It’s kind of like spinning the “Wheel of Fortune” and trying to avoid the “Bankrupt” spaces. Or playing Monopoly where your opponent starts the game owning both Boardwalk and Park Place, you start the game in jail, and to get out, you must consult the rulebook for particular combinations of doubles you must roll and fines you must pay.
What the Quality Payment Program (QPP) lacks in simplicity, it makes up for in deck-stacking. After three years of physician participation, Medicare’s quality program to drive value-based care continues to generate confusion, frustration, and worry that it’s only going to swallow up more physicians in its complex and financially punitive gameplay.
The program’s requirements are getting more complicated. Small and rural practices face disadvantages with little recourse. And recent statistics show physicians are leaving independent practice at an accelerated rate, with bureaucratic requirements like quality reporting often cited as a big reason why.
As the QPP enters its fourth year in 2020, the Texas Medical Association, American Medical Association (AMA), and other segments of organized medicine continue to warn Medicare that the QPP is more burden than boon. But as a new performance year begins, the Centers for Medicare & Medicaid Services (CMS) seems largely determined to stay the course, raising questions about just how taxing QPP might become for practices.
“The government is not even the 800-pound gorilla; they are really Godzilla. They make the rules,” said internist Robert E. Jackson, MD, medical director of the Houston Methodist Physicians’ Alliance for Quality, a collaboration of practitioners who participate in quality programs.
“Organized medicine like the TMA and the AMA is so important to have a voice at the table with CMS. I do have concerns [that] as the complexity increases, the administrative burden, of course, increases,” he said.
In response to written questions, CMS told Texas Medicine that it has “worked to develop a fair set of reporting requirements and scoring systems, but is always looking for ways to improve.” It touted “flexibilities that we have created for the Quality Payment Program, especially within MIPS,” citing a 98% participation rate in 2018. (See “QPP by the Numbers,” page 22-23.) CMS also said, “the initial years were a period for clinicians to build capacity, become comfortable with the system, and engage in quality and cost improvement.”
A game of risk
But even though CMS has painted a rosy picture of the program’s overall performance – based on a limited amount of information released – medicine remains skeptical.
The acronym-steeped QPP features two avenues of participation: The Merit-Based Incentive Payment System (MIPS) or an advanced alternative payment model. A “low-volume threshold,” based on physicians’ and other clinicians’ Medicare billings and services, determines whether they must participate in the program or are exempt.
A top concern: The program’s reporting measures hold physicians accountable for outcomes outside their control and inadequately adjust for such risk, TMA has told CMS. (See “Out of Physicians’ Hands,” December 2019 Texas Medicine, pages 30-34, www.texmed.org/OutofPhysiciansHands.)
For instance, the Cost category – one of four weighted categories that determine a participant’s overall MIPS score out of a possible 100 points – doesn’t adequately adjust for risk and contains certain flawed measures, including “newly implemented episode-based cost measures that have yet to be proven to be fair across all applicable physicians,” TMA told the agency in written remarks.
Risk adjustment means adequate accounting for factors such as social determinants of health, or physicians with patient populations that make hitting targets difficult, like treating mostly older patients or practicing in a region with high diabetes rates.
George Perkins, MD, chief medical officer of The University of Texas MD Anderson Cancer Center’s Physician Referral Service, says the vast majority of health care doesn’t occur in a doctor’s office or hospital.
“Over 90% of health happens in the community, yet hospital-based care accounts for over 30% of health care costs,” he said. “We haven’t had that discussion yet as a country. If the overarching goal is to improve health rather than health care or rescue care, we really have to have this honest conversation about social determinants of health and how we’re going to address them. Because it’s difficult to effectively care for complex patients, who account for the majority of expenses in health care, without addressing social determinants.”
Practices’ return on investment for participating in QPP has been low because of the miniscule bonus payments, TMA has told the government.
The MIPS program was supposed to yield large bonuses for physicians with exceptional performance. For example, practices were supposed to potentially earn up to 22%, or lose up to 4%, of their Medicare billings based on the first MIPS performance year in 2017. As it turned out, while a 4% penalty was still possible, the maximum bonus a practice could earn based on that performance year was 1.88%. For 2018, it was even lower at 1.68%. Because QPP is a budget-neutral program, the practices that incur payment penalties are the ones paying for the bonuses for those who succeed.
Medicare cuts and bonuses for a given year are based on data submitted on care provided two years earlier – the performance year.
CMS tells Texas Medicine that MIPS was designed to maximize participation in its early years, and because most clinicians were successful in the first year, “that left little savings to redistribute in bonuses.”
