI, or uncomplicated hypertension as much as we once did.

When I was a high school student, I worked for our local general practitioner. He would double and triple book 15- minute appointment slots. Today, this seems ludicrous to me as I can do almost no single visit in just 15 minutes.

While I’m not advocating for a system designed around two to three minutes for the patient-physician interaction, the reason he could keep up this pace is because the majority of issues were self-limited concerns. Those with chronic disease had far fewer treatment options. Payment was less complicated as well.

 Thank you for expressing this so eloquently. When I voice this opinion to my specialist colleagues, they seem surprised but do not recognize all of the elements you are describing. We want to give the best of care to our patients, and strive to affect their health beyond the moment of office contact. The root of the problems you are describing revolve around our nation's current issues with job equality, equal health access, adequate education, and mental health; issues which the physician cannot possibly remedy in the office. Yet physicians are given an ever growing list of mandates by governmental and professional organizations who mean well but don't walk in our shoes. My 30 minutes with a social worker regarding one family may do more [good] than 15 minutes in the office doing a sports physical with unproven benefits. And yet the most recent celebratory e-mail from administration was about a landmark increase in patient volume without acknowledging the stress, disrupted care, physical crowding, and unpleasant waiting this causes our patients.

 Thank you for your article! Agreed 100 percent. Correct 100 percent. Are we able to change?

Author | Erica Sprey

Articles

The Race to MACRA and Value

Inbox: Physicians Lament Loss of Control

Practice Rounds: All Payer ACO Comes to Vermont

Inbox: Docs Ask 'What Career Should I Have Pursued?'