David Barbe, M.D., president of the AMA, speaks to the challenges and opportunities inherent in MD reporting requirements under MACRA
Developments continue to emerge around the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law, including around its two broad component programs, the MIPS (Merit-based Incentive Payment System) and APM (advanced payment model) sections of the overall program, administered by the Centers for Medicare and Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS).
Indeed, the June 20 release of the proposed rule for MACRA’s Quality Payment Program (QPP) for 2018 led to yet another wave of provider reactions and discussion—understandably so, given how important the QPP’s provisions will be, going forward.
It is in that context that virtually all of the major national healthcare professional associations have been actively involved in advocating for some form of optimization of the outcomes measure reporting process under MACRA/MIPS. Certainly, the American Medical Association (AMA; based in Chicago and in Washington, D.C.) has been very prominently involved in advocating for the streamlining and optimization of the reporting processes under MACRA, including under MIPS and under the APMs.
Recently, AMA president David Barbe, M.D. spoke with Healthcare Informatics Editor-in-Chief Mark Hagland about this subject. Dr. Barbe, a practicing family physician who lives and practices in the southern Missouri town of Mountain Grove, began serving his one-year term as elected president of the association in June. He leads and represents an association with 240,000 practicing-physician members nationwide. Below are excerpts from their recent interview.
With regard to the MACRA law and its MIPS and APM components, and in particular, with regard to the quality reporting measures involved in the QPP, where is the AMA right now in terms of its policy position?
We welcome the transition from the old legacy programs into the new more coordinated MIPS program. We appreciate that the number of measurements is fewer, that there is an opportunity for them to be more relevant to physicians and practices; and we appreciate the cooperativeness of CMS in making it easier for physicians to successfully transition into the program.
Many physicians in practice are expressing that they’re feeling a growing burden from all the reporting requirements. What is your perspective on that broad complaint?
We absolutely recognize that, and that’s why the AMA has worked so hard to simplify the reporting in any way we can—the number of measures, and the whole issue of the Pick your Pace program—one patient, one measure, no penalty, this year. So if the physician needs more time to figure out how he or she is going to participate more fully, this gives them more breathing. room. We’re working to make the [QPP] measures more relevant; we also believe that shorter periods of more like 90 days, are adequate, and probably a 365-day reporting period probably isn’t necessary. And, outside the rules and regs as such, we need data to be able to be captured more automated way through the EHR [electronic health record]. Manual recovery of data elements doesn’t make much sense in this day and age. So we’re working with the EHR vendors and other developers to reduce the reporting burden.
What can CIOs, CMIOs, and other healthcare IT leaders in patient care organizations, do, to support physicians in practice around the reporting requirements and challenges?
That group is responsible for the infrastructure in hospitals and health systems, and they can play a critical role in helping physicians have the IT tools they need to do what we’ve just described, capture these data elements in an automated way rather than as a single activity. We encourage them to talk to their doctors, to the frontline physicians, and ask them what they need. What’s more, the AMA put out a white paper detailing nine changes the EHR sector can do to make things easier and better for physicians. That looks a little bit beyond what the local CIO can do, but the CIOs will be a significant voice in discussions with the EHR community. And they’re the ones who can say to the vendors, these products aren’t working yet for our doctors. So they have a critical role in this, and I encourage them to work with the medical community.
And could you speak to the role of CMIOs specifically also?
I’m practicing in a large health system myself, and we wrestle with, how do the CMIOs get the sense of what the practicing physicians are feeling? I encourage them to set up a structured format of listening sessions, ways to get feedback from their practicing physicians. I encourage them to become familiar with the tools and comments that organizations like the AMA are making. They need to avail themselves of the very robust information that we’ve collected, and studies we’ve done, and to supplement that with the physicians-on-the-ground feedback, and with useful data from their own systems. That would be a powerful combination.
Is there a legitimate concern over physicians potentially becoming overwhelmed by all of this? Physician burnout is being talked about more and more now.
Absolutely: this whole issue of burnout and frustration with HIT—it is very real. Physicians are overwhelmed, they’re asked to collect data, they’re given tools that don’t do it, and our studies—the first one we did last fall that shows that physicians are doing twice as much time doing data entry and paperwork as in direct clinical time with patients. We just came out with a second study that says the same thing. That is very demoralizing to physicians; we didn’t train to be data entry clerks, we trained to be clinicians; that’s very demoralizing. And we’re essentially now doing some of the most menial tasks. It cuts across every specialty and every setting, including among employed physicians in medical groups. And they may be in groups that aspire to be high-performing, but also
So, one of the issues that’s emerged recently has been a full-blown discussion about the increasing use of medical scribes. Research is beginning to show that there is tremendous variation in scribes’ effectiveness, and even in their accuracy. How do you see this? Are scribes a point of relief for practicing physicians, or are they a sub-optimal response to a deeper and broader problem in the U.S. healthcare system?
