What does the near-term future of healthcare look like to physicians in practice? Scott Weingarten, M.D., the chief clinical transformation officer at Cedars-Sinai Health System in Los Angeles, shared with attendees at the Health IT Summit in Beverly Hills, sponsored by Healthcare Informatics, his perspectives, on Nov. 10. He and his fellow healthcare leaders were gathered together at the Sofitel Los Angeles at Beverly Hills for the conference.
Dr. Weingarten, who has spent decades in medical practice, in consulting, on the vendor side of healthcare, and more recently, in health system administration, sees a complex road map ahead for practicing physicians in the U.S., one informed by accelerating policy and payment changes, which are in turn shaping the choices that doctors might make in the next few years.
In his presentation at the Summit, Weingarten focused on some of the major paths forward for U.S. physicians, all of which are being shaped directly or indirectly by federal mandates. He delved into aspects of the new Merit-based Incentive Payment System (MIPS) under the MACRA (Medicare Access and CHIP Reauthorization Act) law passed by the U.S. Congress last year, which goes into effect on January 1, 2017; and also the category of alternative payment models (APMs) under that law. Under MACRA, Medicare-participating physicians will have the choice of either participating in an APM, which can include participation in an accountable care organization (ACO), or participation in the Comprehensive Primary Care Plus Program, or, participating in the MIPS program, with its numerous outcomes-related reporting requirements for payment. Either way, their choices will be governed by federally mandated participation in some program that measures quality or value in physicians’ delivery of patient care and pays differentially according to the results of that care delivery. Weingarten also discussed aspects of the mandatory bundled payment programs for total joint replacement and for cardiac care, programs that senior officials at the Centers for Medicare and Medicaid Services (CMS) have made clear will be expanded beyond the markets in which the bundled payments have already been mandated (98 metro markets for cardiac bundled payments and 69 metro markets for total joint replacement bundled payments).
After initially laying out some of the broader landscape, Weingarten delved into physicians’ options in the new policy and payment environment. “MIPS will be less attractive to physicians [than participation in an APM] for many reasons: you don’t get the 5-percent annual bonus, and the payment rate enhancements are lower,” he said. “But for those physicians who are a part of APMs or MIPS, how do they do well in this new, post-MACRA world? I’ve presented a lot of this to physicians at Cedars-Sinai, and many want to know how to get into an APM, or how to succeed in a MIPS world. A small number of physicians say this is really hard, and I’m going to stop caring for Medicare patients. But then I share with them that the commercial insurers are quickly moving to risk-based payment, following Medicare. So fee-for-volume is quickly going away. Virtually all the commercial insurer CEOs and executives have declared what their timing is for shifting to risk-based payment. And so if you don’t want to take Medicare and you don’t want risk-based payment from commercial payers, you’re basically left with cash-paying patients, and there aren’t many of those out there.”
Shifting his discussion to mandated bundled payments, Weingarten said, “The Advisory Board Company has modeled reductions under bundled payments, and the reduction in our payments is three times greater under bundled payments than under MACRA. So the bundled payment mandate is a clever way for Medicare to reduce payments,” he warned his audience. What’s more, he noted, “There are 65 Medicare markets in Southern California, including the Los Angeles market specifically, that are already under the total joint replacement bundled payment mandate. So risk-based payment is coming at you, and coming at you fast. Hopefully, most physicians will succeed, but not everyone will.”
Making the numbers work in academic medical center-based care
All of these policy and payment changes are putting pressure on academic medical centers and teaching hospitals as never before, Weingarten told his audience. At Cedars-Sinai Health, which encompasses two hospitals, a medical group, and an IPA (independent practice association), “We’re doing more heart transplants than any place in the world, 132 a year. But we have a cost structure built for an academic medical center, which makes it hard. Are there any advantages? An article in the New England Journal of Medicine that was published about Partners”—Partners Health Care in Boston—“says, we do have options. Academic medical centers specialize in clinical innovation,” he noted. And, he said, the article went on to say that academic medical centers “must now apply their innovative capabilities not only to clinical care, but also to innovation in operations. This is front and center at Cedars-Sinai,” he stressed. “We’re having our executive retreat tomorrow, and we’re all going offsite to talk about this,” he noted. “So as you begin to move forward, how does technology help your organization with its goals to succeed in a risk-based environment?” In fact, he said, technology, especially and including information technology, will play a key role in helping the leaders of patient care organizations, including of academic medical centers and teaching hospitals, to adjust to the emerging healthcare payment landscape.
