How physicians can take charge, protect autonomy and put patients first

Healthcare’s transition to value-based payments is ratcheting up the pressure on independent medical practices battling for survival, and data is the ammunition they need to have any chance of winning.

The Medicare Access and CHIP Reauthorization Act (MACRA) Congress passed last year may be independent practices’ biggest challenge yet. By the government’s own estimates, it will result in Medicare reimbursement cuts to nearly 90% of solo practices, and 70% of practices with two to nine physicians. 

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Such practices are crucial to tamping down healthcare costs. To fight back, and preserve their independence, physicians need to demonstrate they are providing high-quality care to patients. That’s because beginning in 2019, Medicare will reimburse most such practices according to their scores on the Merit-based Incentive Payment System (MIPS), which is part of MACRA. High-scoring practices will receive bonuses, while laggards will be penalized. These “payment adjustments” will begin at 4%, and top out at 9% in 2022. 

“Whenever I talk to small practices, I start by letting them know their ability to be successful in a value-based world will hinge on their ability to collect and measure data,” says Daphne Saneholtz, JD, head of the healthcare practice for the Columbus, Ohio-based law firm Brennan, Manna & Diamond.

The benefits of robust independent practices extend beyond the doctors who own them and the patients they treat. Such practices also are crucial to tamping down healthcare costs, according to an October, 2014 study published in JAMA.

Despite the challenges they pose, however, MACRA and MIPS need not spell the end of independent medicine. Practices that want to preserve their autonomy are already gearing up for the struggle. But it will require planning, creativity and hard work. 

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Dominic Gaziano, MD, a solo internist practicing in Chicago, is determined to maintain his independence. “I see other doctors selling their practices at an alarming rate, and I tell them, ‘stick it out, you can do it yourself,’ he says. “I truly believe independent doctors can do more, by letting the patients be our masters and putting their interests first, and not a corporation or a hospital.”

The challenges of data collection

Given the already precarious finances of many small practices, even minor reductions in Medicare payments could lead to the dilemma of joining a health system or closing their doors.

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Avoiding that fate requires data to show that they are  controlling patients’ hypertension, getting them vaccinated, keeping them out of the emergency department, and the myriad other actions that define quality in today’s healthcare environment. 

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Many of those practices are finding the data collection requirements difficult to meet, Saneholtz says, both because they lack the necessary technology and their priorities lie elsewhere. 

“Most small practices are singularly focused on providing medical services, because that’s what they went into medicine to do. Asking them now to layer on top of that a function of collecting and measuring data is really difficult,” she says.

CMS predicts that overall, slightly less than half of  all practices will see their Medicare reimbursements reduced due to MIPS.  In a subsequent document listing the resources available to help small practices transition to MIPS, CMS notes that the data it used to develop the impact table came from 2014, when many solo and small practices did not report their performance data.

In addition, the document points out, the data don’t reflect “the accommodations in the proposed rule that are intended to provide additional flexibility to small practices,” such as exempting practices with less than $10,000 in Medicare charges or fewer than 100 Medicare patients from payment adjustments. 

The MACRA legislation also includes language allowing solo and small practices to join together in what it terms “virtual groups” for purposes of MIPS reporting. Doing so will enable them to spread the costs over a larger patient base and compensate for some of the methodology bias favoring groups with large patient bases on which to report, explains Shawn Martin, senior vice president of advocacy, practice advancement and policy for the American Academy of Family Physicians (AAFP).

However, CMS has said it won’t issue rules regarding virtual groups until 2018. “That puts small practices at even more of a disadvantage in the first year,” Martin says. “We think that’s a mistake, and we’re worried about it.”

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In April, CMS released a preliminary version of the rule for implementing MACRA. The 426-page document fleshes out the MIPS concept, and describes how physicians will be rewarded or penalized financially for their performance on measures in four broad categories-quality (which replaces PQRS, the Physician Quality Reporting System), advancing care information (which replaces the Meaningful Use program), clinical practice improvement activities and cost. Data for the “cost” category will be drawn automatically from Medicare claims. For the other three, practices may choose from among a menu of categories on which to report.

Next: Starting with the basics

The payment adjustments are scheduled to begin in 2019, and will be based on 2017 practice data. The maximum for either will start at 4% of reimbursements, gradually escalating to 9% by 2022. (For a more detailed explanation of MIPS, see [“MIPS Explained” on page 26.)

Jennifer Pfeifer, MBA, CMPE, who until recently managed an eight-physician internal medicine practice in suburban Chicago says MACRA proves that the government is determined to move the healthcare system away from fee-for-service and towards a greater emphasis on quality and value in reimbursement. “So I think everyone’s going to have to embrace it if they want to be in medicine for the long haul,” she says. 

Start with the basics  

The place to start, experts say, is by learning at least the basics of MACRA and the MIPS scorecard-information that is available through the websites of the Centers for Medicare & Medicaid Services or Medical Economics (www.modernmedicine.com) or from local or national medical societies. Given the law’s impact on the future of reimbursement, surprisingly few providers know much about it, says Chris Zaenger, CHBC, president of Z Consulting Group and a Medical Economics editorial consultant.

“I’ve had multiple discussions about MACRA with clients in the past few months, and most of them just look at me glassy-eyed,” Zaenger says. “The eye-opener is when I tell them the way they get paid is going to change dramatically over the next few years so they need to pay attention.”

Amy Davis, DO, is one who has been paying attention. A solo practitioner specializing in palliative care in suburban Philadelphia, Davis has been reporting data to CMS as part of PQRS since 2012, thus giving her a head start in understanding MIPS and what’s required for data reporting. “But now that they’re developing the regulations I’m trying to learn as much as I can as fast as I can,” she says.

