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 The Medicare Access and CHIP Reimbursement Act, or MACRA, is no longer just the law that repealed the sustainable growth rate.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.

Moderator: Paul N. Casale, MD, MPH, Executive Director, NewYork Quality Care, The ACO of New York-Presbyterian - Columbia - Weill Cornell, New York City

Participants

Cathie Biga, RN, MSN, Chief Executive Officer, Cardiovascular Management of Illinois, Woodridge 

Aparna Higgins, Senior Vice President, Private Market Innovations, and Center for Policy & Research, America’s Health Insurance Plans, Washington, D.C.  

Dipti Itchhaporia, MD, Robert and Georgia Roth Endowed Chair for Excellence in Cardiac Care; and Director, Disease Management, Hoag Memorial Hospital Presbyterian, Newport Beach, Calif. 

James B. Powers, MD, Director, Division of Cardiology, Maine Medical Center, Portland

Thad F. Waites, MD, Medical Director, Cath Lab, Forrest General Hospital, Hattiesburg, Miss.

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 & Innovation

Embrace Core Quality Measures. Demand Data Sharing. 

Casale: In 2016, CMS and AHIP released core sets of quality measures, including a set for cardiology, with the goal of streamlining the reporting burden on clinicians and promoting alignment between government and the insurance industry to assess quality and determine reimbursement. Aparna, at AHIP, you’ve led the Core Quality Measures Collaborative (CQMC) initiative. How does that effort harmonize with MACRA? 

Higgins: The CQMC helped put us in the right direction relative to achieving alignment around quality measures across public and private programs. CMS has been making every attempt to incorporate the measures from the Collaborative and retire measures that weren’t recommended by it. However, more work needs to happen so that providers are not being asked to report on different measures for different programs. We need better public and private alignment in other areas as well, including patient attribution criteria that define advanced APMs, for example, while also giving us room to innovate.

Casale: How do you see MACRA aligning with commercial payers?

Higgins: We need to be thinking about how to make reporting easier on practices. Attribution models are an area where getting better alignment between the public and private payers would be helpful. The other key piece is around data sharing. The private sector models include sharing a lot of data with the practices in these new payment models. Getting Medicare to share data in a timely and useful manner would help practices be more successful.

Powers: We have approached a number of private payers and now are working with Harvard Pilgrim on what we’re calling a “shadow bundle” for acute myocardial infarction. Our area isn’t part of the new CMS bundling program, but our heart center has been doing commercial bundles for different diagnoses for a long time. The shadow bundle will mimic CMS’s bundling criteria and format so we can see how it would have turned out if it were a live bundle.

Casale: Is MACRA a significant part of conversations among plans involved in AHIP?

Higgins: Yes, the plans gave a lot of input during the MACRA commenting period. They are interested in the quality measures and how they’ll align with the Collaborative effort. Commercial insurance plans want to make sure they can continue to innovate. They would like to partner with CMS to build on lessons learned from the private sector. They’ve been very much a part of the discussion about quality measures.

Itchhaporia: Some of the health plans may be trying to identify strategic business opportunities so they can support physicians, and even hospitals, as we start to change the way we practice and as we go to the new payment-at-risk arrangements. They are concerned that, as there’s greater consolidation with physicians and practices with healthcare systems, there also will be more pressure on the health plans in terms of payment rates. They’re starting to recognize that they need to be more of a partner, and they need to be supportive with sharing tools and data so that physicians can make better choices.

Biga: It’s critical that we work on a national effort to tighten up around the core metrics so we are using only 13 or 15 cardiology measures as opposed to everybody adding new ones. There is nothing more frustrating than figuring out your MIPS component only to find out you now have to start all over with a private payer’s metrics, and then another payer’s and so on, because they all are using different measures. There needs to be alignment between Medicare and the private payers, whether it’s through MIPS or the core quality measures.

Powers: We all need to be pushing for a convergence in utilization of the core quality measures. The more we can do it each time we negotiate a new contract, the better we’ll all be in the end.

Higgins: AHIP is tracking progress on achieving alignment of measures among the plans and

CMS as part of the CQMC.

Concerns & Unintended Consequences

Protect Patients. Watch for Unplanned Effects.

Casale: Do you think the implementation of MACRA will lead to improved care?

