Building and Strengthening the Private Practice of Medicine through Patient Partnerships
MACRA Proposed Rule
On April 27, 2016 CMS announced the long awaited proposed rule for MACRA ("SGR Fix") through the MIPS and APM alternatives. This notice spurred confusion about the role of an ACO as an APM since the proposed role created two types of APMs related to ACOs. At the crux of the debate is whether or not a Track 1 ACO (upside only gainsharing) has more than 'nominal risk' as required by the statute. Many organizations including the AMA, MGMA, NAACOs, and the AHA argue that the annual infrastructure costs with no guaranteed financial benefit constitutes more than "nominal risk" as required by the MACRA legislation. Primary PartnerCare ACO agrees, and the Board of Directors is meeting on May 11th to review alternatives and draft our comments to the proposed rule. The resolution will be published in the Final Rule after the 60 day comment period. Primary PartnerCare participants are nicely positioned as the "work" done in the ACO is closely aligned with MIPS: demonstrated quality, decreased medical costs, practice transformation (care coordination, increased access and communication) and use of technology (EMR). To further support practices, Primary PartnerCare has negotiated discounted rates and customization with a preferred EMR. MIPS will alter 2019 fees based on 2017 performance +/- 4%.
Depression Screening
Primary PartnerCare ACO has launched its Depression Screening notification tool on the Physician Portal. All member physicians can now see the last time their patient was screened for depression, the name of the doctor who performed the screening, and the date the next screening is due. Medicare now requires the PHQ-9 for the depression screening and depression remission quality measures. The depression screening is reimbursed in the primary care setting with HCPCS G0444 (local reimbursement ~$21). The remission measure is required for all patients that score 9 or higher on the PHQ-9 screening, and encourages primary care to early identify and treat the disease. This code is not billable in a SNF as CMS does not consider the SNF to be a "primary care setting" which is defined as "one in which there is provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community" The USPSTF notes that 1 out of 6 people age 65+ suffer from depression, and that older adults have the highest risk of suicide, which often goes undiagnosed despite physician visits in close proximity to the suicidal event. Studies have shown that patients successfully conceal depression from their doctors.
Breakdown of the MACRA Proposed Final Rule
Last week, the Centers for Medicare and Medicaid Services (CMS) began the process of implementing the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) by releasing its proposed final rule. Currently, Medicare measures the value and quality of care provided by doctors and other clinicians through a patchwork of programs. For example, some providers are part of Alternative Payment Models (e.g., Accountable Care Organizations, the Comprehensive Primary Care Initiative, the Medicare Shared Savings Program). Most also participate in programs like the Physician Quality Reporting System, the Value Modifier Program and the Medicare EHR Incentive Program. These programs have now been streamlined into a single framework to help clinicians transition from payments based on volume to payments based on value. MACRA will eliminate the sustainable growth formula and replace it with a .5% annual rate increase through 2019, after which physicians are encouraged to shift to one of two Quality Payment Programs: 1) Merit-Based Incentive Payment System (MIPS) or 2): Alternative Payment Model (APM).
Editorial by Harry S. Jacob, MD, Chief Executive Medical Officer commenting on American Hospital Association Press Release on MACRA Proposed Rule, April 27,2016
"As a strong advocate for the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA), the AHA believes the new physician payment programs reflect the transformation happening in health care that hospitals and health systems have already embraced. Today’s proposed rule will have a significant impact on America’s hospitals, and the more than 540,000 directly employed or contracted physicians with whom they partner to deliver quality care to patients and communities.
We are disappointed by CMS’s narrow definition of alternative payment models, which could have a chilling effect on providers’ ability to experiment with new patient-centered, value-driven payment models. Today’s rule fails to recognize the significant resources and risk assumed by the highly motivated, early adopters of alternative payment model."
The views and beliefs of private practice physicians and the AHA are typically not aligned. In this instance we share the same position, and that is good news. The AHA is powerful, and we share its belief that early adopters of alternative payment models, such as our Track 1 MSSP ACO, should be recognized and rewarded. For the last three years we have worked, and continue to work on transforming our practices. We have improved our quality, using the CMS measures as teaching tools to engage our patients. We have examined our medical spending through robust physician-driven analytics, identifying high risk patients and developing interventions to reign in these costs. We have built infrastructure to receive our RHIO clinical events, and help transition our patients home safely with necessary supportive services. We have worked collaboratively to understand medical guidelines and have launched peer review processes. We have developed and implemented systems and tools to ensure our patients receive the robust cadre of preventive care services. This has been and continues to be a resource-intensive process to embrace the rapidly emerging healthcare delivery and payment models. The AHA is 'spot-on' and we stand with it in asking CMS to more broadly define alternative payment models.
