Is there a silver lining to value-based pay initiatives?

Wednesday, June 27 2018

In working with practices around the country, we have heard a variety of reactions to the MACRA-dictated Merit-based Incentive Payment System (MIPS), accountable care organizations (ACOs), and alternative payment models (APM), which are now a consideration of almost every urology practice serving Medicare patients. The reactions range from, “What are you talking about?” to “I do not care” to “We got this and will likely get a bonus.”
The majority of urology practices and health care providers in general feel that the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) programs are yet another unfunded mandate requiring urologists and their staff to spend more time doing busy work that does not help patients or improve care. We can sympathize and agree as we helped many meet the minimum requirements at or near the deadline this past March.
Although we are not big fans of the MIPS required reporting and/or the requirements for ACOs and APMs that are currently available, in this article, we attempt to look past the program and see if there are any silver linings in the administrative cloud.
What drives complaints about health care?
We can start with cost. Virtually everyone in the U.S. would likely agree that health care is costing too much money. Many would also agree that the system does not meet the needs of all the patients nor the physicians. Most would also agree that overall quality can be improved.
While we can point to a number of potential factors that drive complaints about the health care system, we are going to focus on two that appear to be at least obliquely targeted by the MACRA program. Both of these issues can be addressed in a manner that will benefit your practice now while preparing you for the future. As an aside, private payers, while not in the MACRA game directly, are attempting many similar programs and policies to address the growing cost of health care in the U.S.
Factor 1: Fee-for-service health care encourages the health care provider to do more. While most physicians provide only those services they feel are necessary for the appropriate medical care of all patients, it is hard for anyone to believe that every physician is above the pull of capitalism. In fact, many of the rules surrounding reimbursement have resulted in changes to the provision of services, which in turn support this societal gestalt. Luteinizing hormone- releasing hormone antagonists, transurethral microwave thermotherapy, transurethral needle ablation of the prostate, urodynamics, post-void residual measurement, and intensity-modulated radiation therapy have all been targets of reimbursement and rule changes based on the belief that profit was driving overall utilization. The rules and reimbursement changes, in many cases, changed overall utilization (although many will argue that reimbursement and rules are not the sole reason for changes).
Nevertheless, the correlation in these changes and others across the health care marketplace have provided enough consequential data to support further reimbursement and rule changes to curb utilization. MACRA programs are pushing this one step further. APMs and ACOs are essentially compensated in a manner that ignores utilization of services, shifting service choice and remuneration to the provider groups themselves. The MIPS program is stepping into this change with overall cost accounting for each physician by patient with eventual downstream penalties to those physicians deemed to cost the system more than others.
Again, we are not in agreement with the current approach. Particularly, we have a major concern about the accuracy of the cost attributed to each physician.
We do, however, see the point of the programs. And we see an opportunity for groups and individuals to look at the way they practice. We have analyzed several practices in which practice patterns in the same geographic area or the same practice with similar patient diagnoses and ages have vastly different utilization and treatment patterns. For these, we have to ask why. Is the driver for these differences money, training, habit, employment, or something else entirely? And finally, what role does outcome play in the differences, which leads to a second question: How do we consistently measure outcome?