Providers unprepared to meet MACRA guidelines feel sense of urgency

Providers that want to thrive under the Medicare Access and CHIP Reauthorization Act will need to use the remainder of this year to ensure that their IT infrastructures will truly enables physician practices to advance quality, control cost and improve clinical performance.

Physician groups that have kept up with IT investments that support these dramatically different core objectives will have an advantage in meeting MACRA requirements. However, groups that have lagged behind with IT capabilities will need to move quickly to better use analytics to improve performance and to get critical data out to their practitioners.

The Medicare EHR Incentive Program, from which sprang meaningful-use criteria, and the Physician Quality Reporting System (PQRS), which identified quality metrics for physicians to live by, are being ported into the Merit-based Incentive Payment System (MIPS), one of two program options and the route that most physician groups are likely to take in the first years of the transition.

MIPS is the extension of these programs, revised to make it easier for providers to execute quality, resource-use and information-usage activities, says Lawrence Kocot, a partner at KPMG who heads its Center for Healthcare Regulatory Insight. “Practices that have begun to, or already have successfully moved to, the certified electronic health record technologies will be much better positioned to perform well under the advancing care information category of MIPS, and in MIPS generally.”

MACRA prerequisites include having to meet meaningful-use thresholds for certain capabilities, such as medication reconciliation and patient portal use, says Krishna Ramachandran, MD, chief administrative officer of DuPage Medical Group, a Downers Grove, Ill., organization with 560 primary care and specialty physicians at 70 locations.

Meaningful-use directives also sowed clinical practice improvement, a MIPS performance category, by prodding physicians into showing they were using IT to gather and report information in the service of improving care activities and innovation, Ramachandran says.

For medical groups with either a lagging commitment to meaningful use or no EHR platform at all, the final MACRA rule provided the option of easing through 2017 with a light burden of compliance with MIPS metrics. But unprepared practices must exploit this year’s grace period, because otherwise the physician reimbursement program will leave them behind, warns Rob Tennant, health information technology policy director for Medical Group Management Association.

The big fear in policy circles is that the one in three physicians excluded from the first year of MIPS are going to “sit on their hands and do nothing,” says Kocot. “This is definitely going to be a rude awakening for some physicians if they don’t use 2017 as a preparation year. They should start looking at how they should be reporting, and how to get their technology set up for the MIPS program.”

Adding to the time crunch is the reality that the entire EHR-using world, not just the laggards, will have to upgrade to the 2015 version of certified technology to meet the MACRA level of performance, Tennant says. And that’s just one element of IT acceleration that will be necessary.

In addition to executing meaningful-use and PQRS objectives well, Ramachandran says, groups must continually connect physicians with must-know patient data in ways they can understand and act on. And there has to be enough of an analytics platform to point out care gaps they should address.

Not just box-checking

At a surface level, the MIPS program involves achieving specific objectives and attaining levels of performance and outcomes that result in an overall score--initially weighted highest for meeting quality metrics targets, and also encompassing categories of advancing care information (ACI, the replacement for meaningful use), clinical practice improvement activities and, starting in 2018, resource use.

None of this can happen unless the right data are captured, and that requires an effort to determine where in physician workflow to first enter key data and later feed data back appropriately to providers to get the desired results, says Karen Knecht, chief innovation officer of Encore Health Resources. It calls for an understanding of how physicians work, how their workflows are managed, and how they both generate and use information in the context of the performance requirements, she says.

The same data likely will be necessary to meet reporting and performance demands elsewhere, from commercial accountable care organization objectives to Medicare Advantage and Medicare Shared Savings Program operations, says Karen Adamson, CIO of DuPage Medical Group. The challenge for IT planning, especially with the EHR, is to integrate the requirements of all those programs, not just MACRA, she says.

One way to look at the prep effort is to do the minimum to avoid a payment penalty, “and that’s fine,” says Tennant. “But our argument is, how can you leverage the technology to improve the clinical performance of the practice?” Having IT in place and using it can help prevent situations in which, for example, a referred specialist didn’t get records and has to reschedule, or an MRI lacked proper authorization—to overcome these types of inefficiencies, a practice should focus overall on moving data for both clinical and administrative purposes effectively and securely.

A central theme of MACRA revolves around information exchange and interoperability, getting access to the information that makes quality and clinical practice improvement possible, Knecht explains.

One important element of that process is the exchange of summaries of care, a nominal requirement of meaningful use criteria that will have to be enabled fully and achieved routinely to operate in a MACRA environment, Tennant says. It should be on the development agenda for 2017, including in practices opting for the choice of a slower pace. “They may be able to get away with it in 2017, but going forward, we expect that to be a requirement. So can you develop a summary-of-care document through your EHR? If it’s certified, then it has that capability, but can you exchange it with a downstream provider? And ultimately in 2018, you’ll need to receive it as well.”

Integral to such an exchange capacity is a comprehensive set of secure electronic addresses to all practice partners or referral sources outside the range of the internal EHR, using the Direct messaging protocol, says Jackie Lichwell, senior manager of quality performance for athenahealth, a physician practice EHR vendor. Part of Stage 2 of the Meaningful Use program, the configuration of Direct addresses is provided to athenahealth customers as one of the included contractual services, Lichwell says.

The premium on effective collection and sharing of information, as articulated in the advancing care information category, has ripple effects extending to the effective management of patients and care handoffs along the continuum of care, Kocot says. Most of the capabilities required in that category, in fact, set up capabilities elsewhere. “The high performance in the ACI category actually may correlate with higher performance in the cost and improvement categories.”

