Readers Write: How Will MACRA Impact Physician Compliance in 2017?

How Will MACRA Impact Physician Compliance in 2017?
By Michael Nusimow

Up until now, providers and practice groups have been worrying about Meaningful Use and using their own certified EHR technology to avoid payment penalties, earn incentives, and increase practice efficiency. With the release of the final MACRA rule, physicians now have two options for payment paths: Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). MIPS is the consolidation of many different programs and regulations in an effort to simplify reporting and achieve goals that include better health outcomes for patients. Programs that will roll up into MIPS include the Physician Quality Reporting System (PQRS), Value-Based Payment Modifier (VBM), and MU, along with the new requirements of showing clinical practice improvement activities.

APMs is the alternative, in which providers can reach out to the AMA and their board specialties to help determine the best way to structure their care to meet the requirements. Following the APM path exempts a provider from the MIPS pathway.

More Background on MIPS

Providers should be aware that PQRS does and will eventually tie into MIPS. CMS will look at some specific key clinical practice activities. These will be the "measures" and/or key performance indicators that providers need to think about during the transition. Clinical practice improvement activities includes processes such as:

• Expanding access to your practice.
• Coordinating care, such as with phone and digital communications.
• Engaging with patients in active care plan participation and shared decision-making.
• Prioritizing patient safety.

Key Dates to Keep in Mind

MACRA went into effect on January 1 (the start of the reporting year) and continues through December 31, 2026, replacing the Sustainable Growth Rate Formula. In 2018, physicians can potentially expect another transition year of reporting and, in 2019, benchmarks and reporting will start to substantially affect reimbursements.

Does This Apply to Physicians?

Prior to 2017, you had to figure out what you qualified for and were required to report based on your specialty, practice setup, and volume of claims made to CMS. For 2017, a low-volume threshold has been set at less than or equal to $30,000 of claims to Medicare Part B and / or less than 100 Medicare patients. Passing over either of these thresholds will qualify you for 2017 reporting.

CMS, in addition to the threshold, has considered the risk to solo and small group practices in making a new reporting group called “virtual group” to allow them to report together. This option is not available for 2017; more information is expected in the future. For practices that are in rural, need-based areas or that are 15 or more providers in a group, additional resources may be available.

How can Physicians Start to Prepare?

A few important points to keep in mind:

• Don’t bury your head in the sand – start communicating with your professional associations to compare and determine how other providers are preparing and how your practice – based on specialty and size – will be affected.
• Be sure to stay tuned to regular updates from CMS and your EHR vendor.
• Providers might be able to opt out of attesting data in 2017, but will receive negative adjustments in 2019. Special assistance and accommodations will be made available to providers in rural settings and larger practice groups.
• Providers can choose between a 90-day and full-year reporting period. Note that most choices of reporting weight bonuses and penalties. MIPS is a program that will work to encourage providers to adopt quickly and with few loopholes or delays.
• PQRS data will be published and used as benchmarks for 2017.
• Providers will not be evaluated on cost or resource use during the first year. Providers are encouraged to track this to help them determine the progress, baseline, and areas of improvement.
• Work closely with your EHR vendor to ensure you understand how to use the product effectively and efficiently – reporting information is only beneficial when it is calculated correctly.
• Even if your EHR is not calculating or ready to start calculating for MACRA in the beginning of 2017, using your EHR correctly will be vital to ensure calculations are useable at a later date.

Common mistakes for larger practices to avoid include:

• Sharing logins: This is not just a HIPAA violation. It will also cause inaccurate credit and penalties to be applied to patient charts and provider calculations. Individuals at the practice should have their own login.
• Starting/signing charts: If your EHR allows charts to be started by one provider and signed off on by another, it is important to understand how that EHR is applying credit and that the appropriate providers are participating as their scope allows.
• Staying up-to-date: Larger practices that fall behind play a constant game of catch up that make it difficult to record all of the necessary information to increase earning potential. Entering backdated information runs the risk of the EHR not calculating information correctly or it being entered inaccurately.

Final Thoughts

MACRA and MIPS will change the dynamic of many compliance measures, but promises to simplify all recent measures in healthcare to create a value-based healthcare model. Updates on the guidelines will continue to be published from CMS. Make sure you continue to look out for any future updates.

Michael Nusimow is CEO and co-founder of Drchrono in Mountain View, CA.

