Medical Economics/Cerner White Paper

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WHITEPAPER

MAKING POPULATION HEALTH PART OF YOUR PRACTICE How the Centers for Medicare & Medicaid Services (CMS) pays physicians is about to profoundly change.

BY LIZ SEEGERT

S

tarting in 2019, traditional fee-for-service payments under Medicare will be supplanted by MACRA–the Medicare Access and CHIP Reauthorization Act of 2015. MACRA was enacted by Congress to replace the Medicare Sustainable Growth Rate (SGR) formula, providing a permanent “fix” that rewards patient-centered, effective care.

MACRA emphasizes outcomes, quality, efficiency and accountability for patient and population health through data. Lots of data.

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MACRA requirements will have significant impact on physicians’ bottom line, according to policy experts familiar with the new payment structure.

Although the revamped reimbursement takes effect in 2019, physicians should already be preparing for changes. MACRA’s payment system uses 2017 metrics as baseline.

The law is designed to align physician payment with value.

There are two pathways in MACRA; in 2017, physicians must choose either the MeritBased Incentive Payment System (MIPS) or practice in an Alternative Payment Model (APM).

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MIPS replaces the Value-based Payment Modifier (VM), Physician Quality Report System (PQRS) and Meaningful Use (MU). It ties traditional fee-for-service (FFS) payments to how well physicians score on measures of quality (50% of total in year 1), advancing care information (health IT use, 25%), clinical practice improvement activities (15%) and cost (based on claims data, 10%).

Depending on their score, physicians and other eligible practitioners will receive positive, negative, or neutral adjustments of up to 4% in 2019, with gradual increases or decreases of up to 9% in 2022 and beyond.

MIPS is budget-neutral. Higher payments to physicians who score well are paid for by lower payments to physicians who fail to meet performance minimums.

If most physicians do well, the potential payment increases will be much lower than the maximums, according to Bob Doherty, senior vice president for governmental affairs and public policy with the American College of Physicians.

The other pathway is participation in an Alternative Payment Model. These are advanced payment and delivery models that reward physicians for improving quality, or for achieving savings without hurting quality. APMs include models already being tested by the federal government, such as the Comprehensive Primary Care Plus (CPC+) model, the Next Generation ACO model and some patient-centered medical homes. Qualified models, or “Advanced APMs” must meet very specific criteria, including use of certified EHR technology. Physicians participating in APMs that don’t meet the new criteria will be reimbursed under MIPS criteria instead.

FOCUS ON POPULATION HEALTH

MACRA requirements underscore better health management for patients with multiple chronic conditions—diabetes, CHF, asthma, smokers, obesity or other conditions—especially those who frequently suffer suboptimal healthcare and increased hospitalizations. Improving healthcare quality and reducing costs for this population is a key domain under the legislation.

In a report to the Agency for Healthcare Research and Quality, the National Opinion Research Center (NORC) defined practice-based population health as “an approach to care that uses information on a group of 2

patients within a primary care practice or group of practices to improve the care and clinical outcomes of patients within that practice.” Rather than simply reacting to the spontaneous needs of individual patients, it emphasizes proactive management of a practice’s accountable patient base. Earlier intervention through disease-risk analysis can delay or even prevent onset of some conditions.

Physicians need to get a complete picture of their patient populations and think about how to most effectively manage them to achieve the best outcomes. To do that they not only need the data to identify potentially at-risk patient subsets, but also the ability to turn that into new workflows, says Farzad Mostashari, MD, former National Coordinator for Health Information Technology, and founder of the accountable care company Aledade, located in Bethesda, Maryland.

“See your patients before they get sick, and make a plan with them,” Mostashari says. “For that, you need data, and you need to be able to analyze the data in a structured way.” He adamantly believes that better patient and population health requires data exchange among all stakeholders that is transparent and free of additional cost—even if that means the government steps in to create rules against blocking information sharing.

To achieve this requires transparency across all realms of the patient population. Building relationships and sharing data among all care providers, including specialists, hospitals, skilled nursing, laboratories, pharmacies and payers will generate longitudinal records of individual and population health. This is particularly vital when managing

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patients with multiple, complex chronic conditions, the NORC report concluded. Systems must also be user friendly and highly capable of capturing distinct, accurate data needed for population health management.

