On the ongoing journey to value-based care, provider organizations are all over the map when it comes to how advanced they are. Some are just starting out on that road while others are much further along.
In Massachusetts, the Mt. Auburn Cambridge Independent Practice Association (MACIPA), based in Brighton, includes 500 affiliated physicians and operates an ACO (accountable care organization) that is in Track 3 of the federal Medicare Shared Savings Program (MSSP) model—the track in which ACO participants take on the most risk for their patients. Indeed, the organization, headed by Barbara Spivak, M.D., CEO, has been engaged in risk-based contracting since the 1980s. Needless to say, MACIPA is on the advanced side of the road.
At the Boston Health IT Summit on August 8, Dr. Spivak joined Healthcare Informatics Editor-in-Chief Mark Hagland on stage to discuss MACIPA’s value-based care journey, the core health IT and policy-related issues physicians are facing these days, and much more as it relates to healthcare in the state.
Massachusetts healthcare, said Spivak, a local practicing physician for the last 30 years, is unlike most U.S states in that nearly every doctor belongs to some type of health system. But the biggest issue doctors face today, she contended, is that when they belong to a network, they are supposed to keep business inside it. At the same time, the healthcare market is moving more into “open access,” she said. “Patients choose health plans [in which] they can go anywhere [for care]. And now, more patients are expecting that no matter where they go, their primary care physician and specialist should know what happened to them, even if they go to other physicians [in other systems],” she said.
As such, preventing patient “leakage” out of the system has become an enormous pressure on physicians, Spivak attested. “We have talent in every system so it’s not like you will get good care in system A but bad care in system B. They are all great systems that will provide great care. So you can’t deny people based on quality because the quality is great everywhere,” she asserted.
Regarding health IT, Spivak noted that years ago, MACIPA was doing population health management even before the organization ever got an EHR (electronic health record). She said that when EHRs started to gain traction, MACIPA applied for a state grant to get the funding to implement one. And although MACIPA just missed out on that funding request, Spivak said by that time she had already convinced her colleagues to get the EHR anyway, so they did. “And over the years we have done more and more population health, using real clinical data, not just claims data. We were also one of the first Pioneer ACOs, and now we’re in MSSP Track 3 with significant upside/downside risk,” Spivak said, speaking to how far along MACIPA has come.
As such, Spivak said that when MACIPA was considering which ACO model to join, an endeavor that would involve taking on risk for Medicare fee-for-service patients, Mt. Auburn physicians were already accustomed to managing care for their patients via their Medicare Advantage contracts. “Those patients got a lot of support. They were provided social workers, health coaches, and had care managers,” Spivak recalled, noting the biggest complaint from physicians at that time was why MACIPA couldn’t do these things for their Medicare fee-for-service patients as well. “But we didn’t have the data on them and there was no risk involved,” she said.
Spotting Flaws in Quality Metrics
Spivak went on to note that for all of issues facing the healthcare industry, as physicians continue to manage populations of patients, they have to “staff up” and getting the data and documenting is quite challenging. “One of key factors in physician burnout, particularly in primary care, is the documentation required for all of the quality metrics,” she said.
Even though MACIPA is a small organization, its physicians are still held accountable for hundreds of quality metrics that differ across various health plans. But Spivak said her physicians are taught just one set of metrics. For example, if there are 50 diabetic quality metrics spanning across all MACIPA’s health plan contracts, Spivak and her team narrow those 50 down to eight and then teach the physicians just those eight.
Nonetheless, Spivak believes that there are some major flaws in how certain quality metrics are measured, offering CMS’ (the Centers for Medicare & Medicaid Services) measure for screening for future fall risk as an example. Originally, she explained, physicians had to simply ask at-risk patients if they had two or more falls in the past six months and if they were injured. But a new CMS proposal may make things more complicated than that, Spivak noted. If the proposal passes, starting in 2019, physicians will have to ask these patients many more questions, including finding out details about stairs in the patients’ home as well as their vision.
But there are timing issues, Spivak continued. The final rule on this proposal will come out in October and the mandated start date for complying would be in January 2019, meaning EHR systems will have to remove those two original questions and replace them with another seven or eight. “Once that happens, I have to go out and teach all of my doctors, nursing homes, advanced practitioners, and others that the old [method] is out while the new questions are in. And that takes three to four months. Think about health systems that have 1,500 doctors. It’s an impossible situation,” she attested.
What’s more, Spivak offered, there are plenty of quality metrics that don’t measure quality. She noted one measure that looks at whether or not the physician prescribed antibiotics for bronchitis. This, Spivak, asserted, is a “coding measure” and has nothing to do with the amount of antibiotics the physician gave, since it all depends on if that physician coded for viral bronchitis or bacterial, as it’s OK to give antibiotics out for the latter, but not for the former. “Am I a trained or untrained rat?” Spivak jokingly asked. “That’s what this measure is about.”
Indeed, Spivak advised providers to not to blindly listen to the EHR companies who say that quality metrics are imbedded inside their systems, and that physicians can document easily. “Everyone’s quality metrics are a little bit different across the U.S. and its important to work with clinicians on them,” Spivak offered. “One advantage for me is that I still see patients about one-third of the time and it’s not the healthy 20-year-olds who I am seeing. I see chronically ill patients who are tough to document for. So you have to run things by your clinicians, and ask them if the [EHRs] work for them as is or if they’re making documentation [harder]. Don’t just rely on what your vendor tells you.”