Is there a silver lining to value-based pay initiatives?

In working with practices around the country, we have heard a variety of reactions to the MACRA-dictated Merit-based Incentive Payment System (MIPS), accountable care organizations (ACOs), and alternative payment models (APM), which are now a consideration of almost every urology practice serving Medicare patients. The reactions range from, “What are you talking about?” to “I do not care” to “We got this and will likely get a bonus.”

The majority of urology practices and health care providers in general feel that the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) programs are yet another unfunded mandate requiring urologists and their staff to spend more time doing busy work that does not help patients or improve care. We can sympathize and agree as we helped many meet the minimum requirements at or near the deadline this past March.

Although we are not big fans of the MIPS required reporting and/or the requirements for ACOs and APMs that are currently available, in this article, we attempt to look past the program and see if there are any silver linings in the administrative cloud.

What drives complaints about health care?

We can start with cost. Virtually everyone in the U.S. would likely agree that health care is costing too much money. Many would also agree that the system does not meet the needs of all the patients nor the physicians. Most would also agree that overall quality can be improved.

While we can point to a number of potential factors that drive complaints about the health care system, we are going to focus on two that appear to be at least obliquely targeted by the MACRA program. Both of these issues can be addressed in a manner that will benefit your practice now while preparing you for the future. As an aside, private payers, while not in the MACRA game directly, are attempting many similar programs and policies to address the growing cost of health care in the U.S.

Factor 1: Fee-for-service health care encourages the health care provider to do more. While most physicians provide only those services they feel are necessary for the appropriate medical care of all patients, it is hard for anyone to believe that every physician is above the pull of capitalism. In fact, many of the rules surrounding reimbursement have resulted in changes to the provision of services, which in turn support this societal gestalt. Luteinizing hormone- releasing hormone antagonists, transurethral microwave thermotherapy, transurethral needle ablation of the prostate, urodynamics, post-void residual measurement, and intensity-modulated radiation therapy have all been targets of reimbursement and rule changes based on the belief that profit was driving overall utilization. The rules and reimbursement changes, in many cases, changed overall utilization (although many will argue that reimbursement and rules are not the sole reason for changes).

Nevertheless, the correlation in these changes and others across the health care marketplace have provided enough consequential data to support further reimbursement and rule changes to curb utilization. MACRA programs are pushing this one step further. APMs and ACOs are essentially compensated in a manner that ignores utilization of services, shifting service choice and remuneration to the provider groups themselves. The MIPS program is stepping into this change with overall cost accounting for each physician by patient with eventual downstream penalties to those physicians deemed to cost the system more than others.

Again, we are not in agreement with the current approach. Particularly, we have a major concern about the accuracy of the cost attributed to each physician.

We do, however, see the point of the programs. And we see an opportunity for groups and individuals to look at the way they practice. We have analyzed several practices in which practice patterns in the same geographic area or the same practice with similar patient diagnoses and ages have vastly different utilization and treatment patterns. For these, we have to ask why. Is the driver for these differences money, training, habit, employment, or something else entirely? And finally, what role does outcome play in the differences, which leads to a second question: How do we consistently measure outcome?

Factor 2: Consistent and accurate data are lacking. Paper charts are virtually impossible to research. Data sharing via paper is slow and incomplete. Electronic health records do not exchange data well and are rarely set up in a manner that allows for consistent and complete data capture and exchange. To date, this has left the reimbursement/billing records as the most complete (not necessarily accurate) data record of service provision and reason for service.

The MACRA programs, HIPAA, American National Standards Institute standards, the Certification Commission for Healthcare Information Technology, and interoperability initiatives are also attempting to further the development of a complete clinical record. Yet the problem of data exchange remains. The variety of systems and incentives for each of the vendors providing electronic solutions does not help. Many payers are spending significant resources, including money, to acquire clinical record data to further define patient conditions, treatments, and outcomes.

Physician groups, including specialty societies and groups supported by the payers and CMS, continue to develop and release expanded treatment guidelines and care pathways. These show great promise. However, there are many areas that have not been fully developed, and the flexibility built into these recommendations allow for further definition at the practice level and variations in services provided.

Opportunities for large, small practices

Larger groups have a significant opportunity to define and implement systems and protocols that fit within guidelines or establish new protocols. With proper system input and analysis, a group can begin to deliver packaging models that address patient needs and the financial needs of the practice. Smaller practices have the opportunity to work within these national guidelines to begin to establish practice patterns that will provide more cost-efficient and measurable care. Demonstrated ability to implement care guidelines, at least some measure of patient satisfaction, and outcomes data are marketable to payers, physician groups, and patients. Without a way to define your practice and tell the market about your approach to health care, you are at a disadvantage in the marketplace.

It is important to note that whether or not physician groups participate in the development of care protocols, the pathways are being developed. We believe that there is opportunity through collaboration within and among physician groups to make significant progress in this regard. Moving forward quickly, concentrating both on data put into and extracted from systems, is a must.

Analyzing what you do and why can help you develop your practice. Understanding resource consumption and need will require predictable treatment patterns. Your ability to attract quality partners, patients, and contracts can be incorporated into your daily practice routine, but it will take some work.

Accuracy in documentation and coding for procedures and diagnoses based on clinical records is not only a requirement for the future but also for accurate and fair payment in the current fee-for-service market. Get paid through the transition system now and prepare for the future.

None of these changes can be implemented without a commitment of time and leadership. In short, the old adage that “failure to plan is planning to fail” is more relevant today than it has ever been.