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News 1/4/17

Top News

Athenahealth will increase its Atlanta-based workforce to nearly 1,000 over the next 12 months alongside a planned office expansion that will double its footprint at mixed-use development Ponce City Market. The Watertown, MA-based company opened its Atlanta office in 2013 with 500 employees, and has since surpassed its initial employee growth rate by 40 percent. The news comes just a few months after the company laid off 40 employees in Atlanta and 102 in San Francisco.

HIStalk Practice Announcements and Requests

HIStalkapalooza sign-ups are open. The usual rules apply:

• Everybody who wants to come has to sign up on this form (even me) – nobody gets invited automatically.
• Each person who wants to come has to sign up separately even if they’re a guest of someone else (because we use an automated check-in system with individually barcoded tickets),
• Signing up doesn’t guarantee that you’ll get an invitation since that depends on how many people I can invite, which is based on how many sponsors I get. Invitations will be emailed in three weeks or so.
• We pay per click of the House of Blues turnstile and thus close the doors early in the evening since someone swinging by for a late-evening beer still costs many dozens of dollars. If you can’t attend the whole event, please don’t take up a slot.

Thanks to our HIStalkapalooza sponsors who are graciously making the industry’s most talked-about event possible. Mr. H needs need a few more to hit the break-even point. Contact Lorre if you’re interested and she’ll work with you to create a fun sponsorship package for the party.

Webinars

January 18 (Wednesday) 1:00 ET. “Modernizing Quality Improvement Through Clinical Process Measurement.” Sponsored by LogicStream Health. Presenters: Peter Chang, MD, CMIO, Tampa General Hospital; Brita Hansen, MD, CHIO, Hennepin County Medical Center. The presenters will describe how they implemented successful quality governance programs, engaged with their health system stakeholders, and delivered actionable information to clinical leadership and front-line clinicians. Q&A will follow.

January 26 (Thursday) 1:00 ET. “Jump Start Your Care Coordination Program: 6 Strategies for Delivering Efficient, Effective Care.” Sponsored by Healthwise. Presenters: Jim Rogers, RN, RPSGT, director of healthcare solutions, Persistent Systems; Charlotte Brien, MBA, solutions consultant, Healthwise. This webinar will explain how to implement a patient-centered care coordination program that will increase quality as well as margins. It will provide real-world examples of how organizations used care coordination to decrease readmission rates, ED visits, and costs.

Acquisitions, Funding, Business, and Stock

Several media outlets report that Walgreens is piloting a vision clinic at its flagship store on Chicago’s Miracle Mile. The Boots Alliance company is looking to replicate the success of its chain of 636 retail vision clinics in the UK, some of which operate as standalone businesses.

Rock Health releases its end-of-year digital health funding report. A record number of companies were funded in 2016, yet the total amount invested saw an 8-percent decrease to $4.2 billion. Most-funded categories included genomics and sequencing, big data and analytics, wearables and biosensing, telemedicine, digital medical devices, and population health management. Mergers and acquisitions were up 9 percent year-over-year, with Teladoc’s acquisition HealthiestYou and Allscripts’s Netsmart purchase likely being of the most interest to office-based physicians.

Telemedicine

The Pew Charitable Trusts looks at the expanding use of telemedicine in public schools, pointing out that nearly 20 states have authorized Medicaid reimbursement for such visits. Ninety-eight percent of students in Maryland’s Howard County schools, which began offering virtual consults in 2015 with the help of one local hospital and two private practices, have been able to immediately return to their classes after a telemedicine visit for non-contagious conditions during school hours.

People

Hoangmai “Mai” Pham, MD (CMS Innovation Center) joins the Duke-Margolis Center for Health Policy as a senior policy fellow.

Physician consulting firm Continuum Health Alliance hires David Kovel (Sage Growth Partners) as CIO, Andrew Christman (ZirMed) as GM/SVP of performance solutions, and John Juzaitis (Medfusion) as VP of commercial operations.

Announcements and Implementations

CompuGroup Medical US adds real-time genomic decision support tools from ActX to its WebEHR and Clinical EHR products. The addition will enable CGM users to check prescriptions for adverse reactions, dosing, and efficacy based on the full genomic profile incorporated into a patient’s chart. The only caveat seems to be the “affordable patient DNA testing” that would need to occur beforehand – a practice that will likely grow in popularity based on the success of consumer offerings from 23andMe and Ancestry.com. (My genealogy-obsessed mother literally screamed with delight when I gave her a DNA testing kit for Christmas.) As a patient, I’d be much more likely to engage in such a service if it were offered to me at the point of care.

