How physicians can succeed under MIPS

Primary care practices will need to adopt some elements of the patient-centered medical home (PCMH) in order to thrive under the new Merit-based Incentive Payment System (MIPS).

That’s the view of Nitin Damle, MD, FACP, a Rhode Island internist and the  newly-installed president of the American College of Physicians (ACP). Damle spoke as part of a panel discussion on MIPS and MACRA (the Medicare Accountability and CHIP Reauthorization Act) during the ACP’s 2016 Internal Medicine Meeting in Washington, D.C.

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“It’s very hard to do this work [without the structure of a PCMH],” Damle said. “You have to have a practice with experience in collecting and recording data. And you need to understand where your cost centers are.”

Under MIPS, physicians will receive annual performance scores based on four categories: quality, which will account for 50% of the score, advancing care information (formerly Meaningful Use),  25%;  clinical practice improvement activities (15%; and cost/resource use (10%). Scores will start being assigne din 2019 based on data reported in 2017.

 A practice that has successfully implemented PCMH concepts, he said includes four elements: First is increased patient access, such as evenings and weekends and same-day appointments. “You need to keep people out of the emergency room,” he said.

Next: Implementing PCMH requires more personnel 

 Second, “make sure patients understand that they are part of the team, that they are important to you.” His practice has formed a patient council and regularly surveys patients. “It’s remarkable how much we learn from that, and we’ve made changes based on patient perceptions and requests.”

Third is staff development. “Make sure staff feels empowered to make changes and recommendations that you are going to take seriously.”

Fourth is to maximize practice resources by building revenues through ancillary services, such as in-house labs, stress testing and bone density scans. “We’ve found it to be an important practice resource,” he said. The final requirement is close follow-up of patients who have gotten care from specialists or been discharged from the hospital or emergency department.

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Implementing PCMH care, he said, requires more personnel than primary care practices have traditionally used, and generally includes a clinical nurse manager, an IT specialist and a pharmacist.

A clinical nurse manager is crucial, he said, for tasks such as maintaining patient registries, keeping track of deadlines, and identifying and staying in contact with sick patients to keep them out of the hospital or emergency department,

Damle’s practice also uses scribes. “Scribes will make your life a lot easier,” he said, by reducing the amount of time doctors must spend entering information into EHRs. His practice’s scribes are not with the doctor in the exam room. Instead, doctors record their notes on paper encounter forms, which scribes later enter into the EHR.  “At the end of my day I’m not going home and spending two hours doing data entry,” he said.

Implementing all the requirements of the PCMH model, he said, nearly always requires funding beyond what most practices can earn through fee-for-service medicine. “It’s just too expensive,” he said.  His practice has taken advantage of Rhode Island’s multi-stakeholder PCMH initiative that pays participants a per-patient per-month fee, in addition to the salary of a clinical nurse manager. “We would not have been able to do it otherwise,” he said