Waites: MACRA does have the capability to improve care. For example, we were doing our blood pressures in different ways, with various kinds of cuffs, variation in who was checking patients’ blood pressures, whether they were checked in the lobby vs. when patients came into the office after waiting. Now, we have entirely standardized our process of how and where we check blood pressures and are using the same equipment for everyone. All of a sudden our blood pressure capability has improved. We’re treating the right people and everybody is constant starting out. That’s just one thing. Others are around readmissions and chronic care.

Casale: Some of these routine parts of the physical exam, such as blood pressure measurement, seem simple, but it actually takes quite a bit of work to reduce variation in just when and how people are performing them.

Biga: If the MIPS quality measures are utilized or integrated appropriately, then I’ll predict a little bit of a reduction in variability of care, but it may be the bundled payments that lead to the redesign of our care delivery teams.

Casale: Do you worry about unintended consequences of the cardiac bundles? Should we be concerned about patients being undertreated?

Biga: Yes, there are some problem areas that are keeping me up at night. First, should appropriately coded acute myocardial infarctions ever be treated as outpatients? Second, we’re making sure we always keep the patient at the center of our care continuum, but what will happen with staged procedures or implanting ICDs in the 90-day postacute period? Third, with the use of the approved 30-day mortality measure, will there be patient selection issues that result in adverse unintended consequences in the emergency room as it relates to cardiogenic shock and septicemia? These are some of the things to watch very carefully as we start to change our care delivery model to make sure our patients are not harmed.

Itchhaporia: There may be a tendency to avoid sick patients. Or there may be some up-coding or avoiding coding complications in certain periods of time. Will we move a procedure to day 31 rather than day 30? When is the right time for a defibrillator, for example, after a myocardial infarction? Will a bundle affect that decision making? A lot of issues will come up.

Waites: Where do you go with very expensive treatment vs. not using that treatment vs. not allowing particular kinds of patients into your centers? It’s going to be difficult.

Itchhaporia: Let’s say that bundled care can discourage unnecessary care, but can it swing too far in the other direction? Would healthcare systems potentially limit access to certain services or consultants to save money, and maybe deny patients for the sake of money? I’m not saying that will happen, but these are things to think about. What happens to academic centers, which tend to take sicker patients? And, unless we give some special consideration for research and teaching, and make some special payment to address both, how will academic centers not be negatively impacted?

Biga: The most critical element of implementation is going to be making sure we do things for the right reasons. There is enough in our healthcare system that we can facilitate to both decrease cost and improve patient outcomes, but we need to carefully analyze each step of the way.

Powers: I understand the concerns about downstream negative effects such as undertreatment, but I’m not too concerned about it. We’ve been practicing in this environment for some diagnoses, and I don’t see people holding off on required care when it’s indicated. We fall back on the AUC. If it is appropriate, the patient gets the care.

Casale: Are commercial health plans considering the potential dilemma of driving care improvements on one side or causing unintended consequences on the other side?

Itchhaporia: In the fall, the results of the bundled payment for orthopedic care improvement initiative were published. The researchers found a decline in Medicare payments due to reductions in postacute spending but no improvement in quality care (JAMA 2016;316[12]:1267-78). We assume if we decrease costs we’ll also improve quality, but that may not necessarily be the case. 

Higgins: MACRA certainly has the potential to help us get closer to achieving the Triple Aim, but one challenge is that a lot of the measures that we are using now, and are familiar with, came out of a fee-for-service system. We need to be forward thinking about measures to avoid over- and undertreatment. Maybe this gives us an opportunity to have a conversation about how to identify and track consequences, what measurement should look like in this new world of alternative payment models and how different measures need to be compared to a predominantly fee-for-service model.

Coordination & The Care Continuum

Expand the Team. Be Open to New Partnerships.

Casale: Whenever we talk about movement to value and improving the health of our patients, care coordination must be part of the discussion. Are you changing how your teams work? Or constructing teams differently?

Itchhaporia: We have an example of this. In the past, we’ve had a nurse practitioner and a nurse as the two main educators. They worked with social workers to ensure every discharged patient had an appointment scheduled in the heart failure clinic.

Recently, we’ve expanded our team by working with the rehabilitation centers, hospitalists

and home health agencies so that they all can be our partners in decreasing readmissions. Now, we have regular meetings with the rehab centers and SNFs, to bring them up to speed about caring for these patients. We’ve created an order set they can use when accepting new patients. We’re also working with our hospitalists because they usually do the discharge summaries. And we’ve picked a preferred home health agency because it became difficult to work with so many. Now we say, “This is our preferred home health agency to go out to the patients who have heart failure, and these are the things they’ll look for.”

