This year has seen a bevy of new programs and initiatives aimed at moving providers toward a value-based model of care.
In February, HHS Secretary Sylvia Mathews announced a major commitment by healthcare companies and organizations to support interoperability and ease use of electronic health records. Then on April 1, CMS launched its Comprehensive Care for Joint Replacement Model, which will test bundled payment and quality measurement for hip and knee replacements and other major leg procedures. And just weeks ago, the agency unveiled its largest-ever strategy to change primary care delivery and payment in the U.S. - a proposed final rule that will implement the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) under which providers can choose to participate in the Merit-based Incentive Payment System (MIPS) or in certain alternative payment models.
All of these programs, spurred by the Affordable Care Act, aim to improve the quality and coordination of patient care while reducing healthcare costs, but at what price to the providers who must document and report the myriad performance measures the government is requesting?
According to a recent study in Health Affairs, physicians and their staffs spend more than $1.4 billion annually to report quality measures.
Individual hospital systems are clearly having trouble responding at times to the onslaught of different data quality reporting demands, says Richard Riggs, vice president and CMIO for Enterprise Information Services at Cedars-Sinai Health System in Los Angeles. For private practitioners without fewer resources, the challenge can be daunting.
“I think the question that’s out there for me, for smaller practices, is how can they partner with folks to have clinical integration to participate in programs across the continuum” of care,” Riggs says.
He cites CMS’ new oncology care model, which looks at bundles of care for chemotherapy patients and how you manage and group those patients to ensure they are getting the most efficient care. The agency is seeking participation of other payers in the model, which was announced in March.
If a doctor has two patients with the same cancer, one under 65 and the other on Medicare, he or she “might have to have two completely different data sets and elements figured out to make sure you’re adhering to what’s needed, as well as understand how the payment protocols might impact whatever treatment you may ultimately give” to patients, Riggs tells Healthcare Dive.
“I think we’re not anywhere ready to do most of these programs,” says Robert Berenson, a healthcare expert with the Urban Institute who questions many of the Obama administration’s alternative payment initiatives. “I don’t think we have good performance measures, I don’t think we correct the evidence flaws of our basic payment models, and yet we’re inventing new ones.”
According to Berenson, insurance claims and medical records do not provide the data needed to measure the core activities of many specialists. As a result, doctors will be rated based on measures that, in many cases, have little to do with the quality of care they provide, he says.
Under the Medicare Access and CHIP Reauthorization Act, physicians who do well based on certain performance measures stand to gain an extra 27% in fees, while those who perform poorly could lose up to 95% in pay.
Berenson worries that some small practices will close up shop because they cannot absorb the loss and do not have the money to hire people to produce the data.
David Friend, chief transformation officer and managing director of BDO’s Center for Healthcare Excellence & Innovation, disagrees on the impact of performance measures, at least when it comes to hospitals. “It’s not a question of measuring. They know the answers,” he says. “They’re just really worried about how people are going to react when [the star ratings] get published.”
Still, he says the government and consumers need to look at the data intelligently and parse out variables that may affect ratings, such as the difficulty of procedures a hospital provides and the populations it serves. But consumers have shown that they are able to understand information and make wise choices in other areas of their lives, he adds.
Friend imagines a time when a five-star hospital would be paid more to provide a service than a two-star facility. “That’s probably a good thing,” he says, “though it will not be without controversy and it’s got to be done fairly.”
One initiative that has gotten a cautious endorsement, even by the curmudgeonly Berenson, is CPC+, which is designed to provide physicians the freedom to care for patients in a way they think will deliver the best outcomes and will pay them for achieving results and improving care. The program will be rolled out in up to 20 regions and can accommodate up to 5,000 practices.
Doctors want more resources to take care of their patients, and that resource is mostly time, says Wanda Filer, president of the American Academy of Family Physicians.
“What we’ve always said is pay better and differently for primary care,” Filer tells Healthcare Dive. “CPC+, especially when you look at a multipayer project, has the opportunity to begin to flip the pyramid and say let’s put health in the forefront, let’s try to keep people out of the hospital, let’s focus on keeping people as healthy as we can," she adds."That’s going to save the system [money]. More importantly, it’s going to save lives.”
CPC+ builds on the Comprehensive Primary Care pilot launched in 2012, which demonstrated limited success in the first two years of operation — showing some progress in improving delivery of care, but no savings in Medicare expenditures after care-management fees are tallied.
That has led to a “fair amount of skepticism” among family doctors who were not in the original pilot, says Filer. “They’ve been told for decades that we’re going to do what we can to strengthen primary care, and they’ve seen a lot of broken promises, going back before this administration,” she says. For CPC+ to work, doctors will need to be convinced the initiative will live up to its expectations.
To make alternative payment models more attractive, particularly smaller hospitals and practices, CMS needs to make the information as specific as possible and increase clarity around what it is attempting to achieve,” Cedars-Sinai’s Riggs says. “With some of these demonstration or pilot projects, they’re really looking for people to come up with their own ideas. And at a system level you can generate those, but at an individual practice office level, that can be very daunting to, say, set up a care management model for all your diabetics.”
For physicians and practices that decide to accept risk, he recommends that they set aside resources to contract out for case management and other services they cannot provide. “Some of these things are just not clear to physicians … because they’re busy wanting to do medical care,” he says.
The shift to value-based care is moving at a very quick pace, but not just because of the Congress and CMS. Consumers are also demanding a bigger role in their care and treatment decisions. Ultimately, engaging and activating patients through a collaborative team approach could help to move the needle on quality outcomes and reining in costs, Riggs says.