Can ACO Partners Help Physicians Meet the New MACRA Requirements?

Are physicians aware of the changes that will follow the implementation of CMS’ recently released Medicare Access and CHIP Reauthorization Act (MACRA)? How can physicians prepare for what’s coming in 2017? These were some of the topics discussed during a panel on MACRA and other value-driven changes, on the second day of the Fall 2016 ACO & Emerging Healthcare Delivery Coalition.

Participating in this insightful discussion were Travis Broome, MPH, MBA, health care policy lead, Aledade, Inc; James Daniel, Jr, director HDJN; Kate Goodrich, MD, MHS, director, Center for Clinical Standards and Quality, CMS; and Katherine Schneider, MD, MPhil, FAAP, president and chief executive officer, Delaware Valley Accountable Care Organization.

Broome said that a lot of the adoption to MACRA comes from just being aware about its existence. A lot of practices already have partners, such as electronic health record (EHR) vendors, he said, adding, “A lot of it boils down to ‘What am I being scored on and why?’ And for most physicians, it will come down to their partnership with data registries, EHR vendors, and others.”

“When the final rule came out, we were a little disappointed because we have been explaining to our practices what MACRA and [Merit-based Incentive Payment System, MIPS] changes are and how it affects them,” Schneider said. “We have been coaching them and ensuring that the data they gather reaches the right place. But, if losers pay the winners [as might happen with the final MACRA rule], then the curve got a lot narrower. Holistically though, it is the right thing to do.”

Explaining some of the nuances of the new law, Goodrich informed the audience that the final ruling was designed very much with the smaller practices in mind. “We understood that those who had not participated in current programs will participate. So we wanted to design it so that health systems and practices could have a test year without a financial risk.” She warned, however, that the final rule is full of trade-offs, one of which is that high-performing practices will have positive earnings, “But we will not penalize those practices who at least tried,” she added.

“We have very much relied on physician partners like accountable care organizations (ACO), EHR vendors, and others…and we will continue to spend more time with them so they will continue to support our practices,” Goodrich said.

Meeting chair and panel moderator Anthony Slonim, MD, DrPH, CPE, FACPE, asked Goodrich whether the new law gave consideration to the fact that performance data from smaller ACOs was much better.

“We have data showing 87% of smaller practices were doing well, which is an important signal,” Goodrich said. “We definitely did a combination of a data-driven approach, spoke with the practices, and understood their pain points—a lot of our policies were informed based on this data we gathered. And this will remain a dynamic process,” she went on to add.

Schneider emphasized that the status quo will not work if practices aim to perform better. “If you are doing something different in your care model, you stand a better chance of performing better,” she said. “But you need to engage and modify the care model to actually perform better. It should definitely have patient care in the center.”

When asked whether she foresees a time when all this work will help sweep away existing barriers and create an entirely new approach in healthcare, Schneider said this is disruptive innovation. “In my experience, it’s easier to do this on a larger scale rather than work on small process changes. At that point you can look at not micromanaging processes but look at it more holistically since the process has been reengineered,” Schneider added. She acknowledged, however, that you need the constituent parts functioning adequately for the entire machinery to be operational.

“Over time, we envision that payments are distributed over the population and they will be risk-based,” Goodrich said. “While we would like to see MIPS evolve into the various categories, it's more the financial structure and physician payment that drives the process,” she added.

Slonim asked the panel to address the growing concern over high drug costs and how that will affect physician payments under MACRA.

While Daniel suggested a contractual model, Broome said it is important to decide on what is used for benchmarking. “Some of the more expensive drugs do work, but higher-quality care does not necessarily mean lower costs,” he said, and added that we need to start thinking in terms of higher-value care.

Citing the case of how their practices in the Philadelphia region do not have a standardized protocol to choose between 3 different drugs for macular degeneration, Schneider said, “If we can get our clinics to use practice patterns used by the lowest cost one, it could result in significant savings. She pointed out that the perverse incentives associated with drug price mark-ups proves a significant barrier to the process. “Behavior change is the key but it’s not very practical. Regulatory changes by CMS are it,” Schneider said.