Newly opened West Sacramento Urgent Care (CA) goes live on Practice Velocity’s EHR and billing services.

Government and Politics

AHRQ announces a new funding opportunity for research that shows how health IT can improve “patient-centered health outcomes and quality of care in primary care and other ambulatory settings through the scale and spread of successful, health IT-enabled practice models that use patient-reported outcome measures to achieve these objectives.” Interested organizations can start applying January 25.

Research and Innovation

I can’t believe it’s 2017 and we’re still talking about patient portal problems: A Black Book survey of just over 12,000 consumers finds that 96 percent of patients have left their office visit with patient portal instructions that were either poorly communicated or miscommunicated. Forty percent have tried to use their physician’s portal; 83 percent of those report finding it difficult to navigate from their home devices – a stat that in my mind points to the need for greater usability that caters to a wide swath of patient types. (Mr. H points out a number of other revealing health IT adoption stats here.)

Other

Scientific American makes the case for a cashless society, pointing out the many different types of bacteria found on bank notes and coins. American bills – a blend of cotton and linen – are particularly susceptible to picking up and carrying microbes from “a cocaine-sniffer’s nose to a waiter’s hands to someone’s back pocket.” Fun fact: Global studies of cash have found exceptionally high bacterial counts on money handled by food workers or on hospital grounds.

Sponsor Updates

• Aprima employees donate over nine tons of food to Dallas-area families in need through Metrocrest Services.
• AdvancedMD compiles its most popular e-guides and videos from 2016.

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News 1/3/17

Top News

Several trade associations quickly weigh in on the Senate’s introduction of a timeline to repeal the ACA. MGMA President and CEO Halee Fisher-Wright, MD assures incoming lawmakers that the association will work with them if the resolution introduced by Senator Mike Enzi (R-WY) comes to pass. “Many elements of the ACA can be amended and improved with an infusion of new ideas,” she writes in what I assume is an unsolicited statement to President-elect Trump. “As Congress considers legislation that impacts the policies or financial underpinnings of the ACA, it should – above all – minimize disruptions to the nation’s healthcare delivery and payment system during any transition.” Minimizing disruptions is all fine and dandy, but I believe ensuring quality (and dare I add affordable?) patient care should be a Congressional priority – above all.

Not to be left out, AMA President James Madara, MD also penned a missive to congressional leaders stressing the need to clearly outline any steps being considered as part of an ACA overhaul, especially policies related to healthcare coverage. He stresses that, “Patients and other stakeholders should be able to clearly compare current policy to new proposals so they can make informed decisions about whether it represents a step forward in the ongoing process of health reform.”

Webinars

January 18 (Wednesday) 1:00 ET. “Modernizing Quality Improvement Through Clinical Process Measurement.” Sponsored by LogicStream Health. Presenters: Peter Chang, MD, CMIO, Tampa General Hospital; Brita Hansen, MD, CHIO, Hennepin County Medical Center. The presenters will describe how they implemented successful quality governance programs, engaged with their health system stakeholders, and delivered actionable information to clinical leadership and front-line clinicians. Q&A will follow.

January 26 (Thursday) 1:00 ET. “Jump Start Your Care Coordination Program: 6 Strategies for Delivering Efficient, Effective Care.” Sponsored by Healthwise. Presenters: Jim Rogers, RN, RPSGT, director of healthcare solutions, Persistent Systems; Charlotte Brien, MBA, solutions consultant, Healthwise. This webinar will explain how to implement a patient-centered care coordination program that will increase quality as well as margins. It will provide real-world examples of how organizations used care coordination to decrease readmission rates, ED visits, and costs

Announcements and Implementations

India-based RCM vendor ITech Workshop adds patient appointment scheduling capabilities to its billing and PM software.

Cytta upgrades its remote patient monitoring technology to operate on the Oracle Cloud via the company’s VeriSmartPhone technology.

Acquisitions, Funding, Business, and Stock

Charlotte, NC-based startup Tesser Health secures $470,000 in seed funding from a group of investors led by Cofounders Capital. The seven-employee company, which will use the cash to build out its sales team and move into new office space, has developed software that helps employee benefit companies identify cheaper prescription drug options. I’m especially interested in news related to prescription drug pricing thanks to a recent virtual consult that ended up with my MD prescribing $200-plus ear drops that had no generic version available. On the advice of my pharmacist, who also tried to help me find online manufacturer coupons for the drug, I called back to request a different, cheaper medication. The NP who facilitated the second, far less expensive prescription half-jokingly told me that doctors “sometimes have to be nudged” into prescribing generics.

