- Reducing regulatory burden was one of the primary aims of the 2018 Quality Payment Program (QPP) final rule, but current requirements still negatively impact patient care and clinical workflows.
Despite administrative burden associated with Quality Payment Program requirements, LUGPA (Large Urology Group Practice Association) President Neal Shore, MD, views the transition to value-based care in the Merit-based Incentive Payment System (MIPS) as a worthwhile move for specialty practices.
“There’s always been a recognition that this has been a well-intended process to move away from the challenges of volume-based healthcare and fee-for-service reimbursement,” the urologist told EHRIntelligence.com. “But the implementation of MIPS metrics has been time-consuming and anxiety-producing for most administrative teams and urology practices.”
Shore’s independent specialty practice consists of 14 physicians and 10 advanced providers, including nurse practitioners and physician assistants. Another 150 staff members comprise allied health professionals and the practice’s administrative team. While the practice has a full squad of staff members assisting with administrative tasks, clinical efficiency has taken a hit since MIPS implementation began.
“Things have been negatively affected by the requirements,” said Shore. “They’ve significantly slowed down patient encounters.”
“When all these things are slowing down processes and creating more time between the patients and physicians, there’s a level of frustration for patients, too,” he added. “This is clearly seen across the board now for all of medicine.”
With EHR data entry extending patient encounters, clinicians see fewer patients per day. Shore also echoed the concerns of other specialty care providers that maintain current federal reporting requirements are poorly aligned with clinical workflows and outcome improvements.
“It’s caused further consternation in the actual charts — added additional verbiage and space requirements that have not at all contributed significant improvements in patient care,” he said.
In addition to negatively affecting clinical processes, Shore said current MIPS policy also fails to fulfill its intended purpose from a financial standpoint.
Staying Independent Under Regulatory and Financial Pressures
In an effort to assuage provider concerns about payment penalties, CMS has attempted to lessen their severity. Reducing the financial impact of payment penalties was high on the list of CMS priorities when 171,000 eligible professionals faced penalties at the hands of meaningful use requirements in 2017. But the policy decision might prove to be a double-edged sword.
“The most current CMS rule says the bonuses for folks following and complying with various MIPS thresholds has been dramatically diluted so that even if you’re falling way short, the penalties are not excessively high,” he said. “But if you are complying with MIPS, they’ve diluted the bonuses so much as to make it relatively inconsequential.”
Ensuring incentive payments are substantial enough to offset steep EHR implementation costs is necessary to keeping independent practices afloat amidst regulatory pressure to adopt health IT. In combination, increasing administrative burden and heightening health IT-related costs are pushing some independent practices out of business.
“For some practices that are really in the weeds of understanding the constant regulatory burden that’s been imposed by ongoing legislation, certain smaller practices find it very difficult to adapt,” said Shore. “They feel exhausted and frustrated and so they may go into the welcoming embrace of a large institutional system.”
While consolidation may lessen the strain of regulatory compliance, Shore maintains the death of the independent practice would be sad news for patients.
“That’s unfortunate for the healthcare system in general,” he said. “Having the historic independent healthcare system where there’s a close relationship between patients and physicians — and when it’s done well — is the best system. It cuts out all the layers of bureaucracy and regulatory disconnect that patients never like.”
According to Shore, specialty practices — especially those on the smaller side — should work together to fulfill federal requirements and remain independent under current policy.
The 2018 final rule accommodates collaboration between groups of clinicians in the form of virtual groups. Through virtual groups, solo practitioners and groups of 10 or fewer clinicians can work together virtually — regardless of location or specialty — to participate in MIPS for a performance period of one year.
“Smaller practices should look to aggregate with each other and larger groups to maintain independence from large institutional systems that tend not to be run by physicians, but rather by business entities,” Shore advised. “Sometimes that’s okay, and sometimes it’s detrimental to the patient as the consumer.”
The Uncertain Future of MIPS
While there are ways independent practices can succeed under MIPS, Shore believes the program needs to be scrapped entirely.
In October, the Medicare Payment Advisory Commission (MedPAC) suggested MIPS be eliminated in a public meeting. In its place, MedPAC recommended CMS implement the Voluntary Value Program (VVP).
VVP would prioritize aligning quality and value signals across the healthcare delivery system, reducing clinician burden, and equitably measuring aggregate clinician performance in fee-for-service, among other aims.
Shore backs MedPAC’s recommendation to repeal MIPS but contends policymakers should explore further options before jumping to implement an alternative program.
“I’d want to know what all of the options are,” he said. “I’m not sure that all of the ideal options have been proposed or adequately vetted for me to say what I’m in favor of endorsing.”
Whether CMS opts to revise or scrap MIPS remains to be seen. In the meantime, collaboration between practitioners could help to avoid the decline of the independent specialty practice.