Wait! Physicians are not ready for the QPP

Physicians expressed concern over their knowledge of and preparedness for Medicare’s Quality Payment Program (QPP) in a recent American Medical Association (AMA) and KPMG consulting survey. Only 10 percent of responding physicians expressed feeling deeply knowledgeable about the Medicare Access and Chip Reauthorization Act (MACRA) (P.L. 114-10) or the QPP and 90 percent of respondents indicated that they find the requirements of MACRA’s merit based incentive payment system (MIPS) to be slightly or very burdensome.

QPP

MACRA created the QPP, which, in January 2017, began marking the quality performance of physicians. In 2019, the program will make adjustments to physician payments under one of two tracks: (1) MIPS or (2) a 5 percent lump sum bonus payment if the physician has a threshold percentage of patients or revenue in an advanced alternative payment model (Advanced APM). Because little is known about physician preparation under the program, the AMA and KPMG conducted a survey to gauge physician readiness and knowledge. The survey of 1000 physicians was conducted between April 25 and May 1, 2017, prior to proposed updates to the QPP program released on June 30, 2017 (see Halfway through QPP ‘transition year,’ CMS proposes substantial changes, June 30, 2017).

Findings 

Only 51 percent of physicians expressed feeling somewhat knowledgeable about MACRA and the QPP. Seven in 10 respondents have begun preparation for QPP in 2017, however, of those respondents preparing for MIPS in 2018, only 65 percent reported feeling prepared. The vast majority of respondents—90 percent—indicated that they found MIPS’ requirements burdensome. The cause of that burden, for most respondents, was the time and cost associated with reporting. Physicians expressed specific concerns regarding the unknown financial ramifications of the program, with only 8 percent of respondents indicating they were very prepared for long-term financial success under the program.

Impact

The AMA and KPMG survey concluded that some impacts—time and complexity of reporting—impact physicians regardless of practice size, specialty, or previous reporting experience. Additionally, physicians across practice areas agree that long-term financial impacts remain uncertain and that the program would benefit from more APMs.

AHA asks MedPAC to slow its roll on MACRA proposals

The American Hospital Association (AHA) believes that changes to the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) (P.L. 114-10) should wait until more data is available from providers. In a letter to the Medicare Payment Advisory Commission (MedPAC), the AHA expressed concerns about several proposals, including assigning clinicians to groups, aggregating results at the local market level, and replacing most clinician-reported measures. The AHA also addressed rising drug costs, encouraging MedPAC to focus on the issue.

MedPAC meeting

The letter serves as AHA’s response to MedPAC’s January meeting, during which the commission discussed items to include in a report to Congress in June. MACRA created two payment systems, the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM), which are in the early stages of implementation by clinicians and hospitals. The January meeting involved discussion of several policy changes, including a MIPS redesign, which the AHA believes should be delayed until data and experience from these clinicians is available for consideration. The AHA noted that the first performance period for both programs began January 1, 2017, and that CMS views this as a “transition year” for MIPS.

Policy proposals

MedPAC proposed assigning clinicians to groups or regions and assigning an aggregate MIPS quality and cost performance score based on the performance of others in the community. The AHA believes that clinicians should be permitted to voluntarily collaborate, and that applying an aggregate score would be arbitrary. Additionally, the AHA proposes providing an option for hospital-based physicians to use the hospital’s CMS quality and resource use measure performance for MIPS. However, the association opposes the proposal to replace clinician-reported outcomes measures with CMS measures based on Medicare claims data. The AHA pointed out that claims data does not reflect a patient’s particular history, course of care, and risk factors, which would result in basing clinician performance on unreliable data.

The APM has an incentive payment designed to encourage participation in the model, rather than reward or penalize performance. MedPAC proposed only allowing participating clinicians to receive this incentive upon successfully achieving the APM’s goals. The AHA views such a change as a double reward or double penalty for participants, rather than compensation for the learning curve and resource investment required upon entering new payment models. The AHA also expressed concerns about the proposals intended to “balance” incentives offered for MIPS and APMs, believing that these proposals make MIPS less attractive than APMs, even though AHA members believe that MIPS is already a less attractive option.