Casale: So, you expanded your team to do this level of care coordination?

Itchhaporia: Right, and we needed data. Our quality improvement people have had to be involved. We just finished a pilot project where we determined that the sickest patients had a hard time managing medications, appointments and so on, so we gave them a nurse navigator. The idea came from a quality improvement person, who said, “What if we try this?” and pushed the idea. An advantage of

MACRA is that now everybody who is involved in patient care is at the table. 

Powers: We’re moving to a care team model. We want to get there for all aspects of our practice, but we’re moving subspecialty by subspecialty. We’re hiring nurses and APPs to round out care teams in heart failure, electrophysiology and valve replacement. This will improve our contact time with patients, which will have a positive impact on clinical quality and efficiency.

Waites: Our cardiac rehab unit has been handled by an endocrinologist, but we are going to be part of the cardiac rehab incentive bundle, so the cardiologists are going to be involved beyond just referring patients. We’re also increasing our participation in same-day/next-day care for the emergency department, so that if they have a chest pain situation and all the algorithms say it’s okay to let the patient go, we guarantee they’ll be seen within 24 hours.

Casale: Are you also doing work around what the various team members do? Is their work changing?

Waites: We’re involving our APPs much more now, especially with the same-day/next-day chest pain effort. They’re going to be taking on additional load.

Casale: That obviously helps improve access, and certainly will lead to better care coordination.

Biga: I’ve been in this world a long time, and the pace of change is just amazing and has stretched across the whole continuum. We’ve seen an increase in coordinated care and communication with people we never would have thought to bring to the table before MACRA. For example, our cardiologists are now in the nursing homes to prevent readmissions and improve care. We’re also mandating that all of our myocardial infarction and congestive heart failure discharges are seen within 48 hours, in the office, either by an APP or a physician. We’re seeing engagement with nursing homes medical directors, Coumadin clinics and continuing care retirement communities. I never would have thought of these things as recently as a couple of years ago. But the most important thing is that we’ve ensured that everybody, including the physicians, is working to the top of his or her license. It’s so important that we don’t have our physicians rooming patients or our APPs acting as medical assistants.

Casale: Do you think we’ll see new types of partnerships or collaborations evolving for practices, health systems or even across healthcare?

Waites: I’m hoping we can work with Secretary of Health and Human Services Tom Price and CMS to accomplish some of our goals. 

Biga: Except for our current class of fellows-in-training, the care continuum has not been in most physicians’ short sight. Now we’ll really be looking at the 90 days after patients leave the office or the hospital. MACRA is going to let us look at whether they need an APP, dietician, psychiatrist or psychologist. It’s so nice to get away from, “I can’t do that because it’s not a billable service,” to “Yes, that’s exactly the right thing to do.”

Itchhaporia: Because of the laws in California, even collaboration with hospitals is kind of strange. So, on the West Coast, the first stretch will be to develop relationships with hospitals. Next will be health plans. We may start thinking of health plans less as the source of contracts and more as partners we can talk to. There is potential for a relationship with the EHR vendors. When we talk about data—especially ownership of quality data—we need to be working hand in hand.

Higgins: It’s much more of a collaborative environment compared to the fee-for-service model, where plans and providers are working together in terms of improving outcomes and addressing the cost issue.

Actions & Inevitabilities

Study the Strategy. Delegate the Details. Start Now. 

Casale: Acknowledging that perhaps not everyone on the cardiology team needs to be immersed in all of the details around MACRA, what is the one thing every cardiovascular clinician must know, or do, as soon as possible?

Biga: Basically, MACRA is demanding a redefinition of how we deliver care. Physicians don’t have to know the details of the policies, but they must ensure that somebody is watching those details. Every practitioner must understand the 3,000-foot level, and somebody within the organization must understand the details.

Waites: And we must learn how to document more accurately, and learn to work with our coders in the hospital to get the proper documentation coming from our hospital to be able to meet the quality measures.

Higgins: I would say, educate yourself to transition from an encounter-based approach to care to a population-based approach. 

Itchhaporia: This is not the time to bury your head in the sand. We have to understand the costs involved with delivering care. The reports coming out of Medicare are going to be important. The issue is participation.

Powers: It’s time for all physicians to understand and commit to the value equation, quality over cost. We have to own both the numerator and the denominator. It’s way past the time when we can put our heads in the sand about costs—what people are being charged and how much it costs to do tests and procedures.

Biga: The most important thing to remember is that the intersection of cost and quality, to benefit our patients, is here to stay.