Hospitals and health systems should view quality payment programs as opportunities to build alignment among physicians and support for value-based goals.
Despite some uncertainty regarding the future of Medicare payment reform under the Trump administration, the
Quality Payment Program (QPP) established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) remains in effect.
Though primary goals of the Centers for Medicare and Medicaid Services (CMS) in defining QPP implementation included simplifying reporting requirements and reducing clinician burden, many providers are not resourced to sift through the thousands of pages of regulations to determine exactly what is changing and how they will be impacted. CMS minimized risk for providers in the initial years of the program, but there remains a recognition that MACRA is likely to be a catalyst in shifting how providers are reimbursed for delivering care, from Medicare and ultimately across payers.
Ahead of the QPP’s initial performance year in 2017—affecting payment in 2019—the Health Management Academy, Alexandria, Va., was interested in gaining preliminary insight into how physicians were thinking about these changes. The Academy conducted a survey of physicians affiliated with large integrated health systems to determine how knowledgeable they are about MACRA, and how well prepared they are for the new payment and reporting system.
A web-based survey administered to 30 leading health systems was conducted from November to December 2016 regarding provider insights on MACRA. The survey’s 63 percent response rate resulted in a sample of 519 physicians across 17 states, affiliated with 19 different health systems.
The majority of respondents (82 percent) are employed by a large health system. Of those not employed, about 70 percent practice in large medical groups, 15 percent practice in small groups, and 15 percent practice independently. Respondents spanned more than 25 specialties, with approximately 28 percent in general practice, 18 percent in internal medicine, and 54 percent in other specialties.
Key Findings: Physician Sentiment & Preparedness
As many of the Merit-Based Incentive Payment System (MIPs) reporting requirements under MACRA are similar to existing Medicare programs, physicians were asked several questions around familiarity and reporting under PQRS (Physician Quality Reporting System), the Medicare Electronic Health Record Incentive program (Meaningful Use), and the Value-based Modifier program.
PQRS and Meaningful Use awareness. More than half (57 percent) of responding physicians are aware that they report to PQRS, however more than one-third (38 percent) do not know if they report. Of note, while less than 5 percent of employed physicians and those practicing in large groups responded that they definitively do not report to PQRS, 67 percent of independent physicians responded that they do not report. A larger percentage of overall respondents (76 percent) were aware that they attest to Meaningful Use.
QRUR awareness. Nearly three-fourths (71 percent) of physicians are not aware of the results from their last CMS Quality and Resource Use Report (QRUR). The QRURs reflect performance on quality and cost measures for practices nationwide. Of those that are aware of their results, more than half (53 percent) would classify their practice as high quality, low cost and approximately one-third (29 percent) would classify their practice as high quality, high cost. Very few providers would classify their practice as either low quality, low cost (1 percent) or low quality, high cost (1 percent).
MACRA awareness. When asked about their awareness of MACRA, most physicians (83 percent) reported they had heard of the law, and just over half of responding physicians reported being familiar with either MACRA (52 percent) or MIPS (53 percent). Knowledge around Alternative Payment Models (APMs) is seemingly lower among respondents, with about 60 percent unaware of their participation in any of the major ongoing Medicare models.
The majority (61 percent) of physicians report receiving most of their information about MACRA from the hospital systems they work for or are affiliated with, followed by medical societies/associations (14 percent), and their physician peers (8 percent). Most physicians (79 percent) are somewhat or very confident in their health systems in helping them understand and prepare for MACRA.
Physician Confidence in Health System Preparation for MACRA
In an open-ended question, physicians reported knowledge gaps around a variety of aspects of the program, with most responses centered on reporting requirements, effects on payment, and the impact on patient care.
MACRA concerns. Of the physicians who have heard of MACRA, more than three-fourths (76 percent) are somewhat or very concerned about MACRA and MIPS. The most common worry for physicians is the amount of time the QPP will take away from interacting with patients, with 42 percent of physicians rating this as their primary concern. Physicians also noted concerns around determining reporting requirements (20 percent), performing poorly relative to the government’s standards (15 percent), and their technical ability to report the necessary data (14 percent), among others.
MACRA support. Less than one-fourth (23 percent) of physicians report supporting the changes to Medicare payment made through MACRA, with approximately one-third (30 percent) reporting they did not support the changes. Notably, 70 percent of responding independent physicians were opposed to MACRA, as compared with about 30 percent of employed and group practice physicians. Many physicians are unsure about the changes, with almost half (47 percent) of all respondents reporting that they did not know whether they supported MACRA or not.
The Path Forward
With the first QPP performance year starting on Jan. 1 2017, clinicians have likely been exposed to information around MACRA from a wide variety of sources—some accurate, some not—only increasing the potential for panic. The survey responses make clear that most clinicians have relied heavily on their physician groups to report in the past, and are continuing to rely heavily on their groups as it relates to their participation in the QPP.
Given this dynamic, hospital and health system leaders should consider how to best establish themselves as and remain the source of truth for their clinicians. While most clinicians do not need to be intimately knowledgeable on the intricacies of the program, they do want the reassurance that their group or health system will lead them through the changes. Beyond technical implementation guidance, groups and health systems should prioritize communication to physicians regarding the entity’s readiness for the QPP, particularly as it relates to key physician concerns we have identified.
This is of particular importance given the fact that most physicians are faced with the added complexity of navigating multiple payer contracts. While introducing more ambiguity and risk into Medicare payment, hospitals and health systems should also view the QPP as an opportunity to build alignment among physicians and support among physicians for value-based goals more broadly.
Our survey is focused on clinicians affiliated with larger healthcare organizations, but all physicians require relevant, reliable sources of information provided by health systems, professional associations, CMS, or other industry leaders. All physicians subject to MACRA would benefit from tailored education around how direct compensation, patient care, data collection, and reporting will change. As the core tenets of the QPP are likely to expand beyond Medicare in the future, early adoption and support of the QPP by clinicians and other frontline staff will certainly contribute to even greater success down the road.
Jarrett Lewis is executive director, The Academy Advisors at The Health Management Academy, Alexandria, Va.
Caitlin Greenbaum, MPH, is a director, Huron Consulting Group, Washington, D.C.
Sanjula Jain is a doctoral student in the Department of Health Policy & Management, Emory University, Atlanta.
Nathan Bays, JD, is a managing director, Cain Brothers, New York.