Progress Toward Value-Based Care and Better Measures

The passage and implementation of MACRA, or the Medicare Access and CHIP Reauthorization Act, famously repealed the sustainable growth rate, but more importantly it gave the government the opportunity to develop a new program and begin incentives to move physicians into alternative payment models (APMs), Kate Goodrich, MD, director of the Quality Measurement and Value-Based Incentives Group in CMS, explained during the Annual Meeting of the Pharmacy Quality Alliance.

MACRA has taken 3 existing quality reporting programs and streamlined them into the Merit-Based Incentive Payment System (MIPS). According to Goodrich, MACRA has given the federal government a fresh start when it comes to paying for value.

“It’s not that clinicians didn’t want to provide that care,” she said. But “the programs had not been designed to be very user friendly. The benefit of quality reporting didn’t outweigh the cost of burden.”

Goodrich used her session to outline the various aspects of MACRA. Under MACRA, physicians have the option to choose one of 2 paths that link quality to payments: MIPS and advanced APMs.

Advanced APMs have additional criteria that need to be met, such as use of certified electronic health record technology and either the APM has to bear more nominal financial risk or it can be an expanded Medical Home Model.

In addition, MACRA provides additional rewards for physicians participating in APMs and those in advanced APMs are eligible for a 5% lump sum bonus that those in MIPS are not eligible for.

“It does get really complicated very fast,” Goodrich admitted. “It has been challenging to define the policies so they are understandable to clinicians and others.”

And while people are worried that MIPS is going to be difficult to follow, Goodrich said that the reporting under MIPS won’t be very different from any reporting physicians were already doing under Physician Quality Reporting System.

“Just report as much as you’re doing and we’ll calculate it on the backend,” she said. “50% of your score is just for recording it. The other 50% can be reached multiple different ways depending on what makes sense for your practice.”

After Goodrich’s presentation she was joined on stage by Matt Salo, executive director of the National Association of Medicaid Directors; William Fleming, PharmD, president of Humana Pharmacy Solutions at Humana; Helen Burstin, MD, MPH, chief scientific officer of the National Quality Forum (NQF); and Peter Wickersham, MSE, executive pharmacy officer and vice president of health services operations at Blue Cross Blue Shield of Minnesota.

Salo started the discussion by explaining that each stakeholder—patient, provider, plan, payer—needs to start thinking differently about how they engage in the healthcare landscape. As someone representing Medicaid directors, he noted that it is important to get the system to provide incentives around social determinants of health so patients can get health and stay that way.

“We have to figure out a way that the healthcare system is going to be able to maintain business models and profit margins for doing the right thing,” Salo said.

During the journey toward quality, pharmacy cannot be overlooked, Fleming said. The current environment with inflation, the specialty drug explosion, and new and innovative, but expensive, drugs coming to market, means finding the right patient, the right drug is important.

Wickersham added that pharmacy is not necessarily integrated into quality measures, and changing that is one of the biggest opportunities available to healthcare. Pharmacy and medical grew up separately, he said, and now connecting the 2 areas is critical for success.

Goodrich and Burstin discussed the Core Quality Measures Collaborative, which was headed by CMS and America’s Health Insurance Plans with involvement from other organizations, including NQF. The Collaborative released 7 sets of core quality measures to cut down on some of the noise in the market.

“It’s great this alignment is happening,” Burstin said. She added that there had been too much emphasis on lookalike measures when there shouldn’t have been additional energy spent on creating measures that were slightly tweaks. “We need to focus on the gaps.”

Goodrich agreed and said that the Collaborative shouldn’t be afraid of getting rid of the measures that aren’t working. And she pointed out that one of the gap areas noted during the creation of the 7 core sets was that there were not good measures that address the pharmacy space well.

“The scope of this effort was really around what is out there with a lot of discussion about what there needs to be,” Goodrich said. She added, “There was discussion around medication management and medication reconciliation measures.”