Source: American Hospital Association, April 27, 2016
Learn more at:http://www.aha.org/
MACRA Ends Fee For Service
In April, 2015, President Barack Obama signed into law the Medicare Access and CHIP Reauthorization Act (MACRA) to replace the deservedly maligned sustainable growth rate (SGR) physician Medicare reimbursement methodology. Over several decades, SGR had fallen more than 21 percent behind predicted healthcare costs, necessitating annual last-minute congressional renegotiations to prevent a significant drop in physician Medicare reimbursement, which would have had a profound impact on the access of Medicare beneficiaries to physician care. Without much fanfare and with rare congressional bipartisanship support, MACRA became the law of the land and will quietly revolutionize how physicians are paid by Medicare over the next decade. What MACRA does is separate traditional fee-for-service (FFS) volume-based methodology from all of the other "pay for value" methodologies that include: bundled payments, shared savings, risk-based capitation models (PMPM) to name a few, which are all a part of the new Merit-Based Payment System (MIPS) or Alternative Payment Models (APMs).
The administration hopes to recruit as many as 20,000 primary care doctors to participate in its plan to shift how physicians get paid and provide care. The Obama administration is recruiting as many as 20,000 primary care doctors for an initiative it hopes will change the way physicians get paid and provide care. The program, which was announced Monday, will be run by the Centers for Medicare and Medicaid Services. The aim is to stop paying doctors based on the number of billable services and visits provided to Medicare beneficiaries and instead to tie payments to overall patient health and outcomes. Provider practices will be able to participate in two ways. In Track 1, the agency will pay a monthly fee to practices that provide specific services. That fee is in addition to the fee-for-service payments under the Medicare Physician Fee Schedule for care. Providers currently perform a service and then submit a claim to Medicare for payment. In Track 2, practices will also receive a monthly care management fee and, instead of full Medicare FFS payments for evaluation and management services, they will receive reduced Medicare FFS payments and up-front comprehensive primary-care payments.
Source: Kaiser Health News, April 12, 2016 Learn more at khn.org
Bias and Burnout: Is There a Connection?
In this survey, physicians who reported burnout were more likely to also report bias. Forty-three percent of physicians who expressed burnout reported that they also experienced bias; in contrast, just over one third (36%) of non–burned-out physicians reported bias (Figure 9). If one aspect of burnout is depersonalization, then one would expect there to be a particular risk for the burned-out physician to be biased toward the emotional or difficult patient. The Medscape survey, however, showed only a slight relationship between burnout and bias toward "emotional" patients, with 27% of burned-out physicians citing these patients as a bias trigger compared with 22% of non–burned-out physicians (Figure 10). Nevertheless, difficult patients have been found to increase the chance of not only bias but also burnout. Emergency medicine physicians may be at particular risk. In the Medscape survey, the highest percentage of physicians admitting bias was seen among emergency medicine physicians, who were also in the top three of burned-out specialists. One survey found that a high percentage of emergency medicine physicians were burned out from treating patients who repeatedly used the emergency department inappropriately—for primary care or prescriptions, or as social centers. Three quarters of emergency medicine physicians expressed bias against these patients, and 59% had less empathy.
Source: Medscape, January 12, 2016 Learn more at medscape.com
Majority of ACOs Lacking Infrastructure, Protocols to Optimize Medication Use
In a value-based environment, optimal use of medications is key for improving quality and managing costs. Yet when the National Pharmaceutical Council, the American Medical Group Association, and health care performance improvement alliance Premier Inc surveyed a group of accountable care organizations (ACOs) on their readiness to optimize pharmaceutical use, they came across a concerning discovery. “Most ACOs do not yet have the infrastructure and protocols in place to optimize medication use,” explained Kimberly Westrich, vice president for health services research at the National Pharmaceutical Council.
Source: First Report Now, April 10, 2016
Learn more at firstreportnow.com
Pharmacist Roles Expanding in Chronic Disease Management
From optimizing inhaler technique in patients with chronic obstructive pulmonary disease (COPD), to catching red flags when dispensing controlled substances to patients with chronic pain, pharmacists can improve patient outcomes in an evolving treatment landscape... At a recent conference held in NJ, pharmacists reviewed current treatment standards and guideline recommendations for the management of type 2 diabetes, dyslipidemia, allergic rhinitis, asthma, and COPD. In addition, participants learned the pharmacist’s legal responsibilities when a controlled substance prescription is dispensed.
Source: Pharmacy Times, March 14, 2015 Learn more at pharmacytimes.com
Study: More Collaboration Aids Health Care For At-Risk Populations
By teaming with community organizations, doctors and hospitals can deliver high-quality care at good value to disadvantaged people at risk for poor health, according to a new report from a panel of experts.The report released Thursday by the National Academies of Sciences, Engineering and Medicine was produced to aid Medicare officials studying how to fairly pay hospitals that disproportionately serve patients with social risk factors for health problems. Those factors include low income, social isolation, disadvantaged neighborhoods and limited health literacy. The report is the second of five commissioned for the Department of Health and Human Services.
Source: Kaiser Health News, April 7, 2016 Learn more at khn.org
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Breakdown of the MACRA Proposed Final Rule