For 2022 Medicare payments – which are based on the 2020 performance year – a 9% penalty will be possible; in fact, any practice that doesn’t participate as required will automatically get that penalty. But budget neutrality and other factors will almost certainly keep the eventual maximum bonus payment well below the 9% mark. In its comment letter to CMS on the 2020 proposed rule this fall, TMA noted that MIPS bonuses “will remain limited over the next few years.” TMA called budget neutrality the “fundamental flaw” in the law that spawned QPP: the Medicare Access and CHIP Reauthorization Act (MACRA).
So, smaller practices may be required to spend large amounts of money to upgrade their electronic health record (EHR) systems and meet the program’s technological demands – but if they fail, they get penalized. If they succeed, they may be lucky to receive a small bonus that likely won’t cover their costs, according to a 2016 study published in Health Affairs. Meanwhile, the demands of data entry and reporting continue to pull them away from patient care.
Even in retirement, Joel Kerschenbaum, MD, looks upon the QPP with worry for his profession. A general practitioner for 43 years, Dr. Kerschenbaum retired from his two-physician practice in The Woodlands in October 2018. He didn’t think about the QPP much at the tail end of his career, when his practice’s billing company handled organizing and submitting data for the program.
But after learning more about its requirements and complexity, Dr. Kerschenbaum felt compelled to contact TMA and offer his thoughts on what he believes are QPP’s inevitable consequences.
“You get better practicing medicine with time, but you develop a way of doing it. You have a system … you develop a rhythm to doing things,” Dr. Kerschenbaum said. “Every time you have to disrupt that rhythm, it takes a while to incorporate [something] into the things that you wind up doing and make it part of your everyday practice.
“When you disrupt the way you normally do things, it affects patient care. Because now you’re working on entering data into the medical record that has nothing to do with why the patient is there, instead of concentrating on caring for your patient. You’re less efficient and less likely to provide the quality of care your patient deserves.”
“Little things” that create new wrinkles or requirements in a physician’s workflow become significant over time, he adds.
“It’s analogous [to] when I used to see teachers in my office, and they said one of the biggest obstructions that they had to teaching kids was they had to spend so much time submitting their lesson plans and all of the other stuff that they never had time to actually do the teaching,” Dr. Kerschenbaum said. “Nobody really ever takes a step back and says, ‘Is this accomplishing the goals that we wanted? Is this making the difference that we wanted? Because if it isn’t doing it, then why do we continue doing it?’”
CMS says just under 98% of all clinicians scored above the minimum performance threshold of 15 points in 2018, with 1.95% scoring below it. That threshold doubled to 30 points in 2019 and will be 45 points this year and 60 points in 2021.
“A number of MIPS measures and activities take into account social determinants of health such as the Use of Telehealth Services that Expand Practice Access Improvement Activity,” CMS added. “When choosing measures and activities to report, MIPS participants may choose to report on what’s most meaningful to their practice. We also provide bonus points to clinicians based on the complexity of their patient population, as determined by patients’ Hierarchical Condition Categories (HCC) score and dual eligibility for Medicare and Medicaid.”
CMS also says that as the performance thresholds continue to go up, “bonuses and penalties will become more pronounced.”
“Running for cover”
Those penalties could hit even harder as QPP pushes practices into downside risk – i.e., a potentially money-losing venture – before they’re ready, another of TMA’s concerns. The experience of Austin Regional Clinic (ARC), a large clinic system with more structural and technological means than most practices, shows why.
During 2019, ARC had a decision to make, says Cedar Park internist Manish Naik, MD. Through its partnership with other practices in an accountable care organization (ACO), the clinic had been participating in the Medicare Shared Savings Program (MSSP). Previously it was in that program’s easiest track, in which physicians didn’t assume any “downside risk,” meaning they wouldn’t incur financial penalties for failing to meet certain goals.
But this year, ARC’s continued participation in the shared-savings program would mean paying a price if it did not hit its targets. That prospect made ARC seriously consider leaving MSSP altogether, Dr. Naik says.
“Our concern with a downside risk model … was, we don’t have control of all the levers,” he said. “Patients in MSSP are not in any kind of a restricted network. They can basically go see anybody, go to any hospital, go to any specialist with really no restrictions, so it’s real hard to control costs.”
Ultimately, ARC decided to stay in the shared savings program. The reason, Dr. Naik says: The alternative was participating in MIPS, which looked even less desirable because that program’s measures are “becoming very difficult and don’t make a lot of sense.
“The way these MIPS measures are moving, it’s really going to be very difficult to perform highly in that MIPS program, and you get exempted from those MIPS reporting measures when you’re part of a downside-risk ACO,” he explained.
But if staying out of QPP – or outright retirement – isn’t an option, overwhelmed or burned-out physicians may just get out of independent practice and hop onboard with a larger group or hospital.
“They’re running for cover. They’re running for protection because the costs are going up,” said Dr. Jackson of Houston Methodist Physicians’ Alliance for Quality. “What the bigger organizations have is protection: ‘You don’t have to worry about costs, you don’t have to worry about administrative burden, we’ll take care of you.’”
