The Michigan Rheumatism Society’s (MRHS) 2016 Educational Meeting featured a well-rounded agenda of presenters on topics ranging from federal payment legislation updates to patient satisfaction and practice management.
MACRA IS COMING
A packed house at the Westin Southfield Detroit Hotel heard an update on health care policy trends from Michael Schweitz, MD, president of the Coalition of State Rheumatology Organizations (CSRO), focusing on the Medicare Access and CHIP Reauthorization Act of 2015, better known as MACRA.
MACRA replaced the troublesome Sustainable Growth Rate (SGR) formula as a method for physician payment through Medicare. “The SGR was enacted as part of the Balanced Budget Act of 1997,” said Dr. Schweitz. “It determined reimbursement to providers and was tied to the gross national product and to a lot of other things that should not have been in the formula. It did not take long for physicians and for legislators and policy makers to realize it wasn’t going to work.”
“I thought it was a pretty rotten deal, but the alternative was to take huge cuts in Medicare reimbursement under the SGR,” said Timothy Laing, MD, who spoke about alternative payment models at the meeting.
In the ensuing years, the cost of providing services rapidly escalated and far outpaced adjustments from the SGR formula. The result was annual eleventh-hour appropriations from Congress to temporarily “fix” the broken formula. But each year the gulf between the formula’s indicated payments and the cost of providing services continued to grow.
Under MACRA, physicians will be financially rewarded or penalized based on how well they meet quality measures that will eventually be based on clinical outcomes, time spent with patients, adopting and employing new technology and clinical practice improvement activity. The new program will be called MIPS, or the Merit-based Incentive Payment System. Bonuses/penalties begin at plus or minus 4 percent in 2019 and scale up to plus or minus 9 percent in 2023.
Physicians will have an option to participate in “Alternative Payment Models” (APMs) rather being reimbursed under MIPS. Accountable Care Organizations are the most recognized APM and reward physicians based on their increasing participation in a qualified program that targets quality and outcomes.
In the meantime physicians will be reimbursed beginning in 2017 using a formula called the Value Based Payment Modifier, which is based on 2015 claims data provided by physicians through existing reporting channels. It rewards physicians based on how they compare to their peers.
Dr. Schweitz also addressed a new Medicare reimbursement plan for Part B drugs—those drug treatments administered by providers, including biologics used by rheumatologists to treat rheumatoid arthritis (RA).
Currently, Part B drugs are reimbursed at Average Sales Price (ASP) plus 6 percent. A proposed plan emerging from the Centers for Medicare and Medicaid Services (CMS) Innovation Center calls for reimbursement at ASP plus 2.5 percent with a flat fee payment of $16.80 per day, per drug. Ultimately, CMS intends to use a variety of strategies to reduce the cost and increase the effectiveness of Part B drugs, including reference pricing (comparing the cost of drugs to other, related drugs), risk sharing based on outcomes negotiated with drug manufacturers, clinical evaluation analysis by CMS and comparing the effectiveness of certain drugs versus others, again, analyzed by CMS.
Dr. Schweitz said the CSRO has a number of concerns with the proposed CMS policy. He said the new policy focuses exclusively on the cost of Part B drugs, there is little consideration of quality of care and patient safety, analysis is limited to secondary data sources and there is inadequate economic impact analysis.
He also remarked that physicians were not consulted during the formation of the new policy.
CSRO engaged CMS earlier this year to press the agency to withdraw the rule. CSRO also pressed the issue with legislators via letters and in-person visits.
ALSO HEARD AT THE SPRING EDUCATIONAL MEETING
THE TRIPLE AIM
Leonard Fromer, MD, educated members about the National Committee for Quality Assurance (NCQA) Triple Aim initiative. The program focuses on reducing costs, improving the health of populations of patients and improving the “experience of care” for the patient.
The program shifts the focus from the physician’s office to the patients’ needs. Dr. Fromer, who practices family medicine in California, explained that in the old days, a patient would have been released from an acute visit to a hospital and might not get an appointment with him for six months; today, that patient gets seen within 48 hours—and at the patient’s convenience.
That was just one example of the new focus offered under Triple Aim guidelines http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx that illustrates the emphasis of medical practice processes targeted toward patients.
Changes in physician manner to better serve patients are also part of the plan. Physicians are guided toward making eye contact, smiling and shaking hands as well as asking open-ended questions rather than the “yes/no” variety and encouraged to use motivational communication.
Dr. Fromer said the change in focus fostered by Triple Aim has concrete foundations in data: “I’m not blowing smoke. I am telling this from data we collected from almost 250,000 providers in 35,000 practices. They give us feedback. We do surveys and their scores are skyrocketing. But the best thing I can tell you is what’s happening in those practices, the people in the white coats and the teams that support them. Turnover rates drop to near zero. People don’t leave. They love working in that environment. The doctors, PAs and nurse practitioners, and the teams supporting all of us, they don’t leave. That’s how we know it works.”
The Triple Aim program continues to evolve and refine concepts. “The Triple Aim has now become the Quadruple Aim. What is that plus one? We talked about patient does well with their conditions, they have a great experience in the care process as it’s happening and we bring down the cost. The fourth piece is that we have to have a great experience when we show up for work every day. That’s the fourth piece, the health care team’s experience. If that’s not terrific, then how are we going to sustain it?” asked Dr. Fromer.
Jay Salliotte, AB, MBA, addressed in detail workflow and process issues that help the rheumatology practice he manages run smoothly. He emphasized getting and re-confirming prior authorization from insurers to avoid delays when patients come in for therapy. He also discussed increasing patient responsibility by asking patients to actively participate in rebate programs offered by drug companies to keep patient costs down.
Rounding out the agenda was a presentation on “Integrating Quality Measures for Rheumatoid Arthritis Into Your Practice,” by Puja P. Khanna, MD, MPH.