On the first day of the World Health Care Congress in Washington, D.C., two physician leaders reflected on their organizations' push into alternative payment models while expert panelists gave advice to those who are struggling with MACRA (the Medicare Access and CHIP Reauthorization Act) readiness.
Angelo Sinopoli, M.D., executive vice president and chief clinical officer, strategic coordinating organization at the South Carolina-based Greenville Health System, and Adam Myers, M.D., chief medical officer of Texas Health Physicians' Group, were joined on the panel with Kavita Patel, M.D., nonresident senior fellow at the Brookings Institution. The three experts delved into the critical elements physicians around the country need to consider as they get ready for MACRA, a law with a Quality Payment Program that kicked off in January with the goal to reward participating Medicare doctors for the quality outcomes they demonstrate.
While many surveys over the months have revealed that many U.S. clinicians are not at all ready for MACRA and its two payment tracks—MIPS (Merit-Based Incentive Payment System) and advanced alternative payment models (APMs)—Myers and Sinopoli are conversely in organizations that have plunged into risk-based care years ago.
At the integrated Greenville Health System, Sinopoli noted how physicians do participate in at-risk Medicaid contracts with downside risk, and have had some success there. They are also part of a federal accountable care organization (ACO) program, the Medicare Shared Savings Program (MSSP) Track 1, in which there are 60,000 Medicare beneficiaries in that network, with $17.5 million of shared savings gained in the past year, Sinopoli said, adding that the health system also participates in some BPCI (Bundled Payments for Care Improvement) models. And in Texas Health Physicians' Group, within the integrated Texas Health Resources health system, Myers said that the group participates in commercial bundled payment models, has a Medicare Advantage program that's been in for a while, and is also partaking in four commercial ACOs with varying degrees of downside risk. The physician organization has also partnered with UT Southwestern Medical Center in Dallas on participation in a new federal ACO initiative, the Next Gen model.
Needless to say, both Myers and Sinopoli were able to offer advice for physicians by reflecting on how their organizations began their journeys into risk. Sinopoli said that leaders in South Carolina realized that there was a need to come together as a state in developing networks so that various entities could manage populations together. "But everyone is in different states of readiness, support, infrastructure, and experience," Sinopoli said. "It has taken us a decade to develop the competencies we have today, and we're not the gold standard. You need to develop that culture and infrastructure. The feds are going to push risk to the states, who will push it to the MCOs [managed care organizations], who will push it to the providers. So no matter which path you take, providers will be the ones at risk."
Myers offered a comparison to relay race sprinters, noting a need to work on touchpoints and handoffs. He explained: "If i were doing this over again [from the beginning], I wouldn't start with a specific [value-based program] in mind, but rather with the touchpoints. Healthcare is a relay race in a lot of ways. So [in the Olympics] you had tremendous athletes who were gifted sprinters, but they lost because they dropped the baton. A team that was much slower would be able to win if they just effectively managed the handoffs. Healthcare is similar— you have great specialists, primary care physicians, nurses and care coordinators—but it's those interfaces where things get messy. Work on getting those things ironed out and you'd be in much better position to take on APMs and advanced APMs. This means doing things like making sure you're getting medication reconciliation right, and making sure there's communication between the inpatient and outpatient spaces."
Patel, a health policy expert who previously served in the Obama administration working on healthcare reform, and is also a practicing primary care internist, came from a different perspective than the other two panelists since she is not in a position where she can take on downside risk as a provider. So like many Medicare clinicians, some 90 percent, she will be in the MIPS track early on. "The most practical things I see are people struggling to think about staying in MIPS, and they are paying consultants lots of money to see what's the best strategy for them," she said.