Some recent studies point to that trend.
Per The Physician’s Foundation’s 2018 Survey of America’s Physicians, 36% of respondents identified themselves as an employee of either a hospital or a hospital-owned medical group. More than 12% identified themselves as employed by a physician-owned group.
“Physicians are forming into larger groups for the same reasons they are seeking employment: financial security, compliance and IT expertise, and the ability to compete for large population health management contracts,” the foundation said.
A February 2019 report from Avalere Health and the Physicians Advocacy Institute similarly showed the percentage of physicians employed by hospitals ballooned from 25% in 2012 to 44% in January 2018. What’s more, the number of hospital-owned practices more than doubled, with approximately 80,000 hospital-owned practices in January 2018.
In the study’s South region, which includes Texas, the number of hospital-employed physicians rose by 87%, and the percentage of hospital-owned practices spiked by 134%.
In TMA’s latest Survey of Texas Physicians in 2018, 12% of respondents identified themselves as a hospital employee, triple the percentage in the 2012 survey. Also, 11% of respondents said they were planning to leave their practice in the next two years, with nearly a quarter of that group saying they were planning to join a hospital system.
APMs, advocacy, and the future
The only Texas physician in Congress, Rep. Michael Burgess, MD (R-Lewisville), spearheaded MACRA, which passed in 2015 to replace the much-maligned Sustainable Growth Rate (SGR).
In a written statement, Representative Burgess told Texas Medicine bolstering participation in QPP should be a focus.
“The SGR was an across-the-board Medicare payment cut for physicians. If it were not for MACRA, clinicians across the country would still be stuck with the annual threat of the SGR. As a physician, I know that threat much too well.”
He believes that with continued congressional oversight and open dialogue with physicians and CMS, “the future of MACRA and the Quality Payment Program will be strong. I will not waver in my efforts to ensure this program is a success for the physician community.”
As part of that open dialogue, TMA Chief Executive Officer Michael Darrouzet says the future should have physicians, not bureaucrats, define what “quality” means. While some physicians have succeeded in ACOs and the MSSP, many doctors continue to report that MIPS is flawed and does not improve quality, and that they do not have an alternative payment model (APM) available to them, he notes.
“Physicians’ definition of quality is not the same thing as a bureaucrat’s definition of quality, and for way too long we’ve had the regulatory definition of quality,” Mr. Darrouzet said.
TMA’s advocacy during federal rulemaking for the 2020 QPP helped mitigate some of the short-term damage the program could’ve caused. After TMA submitted comments during the rulemaking period last fall, CMS took some of the association’s recommendations. Among them: CMS kept the four MIPS categories weighted the same as in 2019 instead of increasing the weight of the problematic cost category, and the agency maintained the low-volume threshold, keeping many physicians exempt.
CMS says its goal is for more practitioners to participate in advanced APMs than in MIPS. But as for whether APMs are better models, “We don’t have good comparative data regarding MIPS versus APMs because many physicians and groups were excluded from MIPS and APM participation and the early data has not been readily available,” said Dr. Perkins of MD Anderson. (See Quality, page 26.)
“People feel as if APMs will result in higher quality, higher safety, higher patient engagement … [and] decreased cost, faster. That conclusion remains to be determined; whatever answer the data reveals will be a game-changer,” he added. “This program is, in essence, a trial to determine the best way to get from our current state, which has room for improvement, to an optimal state and the transition stages to get the country there with minimal required disruption.”
According to CMS’ 2018 preliminary data, a little less than 357,000 clinicians participated in a MIPS APM. More than 183,000 participated in an advanced APM, which requires downside risk. That was about 15,000 more MIPS APM participants than in 2017, according to CMS’ numbers, and almost double the advanced APM participants.
“This increase in APM participation supports the evolution of the program and incentives towards a system of value that puts patients first,” CMS told Texas Medicine. “CMS’ vision includes increasing the availability of advanced APMs for all clinicians, including those in small and rural practices over time, but aims to support successful participation in MIPS until that goal can be achieved.”
TMA supports voluntary QPP participation. It advocates for Congress to eliminate budget neutrality in MIPS and to finance incentive payments with funds that do not come from payment cuts to practitioners who struggle to participate in the program. (See Rounds, page 16.)
“When doctors enter into a voluntary program or model they truly believe will improve quality and population health for their patients, it seems as if that’s where doctors are freer to be doctors,” Mr. Darrouzet said. “They’re freer to provide the care that they feel is timely, cost-effective, and has a really good outcome. This will not happen in a flawed program, nor when doctors are forced to participate in APMs they do not believe in, or where they would have to accept more risk than they can financially manage.”
Tex Med. 2020;116(1):18-25
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