Reimbursement reform: Educating physicians

It was standing room only at a January physician education event in South Carolina as 140-plus providers in the Palmetto Health Quality Collaborative gathered from around the state’s Midlands region. The topic: the Quality Payment Program, which is Medicare’s new physician payment program.

Established by the Medicare Access and CHIP Reauthorization Act of 2015, QPP ties physician payment more closely to performance and encourages providers to participate in risk-based alternative payment models. QPP launched Jan. 1, causing countless furrowed brows among health care providers trying to determine how to succeed under the complex, acronym-laden program.

Health care organizations are taking varied approaches as they educate and prepare physicians and others for the implementation of the performance reimbursement system.

The Palmetto collaborative launched a multilayered education initiative, including face-to-face meetings, webinars and a newsletter. The clinically integrated network comprises the six-hospital Palmetto Health system and nearly 1,200 providers.

“The dialogue has been really important,” says Palmetto Health Quality Collaborative CEO Bill Gerard, M.D. “With a many-sided topic like this, you can’t just send doctors some typed-up information. This is a case where they want to talk through the implications. Our doctors are really craving information that is specific to how we as a network are positioning ourselves to do well.”

Investing in QPP education for physicians — both employed and affiliated — gives hospitals an opportunity to engage these important stakeholders around strategic goals as well as in QPP preparation. “Partnerships between hospitals and clinicians are required to be successful under value-based care in general,” says Melissa Myers, senior associate director of policy of the American Hospital Association. “The launch of QPP gives hospitals and health systems an opportunity to converse with physicians about improving value in a way that directly impacts them.”

Because the Medicare payment program affects physicians differently based on which QPP track they are in, their employment status and other factors, many hospitals and health networks need to design QPP education that is broad and specific at the same time. Here’s how Palmetto and two other organizations are tackling this challenge.

Big-picture lessons

Gerard hopes physicians walk away from the network’s QPP education programs with four key messages:  

1. Continue to work to improve quality measures.
2. Continue to improve care coordination and data-sharing across the network.
3. Continue to identify ways to reduce overuse and misuse of resources.
4. Engage with the network to stay aware of upcoming changes.

The Palmetto collaborative provides care through the Medicare Shared Savings Program Accountable Care Organization and is in Track 1, which puts many network physicians in the Merit-based Incentive Payment System APM track for 2017.

“Our message is that the quality and cost initiatives that physicians are already engaging in through the ACO makes them well-suited to succeed in the new model,” Gerard says. “We highlight the action steps physicians need to take now to meet all the MIPS metrics and tell them what we will be providing for them.”

Gerard also makes a point to tell physicians that the collaborative is evaluating Advanced APMs to participate in, including the Medicare ACO Track 1+ Model, slated to begin in 2018. “It’s important to get across that we’re headed toward alternative payment models with downside financial risk,” Gerard says. “Every risk-based arrangement we’ve been in so far, with commercial insurers, Medicare and Medicaid, has been a shared savings model. We’ve only had upside risk so far, which has given us time to learn.” 

Another big-picture QPP message that Gerard communicates is “rest assured, we’re monitoring this closely.” He sees the collaborative as a key QPP resource for network physicians. “We tell physicians that we are staying on top of official announcements and that we’ll provide a translation on how any changes will specifically affect them.”

CHI's train-the-trainer approach  

The multistate Catholic Health Initiatives is educating physicians about QPP on a region-by-region basis. With 100-plus hospitals and about 24,000 employed and affiliated physicians, CHI has clinicians in all three QPP tracks:  

• MIPS: This pay-for-performance program gives bonuses or penalties based on how well clinicians perform in three categories in 2017 (quality, improvement activities and advancing care information) and a fourth category (cost) starting in 2018. 
• Advanced APM: Clinicians in this track participate in Centers for Medicare & Medicaid Services–selected APMs, which involve taking on two-sided financial risk, or covering a proportion of their costs if Medicare spending exceeds target (i.e., downside risk) in exchange for a 5 percent payment and an opportunity for additional shared savings (i.e., upside risk). Examples of Advanced APMs include the Next Generation ACO model and Comprehensive Primary Care Plus.
• MIPS APM: This MIPS subtrack streamlines MIPS reporting for clinicians who fall into one of these categories: (1) They participate in certain Medicare APMs that do not require two-sided financial risk (e.g., the Medicare Shared Savings Program, Track 1); or (2) they are in an Advanced APM with two-sided risk but do not meet CMS minimum thresholds for number of Medicare patients or billings.  

“Trying to tailor the ‘what’ and ‘how’ messages about QPP for all of our physicians was complex,” says Christopher Stanley, M.D., former vice president for population health at CHI. Because each QPP track has different compliance requirements, national office staff developed three separate education programs for MIPS, Advanced APMs and MIPS APMs. Education was further customized for employed vs. affiliated physicians, and specialty-specific education was provided through service lines including oncology and cardiology.