But Patel doesn't think that physicians need to be spending so much time debating MIPS vs. advanced APMs. Rather, they need to first understand what they're doing well today, she said. "I don't think most physicians and C-suite leaders understand how they're performing within their internal benchmarks, let alone national ones. There are great sources of data available that I have yet to see people take real advantage of," Patel attested. "So for MACRA, rather than getting so concerned about which track to be in, know that you'll probably be in MIPS unless you have years of experience for years." As such, she urged physicians in attendance to also push their leadership and clinical teams to evaluate where they are in terms of readiness. "In that sense, I think MACRA has opened a dialogue between executive management and the clinical front lines," she said.
Myers wholeheartedly agreed with Patel, further noting how 2017 was set up to be a transition year in MACRA, as government officials wanted to ease physicians into the program. "Have a dialogue to determine what you're doing well and which measures you want to perform on within MIPS, Myers said. "The first year is a gimme; you just need to report on one measure in the different categories for a 90-day period to break even. So it's a good time to do discovery to see what you're doing well on."
Patel actually offered a prediction that has been said elsewhere in health policy circles as well—that 2018 will also be a flexible transition year for physicians. She further noted that there are opportunities to partner with commercial payers to get care coordination fees that will help build the necessary infrastructures. She said that there is a baseline awareness in the primary care setting with patient-centered medical homes and ACOs, and there is an opportunity provided with that, as well as with chronic care management, in that all of these models offer fees that can subsidize the infrastructure. "Most commercial payers will match those fees, and we have been successful in the mid-Atlantic to get the Blues, Cigna and others to match," she said, adding that for an average ACO, the infrastructure cost is in the $5 million to $25 million range, and even higher if more risk is being taken on.
Myers agreed, noting that's how Texas Health Physicians' Group built a navigator program and another program in which nurse practitioners see patients in their homes within 72 hours post-discharge. In that program, nurses do basic things like ask patients if they have their medications, if they know which ones to take, and if they have the right foods. Readmissions were dropped by 12 percent after implementing this program, Myers noted, and that was due to assistance from the organization's Medicare Advantage program—not an advanced APM.
Meanwhile, in South Carolina, Sinopoli said he has been lucky enough to work for an organization that saw this shift unfolding a decade ago and thus had the insight to embark on population health a long time ago. He also said there was also strong support in the health system from executive leaders and the board of trustees who were willing to invest in developing the care model, which meant having strategic thoughts about managing those transitions. "We broke it down into three areas: the provider area, the patient-centered medical neighborhood, and the accountable communities," Sinopoli said. "But we quickly realized that we didn't have adequate data or the training that was necessary, so we needed to invest in all of that."
He added that a core problem was that even though the goal was to re-focus the people who were working on this new model of care, they would naturally get distracted by the urgencies of the day that exist in a hospital. As such, it became necessary to separate it out, and as a result, the Care Coordination Institute in Greenville was established, of which Sinopoli is also president and CEO of. "We recruited our expertise there and put in the infrastructure there, so that's where we collect data and do risk stratifications. It's a full-time job and there are no distractions about what's happening in the ER. This has worked very well for us, and we've been able to scale that and share those services with other systems," he said.
Patel piggybacked on the points made by Sinopoli and Myers regarding how to plunge into risk, also noting that specialists are now "coming into the [MACRA] equation in droves," and asking questions about how to proceed forward. "I love [Myers'] point about handing off the baton; you're going from one specialist to a super specialist and sometimes that's very expensive care," she said, pointing out the oncology bundled payment programs as a sign that specialists want to get involved.
Myers added, "Specialists are asking questions. They are asking if you can be in more than one advanced APM, and the answer is yes, if you have enough of your volume coming through APMs, then you would be able to [bypass] MIPS. Some specialists also come come to me and ask what would happen if they drop out of Medicare totally, if for example, they have 90 percent of their business on their commercial side," he said.
But when thinking about dropping out of Medicare—something that small practice physicians have contemplated with MACRA looming—the key thing to factor in, Myers warned, is that considering referral patterns, providers tend to want to use the same specialists for disease states, commercial or Medicare insurance not withstanding. "So if you pull yourselves out of Medicare, the likelihood that those referrals on the commercial side still come your way will decrease," he predicted.
