Value-Based Payment, MACRA and the Obesity Epidemic

In the era of value-based payments and MACRA, the ultimate goal is to better manage the health and cost of care for patients. This means outcomes matter more than ever for physician practices.

In determining how to participate in the Medicare Access and CHIP Re-Authorization Act (MACRA) and other value-based payment programs, we should consider how managing healthcare delivery for obese patients influences our ability to improve outcomes for chronic diseases.

Many chronic diseases including heart disease, diabetes, and stroke have a direct correlation to obesity and metabolic syndrome (the cluster of conditions that include high blood pressure, large waist circumference, elevated blood sugar and abnormal cholesterol and triglycerides). And those chronic diseases, among other obesity-related conditions including some cancers, arthritis, and sleep apnea, represent not only seven out of the top 10 causes of deaths in the U.S. each year, but drive up the cost of care enormously. According to the Centers for Disease Control and Prevention (CDC), the United States spends $147 billion on obesity-related healthcare costs each year. Eighty-six percent of that cost is related to chronic diseases.

MACRA has two payment tracks, a Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). Healthcare providers who continue to participate in traditional Medicare will participate in MIPS, where they can earn a performance-based adjustment-positive or negative to their Medicare payments. According to Centers for Medicare and Medicaid Services(CMS) calculations, up to 90 percent of healthcare providers will end up on the MIPS track in 2017.

Under MIPS, reimbursement is closely aligned to quality and outcomes, measured by a quality score. To maximize one's score, healthcare providers must report individually, or as part of a group, on a minimum of six measures (or one specialty measure set) for a minimum of 90 days. There are 271 measures to choose from. With 60 percent of the MIPS composite score based on quality measures, the selection of the most appropriate measures is critical.

Obesity counseling, specifically identified in MIPS as "Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan," is among the quality measures physicians can select to be compliant with the new requirements. It is one direct path to help comply with the new regulations. And considering more than 70 percent of Americans are overweight or obese, has the potential to produce significant population health improvements and outcomes.

According to the CMS, under the MIPS BMI screening quality measure BMI may be documented in the medical record of the provider or in outside medical records obtained by the provider. If the most recently documented BMI is greater than 24.9, then a follow-up plan is recommended during or within six months of the encounter. The follow-up plan might include documentation of education, nutritional counseling, exercise counseling and dietary supplements.

This follow-up plan provides physicians a critical opportunity to open up the often delicate conversation about obesity with their patients. In addition to counseling patients about the need to lose weight, there are real solutions that physicians can offer through their practices that combine a low carbohydrate, ketogenic diet to address the root of weight gain, plus the ongoing behavioral counseling to help patients lose weight and maintain that lower weight.

By offering a weight management protocol that is consistent with evidence-based guidelines, physicians can help patients prevent disease progression, improve standards of quality in obesity management, and comply with an achievable quality measure that can contribute to maximum reimbursement. 

In the future, we may expect to see the astronomical human and fiscal cost of obesity prompts the expansion of quality measures for obese patients, including evidence-based obesity prevention and treatment that includes the behavioral, nutritional intervention, and counseling necessary to lose weight and keep it off. And at the heart of MACRA and other value-based payment systems, that's what it's all about.

Douglas W. Rothrock, MD is the founder of Prescott Cardiology in Arizona. He has spent the last 25 years working as an interventional cardiologist in California, Oregon, and Arizona.Since 2011, he has helped people lose nearly 200,000 pounds with the Ideal Protein Protocol. He serves Ideal Protein as Senior Medical Advisor and sits on the Ideal Protein Medical and Cardiology Advisory Boards.