I think there is a role for scribes in some settings. Of course, the fact that scribes are even being considered is an admission of failure of health information technology to begin with. That said, given the fact that it’s going to take a while for the EHR to evolve to meet our needs, an interim step is the use of a scribe. And it’s like any other person on the healthcare team; their degree of usefulness is directly related to their training and collaboration with the rest of the team. And the higher-skilled they can be, the more effective it will be. There’s nothing inherently inadequate about a well-trained individual doing the documentation, but the key is working closely and well with the physician. We wrestle with this in my system. We use scribes in the ED in our health system, as the vast majority of scribes are used. We wrestle with it in our primary care offices, and you either have to allow that to produce more throughput to make the business case for it, or you accept the extra cost in exchange for increased physician well-being. They each their advantages and drawbacks.
Do you think that CMS and HHS will be responsive to pleas on the part of organized medicine for broader relief from some of the EHR-related physician documentation burdens, overall?
The generic answer to that is yes. I think they’ve shown willingness to help physicians transition into MIPS, as we’ve alluded to. That’s a good sign. I think they are hearing us with regard to the number of measures and their relevance. I’m a family physician, and there are a lot of measures I can pick on that are relevant to my practice; that’s not quite true for many specialties—two issues related. One is, how many of these things can you take down to the individual physician level—you need adequate numbers. And the other issue relates to risk adjustment and how sick my patients are.
And it breaks my heart to hear doctors around the country say, ‘You know, I might have to stop seeing some of my complex patients, because they’re bringing down my scores.’ But in order to [avert physicians refraining from seeing those patients], we have to be able to identify and adjust for the complexity of individual patients and populations of patients, and we have to adjust the reimbursement system to match the resources available to treat the more complex patients.
And that brings us to the topic of the shift from volume to value in healthcare. What is your perspective on this very strong shift towards value that’s taking place on the policy and payment front right now, especially with regard to value-based care delivery and purchasing, accountable care organization development, population health management, and care management concepts?
The answer is, it is absolutely the right way to go, and the AMA fully endorses the concepts of population health, of value-based payment. I’m in Chicago now, attending ChangeMedEd, a conference that we’ve designed around, how do we better educate our medical students? The keynote speaker just a half-hour ago, was speaking about population health. He was one of the nation’s experts on population health. He was preaching to the choir, but makes the argument that it’s the only way we’ll accomplish the Triple Aim, improving the health of the country, improving the healthcare to the country, and improved or reduced cost. And population health is a big piece of the way we can move towards that. So yes, it’s the right goal. It is gaining considerably greater momentum over the last few years. And there are now journals devoted to this.
And, getting back to the AMA, we’ve developed through this ChangeMedEd consortium, a plan around three legs of medical training, with the third leg of health system sciences specifically around reporting of outcomes measures, population health, care management—that’s almost as important as the purely clinical, and these sciences will be important to medical schools and residencies, and to practice, as we make that shift.
So, in the past, there was a perception—perhaps unfair—that the AMA as an organization was primarily a resister to change. Can you address that perception, and speak to the organization’s focus in the present moment?
Old perceptions die hard. And it is remarkable to me how we’ll still see articles from time to time, including in the mainstream press, about how the AMA opposed Medicare in the 1960s. Give me break!! Seventy years ago? Come on. The AMA has become a substantially different organization over the last decade or so. We embraced and even led the fight to cover the uninsured in the mid-2000s. We were champions of that. And while I was on the Council on Medical Service, our internal policy think tank, were being adopted by both Democratic and Republican legislatures and legislators. And we supported the ACA [Affordable Care Act], not because it was perfect or flawless, but because it gave us the first structural approach to expanding Medicare and Medicaid. And we’ve opposed wholesale proposals for wholesale cuts in expansion to coverage. So anyone who takes a look at our policies over the last ten years, and says we’re not interested in expanding coverage, is consciously disregarding the truth.
Can you speak to the AMA’s desire to help physicians change their practices in order to move forward towards the requirements of the emerging healthcare delivery and payment system?
The answer is unequivocally yes, we are very engaged in that regard. Five years ago, we changed our policies, including around ChangeMedEd. A second big arc is around improving health outcomes, and it is the boldest patient-facing activity the AMA’s ever been involved in, around increasing awareness and management of pre-diabetes and diabetes and heart disease and the opioid crisis; and the third, a whole arc around practice tools and resources to help inform physicians about changes in the industry, and demands from payers, and how physicians can be successful in transitioning to new models of care and payment.
And let me drill down on that, and this takes us back to MACRA. Specifically around MACRA, we have an interactive payment evaluator module, to help physicians assess their practices’ readiness for MACRA, we have the MIPS Action Kit, which is another suite of interactive modules that allow physicians to go beyond that first product, and dig deeper and be successful, it helps them choose which measures are most relevant to them in their practices, it’s very practical. And then there’s a video, just a few minutes long, that walks a physician, step by step in how they participate in this one-patient one-measure process, if they’re not ready to go full-bore into MIPS. We literally walk them through screenshots of the electronic bill, and that gives them breathing room for 2017. We’re providing physicians with lots of tools, and we will continue to do so going forward.