Dawn of a New Way: Answers & Actions for Adapting to MACRA & Value-based Care

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 - paul-casale
Paul N. Casale, MD, MPH,

2017 brought a new reality to the U.S. healthcare community. The Medicare Access and CHIP Reimbursement Act, or MACRA, is no longer just the law that repealed the sustainable growth rate. With its Quality Payment Program that defines complex new payment models, MACRA is the machine that is nudging clinicians and practices away from fee-for-service and into value-based healthcare.

As the transition begins, many clinicians feel confused as they straddle two payment systems in healthcare delivery. Paul N. Casale, MD, MPH, hosted a Cardiovascular Business roundtable discussion, where participants voiced questions on the minds of many, brainstormed answers and identified new opportunities for the cardiovascular community to lead.

Complexity & Confusion

Expect a Fast, Bumpy Road. Keep the Destination in Sight.

Casale: MACRA officially started at the beginning of 2017. Cardiology practices and health systems are at different places with their decision making regarding whether and how to participate. What are the aspects of MACRA that concern or excite you?

Waites: The biggest negative now is the lack of knowledge in the house of medicine. It’s going to hit practices like an avalanche when they start seeing how the financial bonuses and penalties flow and how performance is going to be evaluated. Less than two months before MACRA started, I asked a medical association audience, “How many of you are moderately aware of MACRA?” Only one person raised his hand, and he’s in charge of a health system. No one else felt they knew anything about it.

The positive, though, is that we are going in the direction we have wanted to go. The quality message—putting value over volume—is now the law.

Itchhaporia: MACRA has the potential to transport our healthcare system from the traditional fee-for-service payment model to the risk-bearing, coordination-of-care model, which makes it a significant step toward value-based care. On the other hand, it’s a complex set of rules. It’s going to take a village to drive MACRA to success. I’m very concerned about physician readiness and lack of familiarity with the requirements. Initially, we get to pick our pace—crawl, walk or run—but the reality is that we only have a one-year respite. Starting in 2018, the pace will be fast. We don’t have a lot of time to get on board. 

Biga: One of the big complexities is in the quality components—the scoring system, identifying measures and understanding how it works in your electronic medical record. Even though quality is the area of MIPS where we have the most experience, it is going to be extraordinarily difficult to figure out how to measure and report. There are different considerations if you are in a multispecialty group vs. an ACO vs. an individual practice. I wish it was just a little simpler. 

Itchhaporia: It is going to be a huge challenge to do the types of analytics we need. You need resources to do it, which means it’s going to be particularly hard for small practices.

Powers: The reporting structure is definitely a big challenge. We’re involved in an ACO and our plan, at least right now, is to report through the ACO. Going forward, we may have concerns of losing our quality identity. Encouragingly, we have a parallel track for analyzing data independently through the PINNACLE Registry to ensure that, when we get to 2018, we can decide which dataset best reflects our quality data that should be reported. 

The upside has been a lot of great, new collaborations between primary care and our cardiovascular service line. This year, we’re building three clinical pathways that start in the office and end in the skilled nursing facility, so we’re hitting the whole continuum of care with the idea of keeping an eye on utilization all the way through the process.

Casale: That’s an interesting point about losing specialty identity around quality. You’re continuing to track quality for your cardiovascular measures as a way to move forward without delegating and saying, “Well, okay, we’ll let the primary care providers take up that reporting piece”?

Powers: Exactly.

Biga: One of the things that excites me, as an administrator, is watching the Triple Aim come together through the MIPS categories—Quality, Cost, Meaningful Use and Clinical Practice Improvement—in sustainable ways. It has helped our dyad leadership relationship and our hospital relationships because now we have not only the quality components but the costs and patient satisfaction elements. 

Alignment