Patient-centric interoperability will help primary care physicians identify subpopulations of patients who can benefit from additional interventions or services, such as reminders for well visits or screenings, or for follow-up after hospitalization. Comprehensive analytics pulled from multiple, disparate sources can identify trends and help assess why these trends are occurring. It can also provide insight on physician and practice performance compared with national guidelines or peer groups and pinpoint improvements over time.

However, integrating data across systems and providers is still a huge challenge. A 2016 report by Charlotte, North Carolina-based healthcare solutions provider Premier, Inc. of C-suite executives finds that while 68% say they’re successful accessing ambulatory data from employed physician networks, only 38% can successfully access ambulatory data from affiliated or nonemployed physician networks.

“Without interoperability across that whole continuum of care, we’re really struggling to have the information we need in a timely manner to take the best possible care of our patients,” says Mike Schweitzer, MD, MBA Premier’s chief medical officer for bundled payments.

As data sharing evolves, it’s important to take a step back and ask what healthcare is seeking interoperability for, according to Mostashari. Data needs to be patient-centric, but he says physicians also don’t need to be inundated with hundreds of pages of information they can’t act

on. Data analysis needs to relate to an explicit problem or issue, such as a hospital discharge.

“That’s a specific piece of information that’s of super high value for a primary care or other doctor to know,” he explains. A simple notification of when a patient leaves the hospital is extremely important, yet often doesn’t occur, because the systems either don’t talk to each other, or the data is so buried it becomes almost impossible to find.

BE PREPARED

The time for physicians to think about MACRA options is now, according to Schweitzer. While some providers are starting to explore possibilities, others may be so deep into their practice that they haven’t come up out of the weeds to realize what the implications are, he says. They may not recognize the performance year is rapidly approaching.

“If you’re truly going to evaluate, you need to clearly understand your options,” he says. Physicians can do nothing and try to meet requirements themselves, look to join a larger organization—like a clinically integrated network (CIN), ACO, health system or specialty group.

Physicians need to figure out how to transfer business and management issues but maintain autonomy to some extent, according to Robert Berenson, MD, policy fellow at the Urban Institute and former vice chairman of

the Medicare Payment Advisory Commission (MEDPAC).

“You want some independence so you can make clinical decisions that are best for your patient, that let you determine who you’re hiring, and set own hours. There are ways to try to maintain autonomy in face of being employed,” he says.

Another successful model to consider is joining an independent practice association, which can leverage combined efforts of smaller practices. While this approach means having to be part of an organization, it doesn’t compromise solo physician or small practice independence, Berenson points out.

How can physicians find success navigating this brave new world of payment reform?

Schweitzer thinks the best solution for physicians and for patients is to join an organization that has resources and interoperability, along with analysts and staff focused on improvement.

“This will help you create change to have better care, lower cost, more satisfaction, not just meet MACRA law because of the incentives,” he says.

This approach enables physicians to achieve the goals of truly integrated, value-based care—sharing clinical information in a timely manner to support decisions that provide best quality of care for patients and for populations.

At Cerner, we’re continuously building on our foundation of intelligent solutions at more than 20,000 facilities worldwide.

Cerner believes the best way to manage the health of a population is one person at a time. Our customizable, comprehensive suite of solutions and services enables organizations to know a population, engage each person and manage to an optimal outcome. We facilitate high-performing networks and align, engage and empower stakeholders through our industry-recognized platform, technology and services.

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ENGAGING INDIVIDUALS IN CARE

Successful outcomes depend on patient engagement. Engagement relies on the strength of the relationship between physician, patient and other members of the care team, according to the PatientCentered Primary Care Collaborative (PCPCC), a Washington, D.C., non-profit focused on patientcentered medical homes.

PCPCC notes that some forward-thinking practices have experimented with innovative strategies to boost patient engagement, including health coaches to educate patients about their conditions and discuss concerns, connecting patients with community resources, using patient advisory councils and creating online portals to expedite patient-provider communication and collaboration.

