At the Health IT Summit in Cleveland, Framing MACRA As an Opportunity

March 23, 2017
Robert Schwartz, M.D., a principal with The Chartis Group, told attendees at the Health IT Summit in Cleveland on Thursday that the requirements under the MACRA law offer both challenges and opportunities for hospital organization leaders

The requirements under the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) present a set of challenges and opportunities for hospital and health system leaders, as they work with their affiliated and employed physicians to fulfill the requirements of the law’s two different components: the MIPS (Merit-based Incentive Payment System) program and the APM (alternative payment model) program, the opening keynote speaker told attendees on Thursday at the Health IT Summit in Cleveland, being held at the Hilton Cleveland Downtown.

Robert Schwartz, M.D., a principal with The Chartis Group, in the Chicago-based consulting firm’s information and technology practice, gave the opening keynote, under the title “MACRA: The Latest Accelerant to Value-Based Care: Are You Ready?” Dr. Schwartz portrayed for his listeners a rapidly changing U.S. healthcare landscape, one in which the leaders of patient care organizations need to move forward, and help their physicians move forward, to meet new payment-based realities.

Among the several new realities, Schwartz told his audience, is that “The cost pressures on us will get worse” going forward, “so it behooves us to become more cost-efficient going forward. We should be reimbursed for doing the right thing, for taking care of patients well, and for having good fiduciary responsibility while doing that. And a rise in healthcare consumerism is a good thing,” he added. “We have to figure out how to get patients involved and keep them involved, while maintaining the professionalism of care.”

Given the emerging landscape, particularly around MACRA, Schwartz told his audience that patient care organization leaders need to focus on five key operational areas: provider network assessment; performance optimization; revenue optimization; payer portfolio analysis; and consumer engagement strategies. With regard to performance optimization specifically, he said that “What MACRA is going to drive is a continuous imperative for us to continually improve what we do.”

Robert Schwartz, M.D.

What’s more, Schwartz said, “We are seeing that the post-election milieu is going to align with the same things that MACRA is going to push us into,” in terms of payment-driven cost-control mandates and mechanisms. As a result, he said, “Things are going to accelerate a bit now,” particularly as the passage of MACRA has meant the combining of several previously disparate measurement systems into one, under MIPS. “We’re seeing the government say, let us have a single goal, a single direction in which to go. That’s the good part,” he said. On the other hand, whether or not the consolidation of different outcomes measurement systems around physician practice, will lead to a lessening of burdens for practicing physicians, “I believe the jury is still out as to whether it will do that or not.”

Schwartz cited several critical success factors that he believes will be needed for physicians to succeed under MACRA. First, he said, “Time is of the essence: if you’re not already doing the things I’m talking about, you’re behind the curve. This is really intimidating,” he conceded, as the work needed to fully implement processes to be successful under the law will be challenging and take time. Within that, he said, “Quality--as it should be—is paramount. It has to be delivered, documented, analyzed, tweaked, and improved.”

Very importantly, Schwartz told his audience, “You must have a MACRA strategy. This is not the time, as I’ve seen in the past, where we take a metric, a regulation, a purpose, an event, and just direct a limited amount of resources to accomplish it. The thing that really comes to my mind,” he said, “is the example of how we took the metric under the meaningful use program, of the requirement to create a patient portal, and a lot of patient care organizations put in patient portals in order to check that box for that program, but haven’t really to a great extent leveraged that tool to improve patient care.” With MACRA, he said, that not an option. The level and scope of all the requirements under MACRA mean that the efforts that patient care organization leaders make need to be focused on capabilities that will help their physicians become successful under either the MIPS program or alternative payment models, in very concrete ways.

What’s more, when it comes to the data and information technology aspects of all this, Schwartz said, “I have not been in a conversation with a health system or client organization that has been successful so far around this, without recognizing how important IT is” to success under changing payment mandates, including MACRA.

How quickly will MDs move into APMs?

Schwartz spent some time speculating on the two tracks that physicians can pursue under MACRA—participating in the MIPS program, or participating in an advanced payment model (APM). “There are 600,000 physicians who are in the MIPS track this year, CMS [the federal Centers for Medicare and Medicaid Services] is estimating, and 100,000 in the APM track,” he said. “The number participating in the APM track is expected to double in the next year. But in order to participate in an APM under MACRA at this time, you have to already have 20 percent of your patients and 25 percent of your Medicare revenues already under some risk contract, in order to join an APM at this time.”

Looking at the options facing physicians, Schwartz noted that “MIPS is easier to qualify for, obviously, while the APM track will be more difficult to qualify for.” Even so, he noted, “They’ve instituted a graduated performance measurement system for MIPS, and that represents a significant change in how business is going to be done. In the past,” he said, “when we were measured on quality and metrics, we knew what the quality [level] was; it was fixed. Not only that, we had a chart that said what it would be in three years. Graduated performance is like being in grade school again, and being graded on a curve. This year, I could be in the 99th percentile and get my bonus this year, whereas next year, since it’s a graduated performance, everyone who I beat out is going to work harder, and theoretically, if I perform at the same level as last year and everyone else leapfrogs me, I could end up in the bottom quartile nationally and end up being penalized. So what this does is to put us into a competitive realm where every year, everyone has to not only get better relative to themselves, but also to the nation. That’s a very, very significant shift in incentives going forward.”

Data and IT considered

In the context of all of this, Schwartz told his audience, it is absolutely vital for patient care organization leaders to consider data a strategic asset. “You need to think of data as a strategic asset, to actively manage your data, and to leverage your data infrastructure, in order to develop such capabilities as asynchronous clinical decision support, and clinical messaging.”

In fact, Schwartz said, a lot of the work needed to equip patient care organizations to optimally help their physicians succeed under MACRA will be distinctly unglamorous, with a lot of basic blocking and tackling. “My question to you in this room,” he said, “is, how many of you have an accuracy level of more than 70 percent of the PCP field in your EHR [electronic health record]?” In other words, how many members of the audience could state confidently that 70 percent of patients’ primary care physicians were absolutely accurately identified in their organizations’ EHRs? Seeing no hands raised, Schwartz said that that was not surprising to him. “When I was at UPMC,” he went on to say, referring to the Pittsburgh-based UPMC health system, where he spent years as an executive, “we started out at 65 percent, and got our level of accuracy up to 95 percent, but it took a lot of work.” And that, he said, is just one example from among many, of the challenges that the leaders of hospitals and health systems face, as they improve their information systems in order to support physicians working to comply with the reporting requirements under both MACRA tracks.

Further, Schwartz asked his audience, “Can you tell me how each individual physician is doing on quality, in your provider network? Are you actually improving quality in your network—and can you demonstrate that? First, of course, you’ll need to define quality, before you can improve it.” There are almost endless operational areas to work on, he asserted.

In terms of data architectures, Schwartz told his audience, “There are actually several layers: the presentation layer, routing layer, business logic layer, analysis layer, normalized-data layer, data integration layer, and data/application layer. And in our IT work, we’ve concentrated on the data/application layer, and in fact mostly on the application layer, and the data has come along for the ride. But most of our information systems remain siloed and locked, because of our appropriate attention to security and privacy. What we need to do,” he said, “is to unlock access at the data layer, and let the applications run, and then bring data aggregation together, and normalize it into the data integration layer,” in order to achieve the data agility to do effective analysis to support MACRA participations on the part of physicians.

“This is going to be a long journey,” Schwartz told his audience, and physicians will increasingly turn to patient care organizations to help them succeed under MACRA—and the ability to facilitate that success will inevitably require intensive and extensive work to improve some of the fundamentals of data and information systems in patient care organizations.