Embracing Change Through MACRA

Change is difficult. This is doubly true when it comes to physicians changing the patterns of how we work.   To be sure, it is not just about the physician.  The delivery of healthcare is often dependent on teams of people performing tasks and workflows yielding a variety of outputs – accurate patient scheduling, the consistent sharing of office notes with colleagues, or gathering the right data for physicians to review and act upon.

One of the more anxiety provoking aspects of the quality payment program (QPP) – a.k.a. MACRA – is the perception that success depends on incorporating so many new tasks, new workflows, and changes to existing workflows.  QPP is complex, but when broken down to the basic decision points it can be managed and adapted to, like so many other complex processes we deal with in health care.

Many practices will be participating in the MIPS (Merit-based Incentive Payment System) arm of the QPP (as opposed to advanced payment models or APMs).  Though MIPS is an evolution of the well-known programs of Meaningful Use (MU), PQRS, and VBM, successful participation depends on practices actively choosing the measures on which they want to report.  This is a change from how MU/PQRS typically worked and is a prime source of anxiety.  Moreover, many measures are scored based on performance in prior years.  For instance, a measure’s 50th percentile of performance could be based on the last two year’s average score.  This means that a practice must also understand how their chosen measures are scored and how this scoring changes year to year.  A second point of angst.  But it is important to remember we are not making these choices alone or in a vacuum.

Choosing measures involves understanding yourself, your practice, and the IT tools you use.  In other words, physicians need to choose measures that reflect the care they best deliver (what specific health care processes or outcomes do you deliver well), measures that have reasonable scoring opportunities (i.e. where higher scoring is not only at 100% of performance), and measures that are based on data that the practice’s EHR can capture (i.e. ensuring you have the right fields in the right places in your electronic record system).  Having the right team of practice managers, IT support, and, in some instances, other consultants can help physician leaders understand and make these choices.  Moreover, CMS and many specialty societies offer numerous tutorials and educational opportunities.

It is easy to get caught up in the details of QPP.  It can seem like an endless pit of acronyms, details, and rules. But fundamentally, QPP is about practice transformation, that is operationalizing the activities associated with measuring quality and practice improvement.  Because this means something different for each physician and each practice, there is by design, many measures to choose from.  For the many nephrology practices that are on the MIPS pathway, each will have to determine how they can best demonstrate their adoption of technology, quality of care, and pace of transformation, through the measures for Advancing Care Information (ACI), Quality, and Improvement Activities (IAs).  But remember, these measures are an evolution of the meaningful use and PQRS programs that so many of us have already participated in for the last 5-10 years.  Ultimately, the biggest change from QPP is the need to be actively engaged in understanding what our practices do well and how we can best capture, measure, report, and improve on those activities.

About the Author:

Adam Weinstein, MD, is VP of medical affairs with Clinical IT Services at DaVita and a part-time clinical nephrologist in Maryland. He serves as the American Medical Association Relative Value Scale Update Committee (RUC) advisor for the Renal Physicians Association (RPA) and chairs the RPA clinical data registry workgroup.

Dr. Weinstein is a co-founder of the Kidney Health Center of Maryland. He has worked as VP of medical affairs at the University of Maryland, Shore Regional Health and has served on the Maryland Healthcare Commission and RPA board of directors. He completed his training in internal medicine and nephrology at the University of Maryland School of Medicine and University of Maryland Medical Center.