According to the Healthcare Information and Management Systems Society (HIMSS), almost all patient activity occurs outside of the realm of the care provider, whether exam room, hospital or clinic. Data and “soft” information collected directly from the patient—self reported outcomes, for example—becomes increasingly important in the wake of new quality measures. Physicians can expedite this process by connecting with patients and families through IT: health and wellness portals, video conferencing, remote monitoring and other technologies. These tools not only improve patient involvement, but also make shared decision making more routine.

Data makes it possible to have more of a relationship with patients, and can really improve their engagement with their own health care, says Mostashari.

“That sharing means the doctor can enlist the patient and their family members as fellow copilots in managing the patient’s care.”

Using the data to generate a longitudinal health record can

fuel conversations on history, trends, help inform treatment decisions and assess their impact. It offers more of a 360-degree view of all care being provided to patients, plus the opportunity to identify who may be at risk and opportunities for earlier intervention. Importantly, it helps patients and physicians mutually set holistic goals of care, tailored to the needs of the individual patient across the care continuum.

“Let’s use this revolution in record keeping as a way to actually bring patients and docs and the relationship closer together,” Mostashari urges.

MANAGING OPTIMAL OUTCOMES

Research indicates that using data to help inform and educate patients makes them more accountable for their own health. This could develop into “predictive analytics”—enabling organizations and physicians to essentially “see the future.” That means more personalized care and an ability to forecast patient behavior.

Predictive analytics can help physicians with decision support, such as whether or not to hospitalize a patient, according to Linda A. Winters-Miner, PhD, an analytics consultant and professor emeritus at Southern Nazarene University in Bethany, Oklahoma. Analytics can help determine exact treatment for specific patients based on individual history and even identify health risks sooner through genome analysis. It can also identify gaps in care—such as missing follow-up exams with specialists, need for preventive screenings, or post-discharge care coordination—presenting opportunities to take immediate action.

The U.S. Department of Health and Human Services acknowledges that questions 4

still remain about which data elements improve predictive accuracy and how these may differ for various subpopulations. Simply relying on prior hospitalizations has been shown to be a poor prediction of future use. Inclusion of variables like functional status, behavioral health and social determinants of health better predict those at higher risk. However, finding and including this type of information into current health records remains challenging.

SIMPLY RELYING ON PRIOR HOSPITALIZATIONS HAS BEEN SHOWN TO BE A POOR PREDICTION OF FUTURE USE. Systems that can leverage disparate data from across the care continuum and deliver proactive recommendations embedded in the workflow are needed for optimal care management.

It’s crucial to automate evidence-based care practices with embedded workflow management technology to help coordinate care team activities, according to J. Marc Overhage, MD, PhD, FACMI, associate professor of medicine at Indiana University School of Medicine and chief clinical informatics officer, Cerner Corporation.

In a presentation for the American Medical Informatics Association, he emphasized that near seamless connectivity

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between information systems as well as between patients and care team members through preferred communication channels is indispensable for overseeing and quantifying care processes.

That improves outcomes and holds down costs.

There can’t be a revolution in payment reform and care delivery without revolutionaries.

Stakeholders—physicians, patients and health systems among them—must be “willing and able to use insights from the data,” a recent McKinsey & Company report concluded. It requires a personal revolution as much as an analytical one, and a departure from traditional practices.

The authors of MACRA understand that big systems aren’t the solution for everyone, says Eugene Rich, MD, senior fellow and director for Mathematica Policy Research’s Center on Health Care Effectiveness in Princeton, New Jersey. That’s why the legislation also incorporates alternative payment models that work for small practices and those in more rural areas.

Additional models are likely on the horizon.

CONCLUSION

Whichever payment model is selected, most experts agree that successful practices will be ones that build a strong ambulatory foundation, find the right partners to deliver care across the entire continuum, engage individuals and patient populations in proactively managing their care and use metrics strategically to create healthier communities at lower cost.

This approach is already working in communities across many different diverse populations, according to Schweitzer.

“As a result, everyone in the community is happier. So it can be done, but we need to spread the knowledge faster.” n