People

Staffing company Supplemental Health Care hires Mary Lucas (Staffmark) as chief talent officer and Donna Carroll (North Highland) as chief sales officer. The Park City, UT-based firm has promoted Missy Blankenship to president of local offices; Monty Houdeshell to chief financial and administrative officer; and Chris Long and Linda McDonnell to SVP of nurse operations and travel nursing sales, respectively.

Telemedicine

EarlySense adds American Well virtual consult access to its wireless home-monitoring technology, which includes the new Live under-the-bed sensor that monitors and analyzes heart, respiratory cycles, stress, and sleep indicators.

New York-based payer MVP Health Care begins offering telemedicine services (including mental health consults) from American Well to its members in New York and Vermont this week. Chief Executive Denise Gonick believes the nonprofit is the only health plan that offers virtual visits to Medicaid beneficiaries.

Research and Innovation

A new survey from payer-focused health data company Healthmine highlights the ongoing disconnect between the plethora of digital health tools available to consumers and their ability to incorporate them into health and wellness programs. Of the 2,500 health plan members surveyed, 75 percent are willing to share health data collected via apps but only 32 percent report this happens automatically. Though 60 percent of consumers access their EHRs to stay informed, just 22 percent use that digital data to make healthcare decisions – a stat that belies the need for more discussion between physician and patient on the role, if any, such tools can play within a particular practice. Most surprising to me is the fact that 39 percent of those surveyed – all users of digital health tools – have never heard of telemedicine. Perhaps I have lived in my health IT bubble for too long …

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Jenn, Mr. H, Lorre

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Readers Write: Five Predictions for Virtual Care in 2017

Five Predictions for Virtual Care in 2017
By Ralph Derrickson

The New Year is upon us, as is a soon-to-be new administration, a move from fee-for-service to fee-for-value, and increased patient interest in healthcare convenience – all of which could make 2017 a very interesting year for the healthcare industry. What exactly can we expect? There are few certainties, but we have enough information, looking at existing trends, to make some predictions for the coming year.

Consumers Assume Greater Costs and Greater Responsibility

There is little doubt that health plans will become more expensive for patients, as they are asked to take on higher deductibles, accelerating the consumerization of healthcare. Assuming ever greater responsibility for their own healthcare, consumers will seek additional care options and compare related costs. More consumers are becoming increasingly active in their education and healthcare decision-making. It’s essential that physicians prepare for this changing landscape by providing support for cost-conscious patients including strategic pricing options, convenience, and ease of access.

A recent American Telemedicine Association survey of active healthcare consumers revealed that convenience remains the top motivator behind their demand for telehealth services. I predict that greater telemedicine access in 2017 will shift patient thinking to recognizing telemedicine as a cost-conscious option – not just one of convenience.

Value-based Care Will Shape Virtual Care

This year will be the first in a giant shift to value-based payment models through MACRA, which will in turn highlight the need for cost-effective measures focused on quality metrics. At the same time, MACRA will drive physicians to look for solutions to expand practice access. MACRA encourages physicians to focus on the whole patient, providing new guidance on health records tracking and improving population health management. MACRA will also mean pushing the envelope on innovation and new care delivery models. In this new value-based care landscape, integrated telemedicine will offer a new care delivery model that addresses access issues. Configurable EHR integration and population health management will make telemedicine a natural and agile response to MACRA requirements.

Retail Clinics Create Stiffer Competition and Greater Fragmentation

Physicians will face greater competition as more retail and non-health system organizations look to attract patients through direct-to-consumer advertising. A consumer walking into a familiar pharmacy will bring routine retail habits to their interaction with affiliated clinics. This will make them likely to use a convenient option operating in affiliation with a comfortable retail brand, without thought of how that option impacts their larger relationship with their physician.

The retail clinic market will continue to make services even more convenient for consumers, leading to greater competition in local markets; but it will also lead to greater care fragmentation. To compete, physicians will need to adopt and promote integrated telemedicine services that provide 24-7, on-demand access. Digital marketing, value differentiation, and healthcare brand affinity will be increasingly important as physicians compete to keep current patients and attract new patients looking for greater ease of access.