One key area that Weingarten told his audience offers tremendous opportunity is in clinical decision support (CDS), on numerous levels. What’s more, as he noted, clinical decision support tools will be needed more than ever, as physicians in practice are inundated with new knowledge and information in the clinical literature. “There are a lot of miracles occurring in healthcare, and a lot of new knowledge is being created, he said. “But with about 20,000 biomedical journals out there, and 8,000 articles a day being published worldwide, that is literally a clinical journal article being produced every 26 seconds. In addition, doctors will be presented with genomic and biometric information. How does anybody remember any of that? It’s been said that if you’re a physician and you finished medical school and residency and you know absolutely everything, and you read and retain the information in two articles every day, you’ll be about 1,225 years behind, at the end of every year, on all these new articles!” he exclaimed. So clearly, he said, physicians will need to have user-friendly access to more and better clinical decision support tools than ever before.
In that context, Weingarten said, efforts by healthcare IT and informaticist leaders at Cedars-Sinai and other patient care organizations to move fully into electronic health record optimization, now that they’ve been working with EHRs for years, are going to be crucial in supporting physicians in the new healthcare. “We’re really moving into this next wave of EHR optimization” now in the more advanced patient care organizations, he noted. “We have these things,” he said, referring to EHRs, “and the physicians by and large don’t love them. But we have to make them work.” And he compared the advantages brought by advanced clinical decision support systems to blind-spot monitoring systems in passenger cars. “That’s what the EHR and clinical systems are” when they include CDS, he said: “they’re accident avoidance systems. And it’s impossible, if you have thousands of opportunities to make mistakes, not to make any mistakes. So what we’re talking about is providing information at the point of care.”
Weingarten offered his audience an example of the great potential benefits of CDS systems from his own clinical practice experience from a few years ago. “I remember I had a 53-year-old woman who ran the L.A. Marathon every year,” he said. “Very often, she would come to me after the Marathon with a sprained ankle, and unfortunately, there wasn’t much I could do about that. But one year, she came back, and we did a mammogram on her, and we detected breast cancer. And it turned out that she had not had a mammogram the two years before that year. And had I had an alert to have her get a mammogram, I would have ordered it. But doctors can’t know or remember anything. So that is an example of where having an alert in my EHR advising me to consider ordering a mammogram for her would have made a big difference.”
Choosing Wisely: when MDs set the parameters
In the broader context of the rapid advance of value-based payment requirements into all areas of medical practice, both on in terms of Medicare payment and also in terms of payment by commercial health insurers, what is it that physicians can do to retain some level of control over clinical decision-making, while at the same time succeed under new payment regimes and requirements? Weingarten spent some time sharing with his audience his perspectives on the Choosing Wisely program, which offers evidence-based support for decision-making in most medical specialties, and has been created and enriched by physicians themselves. “I’m a big supporter of Choosing Wisely, for a number of reasons,” he said. “About 70 physician specialty societies got together, under the coordination of the American College of Cardiology, and decided to define waste in 70 different specialties,” he noted. “And that range of specialties represents about 600,000 physicians. And what I love about this is that it’s physicians figuring out what waste is. It shouldn’t be the government, or even health plans,” who should do that, he said. Giving one example, Weingarten noted that Choosing Wisely informs an ordering physician that, based on a British Medical Journal study that was performed in Australia, the chances of a child who has been ordered a CT scan getting cancer increase by 24 percent. And it is having such evidence at their fingertips at the point of ordering that will be crucial for physicians to make the best utilization and treatment decisions on behalf of patients, but also ones that make sense economically, he said.
In addition, Weingarten noted, the use of clinical decision support helps to reduce the incidence of false-positive results from tests that are unnecessary in the first place. Equally importantly, CDS can give physicians context for the ordering of diagnostic tests and for other actions. “For example,” he said, “we had a physician in our organization who had been ordering a huge number of Lyme disease lab tests. But the fact is that there are very few cases of Lyme disease in Southern California. In L.A. County, among people who haven’t traveled to Lyme disease-infested areas, there was one single case of the disease in the past year. So your chance of being bitten by a shark or even of being injured by a vending machine, in L.A. County, is greater than getting Lyme disease.”
And, partly because of the successful adoption of the Choosing Wisely program both within the Cedars-Sinai Medical Group and within the Cedars IPA, Weingarten noted that “We achieved an 8-percent cost savings at CSMG in the last year, and a 6-percent savings in the IPA. As a result, we achieved the most savings of any Anthem ACO in the country. And so, thanks to our adoption of Choosing Wisely, we’ve had a wonderful, significant reduction in costs that have come out of waste.”
In the end, Weingarten advised his audience that the realities that physicians face under value-based payment systems are only going to intensify in the coming years. And regardless of the specific changes that may evolve forward within specific federal, state, and private payment regimens, physician practice is becoming irrevocably transformed by payment change generally. But clinical decision support and other clinical information systems will be a critical factor in the success of those physicians who are able to adapt to the new world order in U.S. healthcare.