This segmentation helped to ensure that education was targeted to address specific implications for physicians. “For example, employed physician groups usually use one electronic medical record,” says Stanley, who is now director of health care practice at Navigant. “So they would all use the same method to extract their data for MIPS reporting. In contrast, if you had five affiliated physician groups, you may have five different EMRs.” 

Using a train-the-trainer approach, national office staff educated key physician, hospital and network leaders in each region. Local leaders, mostly physicians, are now charged with training individual physicians in their areas and serving as the area resource for QPP implementation. “We wanted the messages to be carried down through clinical advisers because physicians tend to trust other physicians who can speak their language,” Stanley says.

The education typically was divided into three one-hour sessions: First, national staff provided an overview of QPP. Second, they addressed the specific requirements for the QPP tracks in which CHI providers were participating. The third meeting focused on how to meet the requirements.

The last two sessions were working meetings designed to help regional leaders make various QPP compliance decisions, such as what metrics to report and how to report them. “We came with a playbook, or recommendations and insights from our other markets and other organizations,” Stanley says. “Then we helped them to determine how to operationalize those recommendations.”

Creating a MIPS scoring proxy

Chicago-based Northwestern Medicine has assigned six work groups to prepare for different aspects of QPP: communications, operations, performance, finance, independent physician alignment and information technology.

The communications work group, led by the system director of communications, is handling QPP education. The group began by surveying Northwestern physicians and hospital leaders about their preparation level for QPP. “That helped us to understand that we had to start from scratch in educating physicians,” says Gary Wainer, D.O., medical director of Northwestern Medicine Physician Partners.

The seven-hospital system has physician groups spread throughout the Chicago area. Some groups will be in MIPS, while others will be in MIPS APM. Like CHI, Northwestern is compartmentalizing physician education based on track, employment status and other factors. Wainer and other leaders are providing customized presentations to all Northwestern physician groups. In addition, the communications work group put up a website where Northwestern physicians can find the latest QPP information. Regular email communications focused on specific aspects of QPP also are being sent.

Significantly, Northwestern’s data analytics team is working on an internal scorecard that will give timely insight into physician performance on MIPS metrics and encourage improvement efforts. While CMS plans to provide feedback to providers on their 2017 MIPS performance, the information will be outdated by the time it is sent in 2018. “We want to measure how we are performing today and hold our leaders and physicians accountable for their recent performance,” says Danny Sama, director of analytics of Northwestern Memorial HealthCare, Northwestern Medicine's parent.

To create the MIPS scorecard, Sama and colleagues are developing proxy metrics for two of the MIPS categories: quality and cost. Tracking performance on the other two MIPS categories, improvement activities and advancing care information, involves checking off whether certain activities are performed each year. But the quality and cost categories require running various data through algorithms to arrive at scores for the applicable metrics.

Without access to all Medicare claims data, Northwestern must create proxy metrics that statistically correlate with the CMS metrics. “We can’t produce exactly what CMS will calculate, but we will be directionally accurate, Sama says. “To us, getting our providers working in the right direction is more important than waiting for the perfect solution.”

Creating a proxy metric for the cost category is proving to be particularly challenging because MIPS covers total Medicare spending, including acute, outpatient and post-acute care. But Northwestern doesn’t have access to certain Part A and Part B utilization data, such as recent pharmacy spending, outpatient physical therapy visits and admissions outside the Northwestern system.

The end goal is to give Northwestern physician groups a scorecard that shows their overall quality and cost scores. Then physicians will be able to drill down to see their individual performance on specific metrics compared with peers and against baseline. “Physicians want to know two things: how they are doing and how they compare to other physicians,” Wainer says.

Maggie Van Dyke is a freelance writer based in the Chicago suburbs.

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7 ways to educate physicians about QPP

Health care leaders and experts suggest the following tactics for educating and engaging physicians around the Quality Payment Program, or QPP, Medicare’s new physician payment system:

Start with the basics. “A lot of physicians are still at the 101 course level,” says Melissa Myers, senior associate director of policy for the American Hospital Association. “They need an overview of QPP and its components.” Hospitals can download and adapt QPP fact sheets, presentations and other educational information from numerous sources, including:

• The American Hospital Association.
• The American Medical Association.
• The Centers for Medicare & Medicaid Services' QPP website.

CMS is also sending staff to hospitals and physician groups to provide QPP education and answer questions. Providers can request an educational session. Small practices with 15 or fewer clinicians are also eligible for technical assistance from CMS.  