Drug pricing

The AHA believes that changes to Medicare Parts B and D could alleviate some of the drug cost burdens borne by the federal government and beneficiaries. The AHA expressed several concerns about Part B drug payment policy solutions, fearing that these changes could penalize hospitals for price increases and shift the burden for high list prices onto physicians. However, the AHA supports MedPAC’s Part D proposals while offering proposals of its own: disallowing co-pay assistance cards, developing value-based payment arrangements, requiring rebates, varying patient cost-sharing, and issuing annual reports.

$100M allocated to help small practices use the Quality Payment Program

Congress, through the bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (P.L. 114-10), has recognized the importance of small and rural medical practices and provided funding for their assistance in navigating the new Medicare Quality Payment Program (QPP). To this end, CMS has announced the award of approximately $20 million to 11 organizations for the first year of a five-year program to provide on-the-ground training and education about the QPP. The program is for individual clinicians or small group practices of 15 or fewer clinicians. CMS also intends to invest up to an additional $80 million over the remaining four years of the program.

The Quality Payment Program

MACRA ended the sustainable growth rate formula, which threatened clinicians participating in Medicare with potential payment cliffs for 13 years. The QPP improves Medicare by helping practices focus on care quality. The QPP has two tracks to choose from: (1) the Advanced Alternative Payment Models (APMs); or (2) the Merit-based Incentive Payment System (MIPS). If a practice decides to participate in an Advanced APM, through Medicare Part B, it may earn an incentive payment for participating in an innovative payment model. If it decides to participate in MIPS, it will earn a performance-based payment adjustment.

A practice is part of the QPP in 2017 if it is in an Advanced APM or if it bills Medicare more than $30,000 a year and provides care for more than 100 Medicare patients a year. If a practice is below either threshold, it is not in the program. For MIPS, the practice must also be a physician, physician assistant, nurse practitioner, clinical nurse specialist, or a certified registered nurse anesthetist.

Training and education effort

The training and education contracts have been awarded to the following organizations: Altarum; Georgia Medical Care Foundation (GMCF); HealthCentric; Health Services Advisory Group (HSAG); IPRO; Network for Regional Healthcare Improvement (NRHI); Qsource; Qualis; Quality Insights (West Virginia Medical Institute); Telligen; and TMF Health Quality Institute.

These 11 organizations will provide hands-on training to help thousands of small practices, especially those that practice in historically under-resourced areas including rural areas, health professional shortage areas, and medically underserved areas. The training and education resources will be available immediately, nationwide, and will be provided at no cost to eligible clinicians and practices. The organizations will provide customized technical assistance to clinicians and practices. For example, clinicians will receive help choosing and reporting on quality measures, as well as guidance with all aspects of the QPP, including supporting change management and strategic planning and assessing and optimizing health information technology.

Other free training and education

CMS reports that thousands have received free training and education through webinars and in-person training from CMS staff since the QPP Final Rule was released last October (see MACRA final regulations reflect input from ‘months-long listening tour’, October 14, 2016).

In addition, every clinician in the QPP can receive in-person training through the established Quality Innovation Networks, the Transforming Clinical Practice Initiatives, and the Alternative Payment Model Learning Systems.

HHS provides funding for training small practices in Quality Payment Program

HHS will provide $20 million in funding that will be used to train Medicare clinicians in small practices on the Quality Payment Program. These funds will be primarily directed toward clinicians practicing in underserved areas, including rural areas and health professional shortage areas. This amount of funding will be provided annually for the next five years.

Quality Payment Program

The proposed Quality Payment Program would implement the changes created by Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which reformed clinician payment for serving Medicare patients. The proposal streamlined various value and quality programs into two paths. Under the program, physicians would be able to choose from the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs) (see Physician reporting streamlined, less burdensome under flexible Quality Payment Program, Health Law Daily, April 28, 2016).

Under MIPS, physicians would submit information about four performance categories. Then, a composite performance score is generated and compared against a threshold. This threshold determines the payment adjustment. Under APMs, physicians would receive a lump sum payment that could grow annually.

Small practices

Secretary Burwell emphasized the administration’s commitment to providing resources to small and rural practices that will allow them to provide quality care. Organizations must show that they are able to provide training to individual clinicians or small group practices of no more than 15 clinicians to become eligible for funding. The training would include creating a strategy for Quality Payment Program participation, such as adding electronic health record (EHR) capability, joining an APM, and evaluating practice workflow.