New Legislation Drives Increased Telehealth Reimbursement

The number of states with telemedicine-reimbursing parity laws has almost doubled in the last three years, reflecting legislative understanding of the coverage barrier to telemedicine. With many state medical boards across the country enacting or considering increased requirements for virtual care, legislation on virtual care reimbursement will become more commonplace. As new rules and legislation are considered, telemedicine providers must work with state medical boards to ensure that patients receive the highest quality of care.

Greater Employer-based Health Plan Coverage for Telemedicine

In 2017, the National Business Group on Health estimates that 90 percent of employers will make telemedicine services available to employees in states that allow it. This is a significant increase over the 70 percent of employers who currently offer virtual care to their employees. This is further evidence that employers are ready to throw their weight behind patient preference for convenient healthcare options. Employers realize virtual care is central to meeting this demand while improving outcomes, managing costs, and minimizing the wait time burden of in-person visits.

I expect that increased health plan coverage for telemedicine in 2017 will increase national rates of telemedicine utilization as more patients gain access. I also foresee greater demand for virtual-care training for providers who are entering the digital clinic space.

At the end of 2017, we can be certain that innovation in healthcare will be driven by the needs of patients, that care quality will always be paramount to technology – virtual or otherwise, and that, like its predecessor, the year will be one of continued changes in healthcare.

Ralph C. Derrickson is president and CEO of Carena in Seattle.

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Readers Write: Survey Says – Independence Trumps Hospital Employment

Survey Says: Independence Trumps Hospital Employment
By Lea Chatham

There has probably never been as much uncertainty about the future of healthcare as there is right now. On the heels of the release of the MACRA final rule came the unexpected results of the presidential election. The President-elect has made it clear that he will make changes to the Affordable Care Act, which has been the law of the land for nearly eight years. And MACRA solidifies the industry shift away from fee-for-service to value-based care.

It might seem like with all these challenges, independent physicians would be looking to shift to employment, but the opposite seems to be true. There actually appears to be a slowdown in employment as physicians look for ways to stay in independent practices.

According to the AMA, only 33 percent of physicians currently work in hospitals or hospital-owned practices. The other 67 percent are in private practice, with 60 percent in practices of 10 physicians or less. Half of the physicians in private practices are owners or co-owners of the practice. While that means the other 50 percent are employed, they are working in private, independent practices, and they do find that more satisfying than hospital employment. A recent survey from MedData Group showed that 80 percent of physician owners and 61 percent of employed physicians strongly or somewhat agree that private practices offer satisfying career opportunities.

That same study also showed that 20 percent of employed physicians are considering owning their own practice in the future. This makes a lot of sense when you consider that self-employed doctors have higher satisfaction then employed doctors, according to Medscape. The same survey also showed that 71 percent of doctors said their work satisfaction improved when they left employment.

And it turns out that the physicians who are already owners or co-owners are loathe to sell out or close. Seventy-three percent of practice owners said they would prefer not to sell their practice. Seventy-two percent of practice owners said they envision a significant number of physicians who have been employed returning to independent practice.

“We have seen this trend firsthand,” says Kareo CMIO Tom Giannulli, MD. “In 2015, 15 percent of our new customers were starting new independent practices, and that has remained steady.” He adds that a recent survey of customers about MACRA showed that 85 percent are planning to participate to the best of their ability and only 2 percent are planning to speed up retirement or close or sell their practice. “What this tells me is that they are willing to tackle the challenges to stay in private practice,” he explains.

Giannulli has also been watching a growing trend of independent practices testing alternate payment models, which he attributes to their ability to be more agile and flexible in the way they practice. The 2016 Practice Models Perspectives survey, sponsored by the American Academy of Private Physicians, showed that 25 percent of physicians are already using some form of concierge, direct pay, or membership model in their practice; and another 35 percent are interested in trying something like that as well. The most striking finding of the survey was that most practices testing these models are not making a complete change. Only 30 percent are using a direct pay or membership model with all of their patients. The majority are using these models with only a portion of their patient population.

“They are trying out these options to see how they work and if they help reduce health plan and government program challenges,” says Giannulli. “The survey also showed these practices were more likely to be trying telemedicine and looking to potentially increase virtual visits.”

The nature of smaller independent practices makes it easier to try new payment models, test out new technologies, and either keep moving if it works or try something else if it doesn’t. Considering this and looking at all the latest trends, we may actually begin to see the slowdown turn into a reversal with more physicians choosing independent, private practices over hospital employment in the coming years.

Lea Chatham is an editor at Kareo in Irvine, CA. 

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