- Federal quality reporting programs aim to improve the patient experience and health of populations and reduce the cost of care, goals their participants are clearly in favor. However, the latter take umbrage with the expense required of physicians, nurses, and other clinicians to meet requirements of these programs — whether in the past as part of the EHR Incentive Programs or more recently as part of the Quality Payment Program.
According to the American Medical Association (AMA), the lack of alignment between program requirements and clinical workflows is having a serious impact on the professional and personal lives of providers.
“It has come at a pretty substantial cost,” AMA President David O. Barbe, MD, MHA, told EHRIntelligence.com. “The investment that physician practices have had to make has been significant for technology and human resources. And it has taken a toll and changed the way a physician’s day goes and how it feels. That has led to incidents of physician frustration or even burnout.”
Part of the problem rests with the measures required to be reported and another with the mechanisms for reporting them.
“There are things we’re measuring and processes we’re using that really don’t add value,” Barbe continued. “Not only do we not get what we need from these highly-trained professionals, but it also frustrates them in the process. It’s a double negative.”
While AMA has worked with federal officials to address quality reporting program requirements, its goal of reducing administrative burden on providers remains elusive.
“We are not seeing as much of that as we would like,” added Barbe. “There is substantially greater opportunity for reducing regulatory burdens at a variety of different levels, of simplifying data collection and reporting. The number of metrics, their collection, and relevance are moving the right way, but we’re not even close to where we need to be yet.”
Beyond quality measures, the tools necessary for reporting this data to CMS and federal agencies fall woefully short of AMA’s expectations and those of providers.
“Some of it is related to EHR vendors and AMA’s belief that they have not attended to the needs of clinicians and practicing physicians in simplifying the user interface for capturing, aggregating, and reporting these metrics — many of which could go on automatically in the background and lead to much less effort by physicians or their office staff,” Barbe maintained.
The disappointment in current EHR and health IT systems is made even stronger by the fact that physicians such as Barbe recognize the potential of new and emerging technologies to benefit their practices.
“Most doctors feel like they fight their EHR more than it helps them,” he said. “The promise of that technology is there. We see how helpful technology can be in other areas of our society and why we can’t move in that direction in healthcare is very, very frustrating to physicians. We adopt technology readily. Look at clinical technology. When that’s proven to be beneficial, doctors will adopt that in a heartbeat. They will adopt technology that works for that.”
Debating an investment in value-based care
Early in 2015, CMS announced a plan to shift half of all Medicare payments from fee-for-service to value-based care in the form of accountable care organizations and bundled payments by 2018.
As part of MACRA, the Quality Payment Program represents a mechanism for accelerating this shift in reimbursement so long as providers participate and transition from the Merit-based Incentive Payment System (MIPS) to Advanced Alternative Payment Models (APMs).
According to Barbe, early signs about the transition to MIPS do not bode well for this industry-wide shift.
“It started pretty rocky,” he said of the program which began at the start of 2017. “We had high numbers of physicians who literally did not understand it and felt somewhat frustrated by it — and that is in spite of considerable effort on the part of the AMA to inform physicians last year while we were waiting for the final rule.”
The AMA chief noted that MIPS exemptions have removed one-third of physicians from the program this year. And despite the “pick your own pace” strategy employed by CMS, many physicians are still deciding whether to participate based on the investment of time and money they must make to earn a bonus.
“If a physician has $100,000 in Medicare receipts and gets the maximum incentive on that of 4 percent, that’s $4,000,” Barbe observed. “It costs multiples of $4,000 to ramp up IT and staff in order to do that. Some will simply make the decision on a business case — the investment is not worth the return. We understand that.”
“On one hand, that’s fine and it makes good business sense; on the other hand, that shouldn’t be the case,” he continued. “We want physicians in. We want them to be appropriately rewarded for the investment in time, energy, and the hard cost of staffing and IT to move the health system in the direction we want to go. Right now, the bonuses aren’t high enough and the downside is discouraging. It’s making it hard for physicians to get on board with these programs.”
If providers are struggling to participate in MIPS, which Barbe refers to as “pretty basic,” the likelihood of them eventually transitioning to Advanced APMs is slim — that’s before even taking into account complications related to implementing a value-based care model.
“We want physicians in. We want them to be appropriately rewarded for the investment in time, energy, and the hard cost of staffing and IT to move the health system in the direction we want to go."
“Loosening the restrictions and making it easier for physicians to participate in APMs is the way we should go,” Barbe argued. “APMs are probably a better model ultimately for these quality-based programs. They do allow much more flexibility within the group on how they are going to work to improve quality and lower cost.”
To date, a select few QPP participants are equipped to succeed in this QPP pathway provided.
“There are so few opportunities, which touch probably fewer than 20 percent of physicians and only the ones who are in large groups,” Barbe noted. “We are working very hard to get CMS to expand the opportunities for physicians to participate in APMs.”
A virtual group is one such mechanism currently under consideration that AMA hopes will come to fruition. “That might let small- and medium-sized practices ban together and therefore be able to more appropriately justify the investment in IT and personnel it would take,” said Barbe.
What’s clear from AMA’s perspective is that federal official must recognize the demands on providers to change the practice of medicine and the challenges associated with acquiring the right combination of tools and resources to improve practice efficiency. Ultimately, any success in transitioning to value-based care will require strong leadership from physicians and clinical staff who collectively have the most control over improving the delivery and management of care and cost.