Share the action plan for the hospital or network involved. Once physicians understand what QPP involves, they will need to know how the program applies to them and how to comply. For instance, will they be in the Merit-based Incentive Payment System track? If so, what metrics should they report and for what time period? How will the data be reported? These are just some of the questions that hospitals need to be prepared to discuss with physicians. 

Customize content. “The education really needs to be organized based on the segments of physicians you are educating,” says Ken Abrams, M.D., managing director of Deloitte Consulting LLP. “This is not a one-size-fits-all approach. An organization needs to spend time determining how to best segment their physician groups by virtue of employment relationships, specialty and care site.”

Employ different educational media. “Physicians are classic adult learners,” says Gary Wainer, D.O., medical director of Northwestern Medicine Physician Partners. “They will seek information when it’s critically important to them. But when it's not, they won’t retain the information.” Wainer recommends a broad-based approach, posting information online in different formats while also appointing a physician leader to answer questions. “When physicians have questions, they can go to the website or call a team member to get answers,” he says. The medium will need to change as messaging changes over time, believes Bill Gerard, M.D., CEO of Palmetto Health Quality Collaborative in South Carolina. “It's important to start off face to face, but as physicians get divided by various segments and payment programs under QPP, you’re going to have to deliver different messages to different groups,” he says. To address this, the collaborative is looking into filming short videos on different topics.

Educate physician practice staff, too. In addition to physician leaders, the Palmetto Health Quality Collaborative is inviting physician practice managers to QPP education. “Practice managers really run the show,” Gerard says. “They do all the back-end work related to the documentation and reimbursement.”

Share performance data. “As hospitals engage clinicians in the process of selecting measures to report under MIPS, it would be helpful to share performance data so that clinicians know how they're actually performing,” says the AHA’s Akin Demehin, director of policy.

Since Medicare's MIPS is just getting started, hospitals do not have MIPS performance data. Many physicians have been participating in QPP precursor programs, including the Physician Quality Reporting System and meaningful use electronic health record incentives. Performance data from these older Medicare programs can inform MIPS discussions.   

Plan ongoing education. Hospitals and health networks need to plan for ongoing QPP education, advises Myers. “MACRA is still evolving. We expect to see some changes to the program as CMS decides next steps. QPP education cannot be just one educational session. It definitely needs to be an iterative learning process.”

— Maggie Van Dyke

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Trustee takeaways: The CMS perspective

Robert Furno, M.D., chief medical officer for the Centers for Medicare & Medicaid Services' Region V, shared three takeaways for clinicians in the Merit-based Incentive Payment System track of the Quality Payment Program.

Pick your pace. Furno recognizes that a lot of providers are overwhelmed and confused by MIPS. “Don't give up,” he urges. “This first year, it is easy to report a minimal amount of information to avoid a negative payment adjustment in 2019 and potentially receive a positive payment.”

Furno is referring to the “Pick Your Pace” MIPS timeline for 2017, which gives providers time to get used to reporting requirements:

Path	Result
Don’t participate at all	4 percent negative payment adjustment in 2019
Submit some data	Avoid the penalty
Report on 90 days in three categories	Potentially earn a payment bonus in 2019
Report a full year of data for 2017	Potentially earn the maximum bonus

 

Report what you’re already doing well. “Clinicians are already doing a lot of the activities and metrics that are built into MIPS,” Furno says. “They just have to report it to make sure they’re getting credit.” 

Mark Oct. 2 on your calendar. For procrastinators, this is the last date to start collecting data to meet the 90-day reporting threshold for 2017, which puts providers in line for a payment bonus in 2019.

Even providers that are only planning to submit the minimal amount of data should mark Oct. 2 on their calendars. Most MIPS metrics involve collecting data for a sizable number of patients, which may take weeks to months. “I don’t want physicians to think that on Dec. 31 they can take one patient’s hemoglobin A1c, and that will count for MIPS reporting,” Furno says. 

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How well do you know QPP acronyms?

Match the acronym with the description:

1. QPP	a. Alternative payment models that involve taking on two-sided financial risk.
2. MACRA	b. Medicare's pay-for-performance program that gives eligible clinicians bonuses or penalties based on how well they perform in four categories: quality, cost, improvement activities and advancing care information.
3. MIPS	c. This 2015 law, passed with bipartisan congressional support, replaced the Sustainable Growth Rate formula with a new approach to physician payment that rewards the delivery of high-quality, cost-efficient patient care.
4. Advanced APM	d. This MIPS sub-track streamlines MIPS reporting for clinicians who participate in certain Medicare Alternative Payment Models or Advanced APMs but don’t meet various Centers for Medicare & Medicaid Services thresholds and requirements.
5. MIPS APM	e. The official name for Medicare’s new physician payment program.

 Answers: 1 = e; 2 = c; 3 = b; 4 = a; 5 = d