Knowing the performance facts

As clinical settings evolve into integrated networks, and begin to be judged and paid as groups, the ability to look inward to the causes of higher cost and outward to patient encounters outside the network escalate in importance, as does the IT infrastructure to track and analyze cost, quality and utilization.

This is where variable performance among providers really starts to affect a group’s overall scoring, says Kocot. “Clinicians do have to assess the relative performance of specialists--and, frankly, other members of the care team--when they’re deciding on how to line up referrals or establish networks.” Having good data on the doctors, especially when effective providers are working with others not doing as well, will by necessity lead to self-policing within the group, he says.

An organization as large as DuPage Medical Group uses a group-wide reporting option for PQRS and Medicare ACO performance, and will do the same for MACRA, says Ramachandran. But internally, reporting is by physician, and dashboard displays are at the individual doctor level--colored red or green, measure by measure, depending on whether each one was met or not. “No change happens on a team level; it’s people who change,” he says. A combination of competition and collaborative assistance, enabled by the reporting detail, improves the group-reported results for all.

For resource use management, currently a factor in DuPage’s ACO contracts and soon a component of MACRA, the organization has to have data on not just what costs a group doctor generates, but also what a patient generates anywhere. Out-of-network “leakage” creates expenses that the group doesn’t have the opportunity to manage.

“We have some of the data and technology to get us to figure out where is the leakage happening, where are the claims going, how do we redirect care appropriately,” says Ramachandran. For example, it’s four times as expensive to perform the same MRI study outside the group, which, if curbed, is an easy cost fix.

The IT “doesn’t have to be fancy,” he says. To make sense of overuse of resources--inpatient stays, medications, specialists and so on--common data science software such as Tableau can go through many lines of claims code looking for a spike in expenses that a doctor did not order for a patient, but is on the hook for because the plurality of costs for services is attributed to the physician and the group.

For internal analysis of physician-level performance, a handy tool for the DuPage Medical Group is an electronic spreadsheet, with one line per doctor, one column per measure. “A bunch of bright people in a room, working on Excel conditional formatting with raw data from (the EHR), can move the needle,” Ramachandran asserts.

Alternative payment is the goal

The MIPS program, like the meaningful-use and PQRS predecessors, is full of criteria to meet and report, the many elements rounding into a payment-associated assessment. Exceeding the target can earn bonus percentages of Medicare billings; falling short will cost up to 4 percent of Medicare revenue.

As providers do their best to formulate clinical and technology responses to the ins and outs of MIPS, however, they also have to keep in mind that the federal government considers the program a bridge to the longer-term goal of living under alternative payment models (APMs), and as a vehicle to distance the practice of medicine from its fee-based foundations, says Kocot.

The MACRA rule’s Quality Payment Program “was designed to make it increasingly uncomfortable to remain in fee-for-service ... to establish first a glide path to get to APMs, and that is the MIPS program,” he says. Providers will be rewarded for succeeding at the MIPS approach, but the goal is to reward them for the types of process changes and results that they will be aiming for in APMs, Kocot explains.

Advanced health systems or large multispecialty medical groups that are set up to operate an integrated continuum of care and accept financial risk are headed straight to the APM track of the Quality Payment Program, says Knecht. The APM option has bonus payments already built in and dispenses with many of the specific process and technology targets contained in MIPS--because they’re by definition built into a network that can handle ACO risk, including the gradations of downside risk in recently added higher tracks of the Medicare Shared Savings Program. CMS projects a small number of APM participants in the first year or two, but that’s ultimately where health systems want to go, Knecht says.

Large integrated clinical networks are not typically homogeneous in their readiness for alternative payments and may elect to participate in both tracks. DuPage Medical Group, for one, has aggregations of physician practices transitioning to both the MIPS and APM options, says Ramachandran.

Rather than MACRA-specific, the efforts tie in with the multiple frameworks necessary for other payment structures, from federal and commercial bundled payments to the DuPage organization’s government/commercial partnership forged for a Medicare Advantage population of 75,000 beneficiaries, as well as commercial ACOs, he says.

Thus, clinical and cost-management objectives need to take into consideration both the immediate goals of meeting MIPS targets and building the core technology to manage care quality and financial risk as a coordinated enterprise.

For example, it’s no small challenge to undertake information collection from a contingent of physician practices that is geographically dispersed and operating disparate EHR systems. Data from markedly different IT systems must be coalesced by practices to produce valid reports on quality metrics for MIPS participation, an information exchange capacity has to be addressed at the outset, says John Halamka, CIO of Beth Israel Deaconess Medical Center, Boston.

“We are going to need to compute quality and cost, [which means] taking an approach of building a registry yourself or with a third party, or partnering with a vendor of whatever is prudent, because it will be flexible and agile for whatever the future brings,” Halamka says. Such vehicles already are in place, a carryover from the PQRS reporting process called a Qualified Clinical Data Registry.

Beth Israel Deaconess and other Boston-area health systems are using one such registry, the Massachusetts eHealth Collaborative, operated by the Massachusetts Medical Society. Halamka says it aggregates data from 2 million patients and 26 EHRs in the Beth Israel Deaconess network into a single database than can compute any quality metric submitted to any federal agency.

That’s a solution to not only MIPS reporting but the realities of an ACO world, with physicians not owned by the system but rather “loose coupled cousins” spread far and wide, he says. With a central data collection and exchange point, EHR systems don’t have to be all on the same vendor platform; they just have to produce the manner of data that has to be reported.