Next Monday is the deadline for public comments on a proposed rule implementing key provisions of MACRA (Medicare Access and CHIP Reauthorization Act of 2015).  Released in April, this draft regulation explains how physicians should measure and report the quality of care they provide and how they will be compensated under Medicare. It is the first real step implementing last year’s historic, bipartisan physician payment reform legislation.

With MACRA, legislators of both parties sought, not just repeal of the Sustainable Growth Rate’s system of automatic payment cuts to physicians, but a fundamental change in the way that physicians are compensated.  And true to that aim, the proposed rule stresses paying clinicians for their performance on an array of measures that promote improved patient outcomes and higher-value care.  It would also establish strong incentives for physicians to move towards alternative payment models (APMs) that better integrate health care delivery.  The details of these proposals are important and NCHC will be offering its comments next week.

Read more here.

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MACRA Quality Metrics: Looking Beyond the Walls of the Clinic

JUNE 24, 2016 BY NISHA BHAT

Next Monday is the deadline for public comments on a proposed rule implementing key provisions of MACRA (Medicare Access and CHIP Reauthorization Act of 2015).  Released in April, this draft regulation explains how physicians should measure and report the quality of care they provide and how they will be compensated under Medicare. It is the first real step implementing last year’s historic, bipartisan physician payment reform legislation.

With MACRA, legislators of both parties sought, not just repeal of the Sustainable Growth Rate’s system of automatic payment cuts to physicians, but a fundamental change in the way that physicians are compensated.  And true to that aim, the proposed rule stresses paying clinicians for their performance on an array of measures that promote improved patient outcomes and higher-value care.  It would also establish strong incentives for physicians to move towards alternative payment models (APMs) that better integrate health care delivery.  The details of these proposals are important and NCHC will be offering its comments next week.

However, MACRA’s impact on health care outcomes and costs may ultimately depend upon the answer to a question that is barely addressed in the 962 pages of the proposed rule: how will quality measures assess the extent to which physicians and other clinicians can reach beyond the four walls of the clinic to address a range of non-clinical factors that influence health outcomes and costs?

Admittedly, current federal law presents barriers to broader use of non-clinical interventions.  Medicare generally does not reimburse providers or most plans for non-medical in-home support or nutrition services – even when they might prevent future downstream medical costs.  If providers or plans do furnish these services to enrollees, they can risk running afoul of anti-kickback regulations. Congressional action is required to fully address these barriers.

Yet even under current legal authority, CMS could do more to encourage physicians to connect patients who would most benefit from supportive and preventative services to appropriate community resources. CMS’ final rule on MACRA, due November 1, should start moving us in that direction.

Quality metrics that encourage physicians to utilize targeted upstream community-based interventions could result in both cost savings and reduced prevalence of disease. For example, the recently launched Prevent Diabetes STAT program is working to increase the number of physicians who screen patients for prediabetes and refer them to community diabetes prevention programs.[i] One analysis estimates prediabetes screenings and lifestyle change interventions have the potential to save $539 billion in medical costs over a 10 year period.[ii] The dramatic potential for savings underscores the need to make such screening for and referrals to the programs like this a priority.

Effective clinical and community collaboration could also address important social determinants of health. Analyses of “super-utilizers” of emergency departments show a high prevalence of multimorbidity, substance use and mental health disorders, as well as social barriers to care such as homelessness.[iii] Partnerships with community-based social services are vital to meeting the medical and non-medical needs of these high-risk patients and avoiding substantial downstream costs.

Unfortunately, quality measures that incentivize collaboration and connection with these community resources are few and far between in CMS’ draft regulation.

To their credit, CMS has begun to think through these possibilities.  The proposed rule seeks comments on the possible inclusion of a “social and community involvement” category in the “clinical practice improvement activities” (CPIA) component of MIPS.  Under this option, clinicians could get some credit for completed referrals to and partnerships with community and social services.  It is a good idea as far as it goes.

But because a clinicians’ performance on CPIA comprises only 15% of their total performance score under the law, this particular proposal would provide only weak incentives for providers to harness community resources. Moving forward using their existing statutory authority, regulators should ensure that the quality component of MIPS, accounting for 50% of physicians’ score, also include robust, valid measures that broaden clinicians’ sphere of concern beyond the four walls of their office or clinic.

To be sure, the MACRA proposed rule is an important step to a payment system based upon value not volume. But to effectively move towards the goal of integrated, high-quality health care, physician incentives must promote effective and targeted upstream interventions and community partnerships. As MACRA’s Quality Payment Program evolves, metrics which encourage these activities must be included and appropriately weighted.

[i] Read more about the initiative here.

[ii] “Prediabetes: Screen, Test, and Act Today.” http://www.mass.gov/eohhs/docs/dph/com-health/diabetes/prediabetes-exec-summary.pdf

[iii] Johnson, Tracy L., et al. “For many patients who use large amounts of health care services, the need is intense yet temporary.” Health Affairs 34.8 (2015): 1312-1319.