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 Acquiring that knowledge is especially important given that doctors may have only a few months at most between issuance of the final rule and the start of 2017, when they’ll probably have to begin reporting data for MIPS.

In addition to learning the basics of the law itself, experts say, doctors should review their Medicare Quality and Resource Use Reports (QRUR). These are reports that Medicare makes available to all practices, showing how the practice compares to its peers on a wide variety of cost and quality metrics. 

Next: Choosing the best reporting categories

“Those reports are really key, and practices should look at them to find out how they’re performing now,” Pfeifer advises. “Glean the information you can and make any changes necessary to improve your scores so that you’re in a good position for MIPS.” (For more information on QRUR reports and how to obtain them go to
bit.ly/QRUR-reports).

Choose the best reporting categories

Armed with information from the QRUR and some knowledge of how MIPS works, the next step is deciding which measures to report on. Those should include the activities the practice already does well, so as to obtain the highest scores possible. “Identifying the measures that are relevant to your practice, are helpful to patients and are easy to track, all of those are really important,” notes Pfeifer.

For Davis, the process of identifying categories is fairly easy:  She plans to continue reporting in the same categories she’s used for PQRS. Her goal in the first year or two of MIPS, she adds, is simply to maintain her current level of Medicare reimbursement and not worry about trying to earn a bonus. 

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“I think the initial goal for small practices needs to be, ‘how do we stay afloat?’” she says. “The way I’m looking to do that is to get credit for doing what I’m already doing. The overhead involved for the points that get you a bonus is not cost-effective for a small practice like mine.”

For larger independent practices, though, qualifying for higher reimbursements under MIPS may well be cost-effective, and thus a goal they should aim for, says Lucien Roberts III, MHA, administrator of Gastrointestinal Specialists Inc., a 22-provider practice in central Virginia. 

“The goal is not to think in terms of meeting the measures, but of beating them across the board so that you can qualify for increases,” he says. “But to do that you need to identify your measures and then consistently hit them.”

In addition to reporting PQRS and Meaningful Use data, Roberts says, Gastrointestinal Specialists has been developing its own set of internal quality measures specific to its specialty, such as endoscope withdrawal times. In addition to improving care, the process has helped prepare Gastrointestinal Specialists for MIPS.

Next: Finding strength in numbers

“We’re not just thinking in terms of avoiding getting penalized or getting maybe a 1% bump,” he says. “We’re saying, ‘if we want to move the reimbursement needle we need to do better than average consistently.’”

Find strength in numbers

For some solo and small practices, joining forces with others through an entity such as an accountable care organization (ACO) or clinically-integrated network (CIN) can help offset some of the costs data reporting, without foregoing independence. The internal medicine practice Pfeifer worked for was part of Advocate Physician Partners, which was both a CIN and ACO. Not only did being part of an ACO meet some of the practice’s reporting requirements for PQRS, she explains, it provided performance bonuses to member practices, helping to shore up her practice’s finances.

An additional benefit came in the form of easier information sharing with other providers and institutions. “That allowed us to track our ED visits, our hospitalizations and discharges, our specialist referrals, and helped us to manage those numbers,” she says.

Of course, knowledge of MIPS scoring and payment adjustments means little without the ability to actually collect and report the necessary data. And doing so is virtually impossible without an EHR, say those with experience in reporting. 

“If you weren’t using an EHR you need to get one and start using it,” says the AAFP’s Martin. “That’s a cost, but it’s also a necessity for any program you want to participate in, public or private. This isn’t just Medicare now, all the commercial payers are going to start mandating these capabilities as well.”

EHRs present their own challenges when it comes to data collection and reporting, however.  Chief among these is cost. Martin notes that many vendors levy a charge for data extraction, saying it’s not a core function of the technology. Large healthcare systems may be able to absorb that charge, he says, “but if you’re a two-physician rural practice that’s a pretty big cost to you.”

Accuracy can be another pitfall of EHRs. When Gaziano wanted to begin attesting to meaningful use a few years ago, he discovered that his EHR was calculating some of the data he needed incorrectly. Now he does spot checks against the paper charts, which he keeps for times when his system goes down. 

Make technology work for you

But sometimes doctors themselves must shoulder part of the blame for problems they ascribe to EHRs, says Linda Delo, DO, a solo practitioner in Port St. Lucie, Florida who’s been reporting PQRS data since the program began in 2011. That’s because many don’t take the time to explore the technology’s full capabilities and configure it to their needs.

Next: "I have to be as efficient as I can"

“These computers will do incredible things for you, but you have to take the time to program them,” she says. “Too many want to just go in and do the bare minimum to get by. They don’t take the next step to figure out how to make it really work for them.”

The critical step, say Delo and others, is to customize the EHR’s software to make data collection as easy as possible and integrated into the practice’s workflow. For example, Delo has created templates that enable her staff to enter quality-related information she needs to report on for her patients with diabetes, such as the date of the patient’s last foot or eye examination. 

“When you take the time to program the technology to do what you want it to do it makes for a much easier workflow,” she notes. 

Roberts’ staff at Gastrointestinal Specialists creates “short lists” of quality metrics for physicians’ use in the practice’s EHR. “That way it’s not something they have to remember, it’s part of the standard documentation,” he explains.

Expecting a time-pressed doctor to go to a different page every time he or she needs to document a quality metric means “you’re going to have a tough time hitting that target. So try to make it a habit rather than an extra burden,” he says.

Gaziano is using the approach of MIPS reporting requirements to re-visit how he uses his EHR throughout his practice. To that end, he has been having a recent medical school graduate with strong computer skills shadow him and suggest ways to gather quality data more efficiently. 

“I understand enough about the changes going on in medicine to know that if I want to be active in 20 years,” he says, “I have to be as efficient as I can.”