With a complete roadmap unavailable, and rank-and-file physicians not really paying attention, the next-best guides for physician practice leaders include existing programs such as PQRS, the value-based modifier, and meaningful use.
The future of physicians isn't much clearer than it was before the Centers for Medicare & Medicaid Services (CMS) released proposed rulesfor theMedicare Access and Children's Health Insurance Program Reauthorization Act (MACRA) last week.
Despite medical groups' pleas to delay the January 1, 2017, start date of the first reporting period under MACRA's Merit-Based Payment Incentive System (MIPS), CMS has so far stuck to its guns, leaving medical groups just a month or so after the release of its final rule—expected in late fall of 2016—to prepare.
Physicians will need to digest the regulatory information, figure out their quality measures, and get their systems ready to report data that won't result in a penalty or reward until 2019.
So with the timelines firmly set, healthcare leaders should not wait to prepare for changes.
But that lag time potentially undermines the purpose of the program, and represents one of many problems the Medical Group Management Association (MGMA) intends to share with CMS during the public comment period ending June 27.
"The feedback mechanisms are too removed from the performance years," says Anders Gilberg, MGMA's senior vice president of government affairs.
"If you're really going to attempt to improve quality through these programs—not have them just be reporting programs with incentives tied to reporting—you need feedback.
You need timely, actionable information. And you need incentives to be closer to when you're actually providing and measuring that care."
Good News, Bad News
A less obvious issue, according to Gilberg, is CMS's proposal to reduce the total number of quality measures practices will need to report under MIPS to six from the nine currently required under the Physician Quality Reporting System (PQRS).
"On first blush, that looks like an improvement," he says.
"But at the same time, CMS proposed to raise the threshold you need to achieve those measures as high as 90% for some… while for some, 50% has been hard to achieve, either because of the nature of the measures or difficulty in reporting."
More positive, however, is CMS's willingness to allow medical groups to select a set of quality measures (which account for half of the total score in year one of the program) that applies to their specific practice, says Chet Speed, JD, LLM, vice president of public policy for the American Medical Group Association.
Overall, Speed rates CMS's proposal as fairly positive.
"They heard from us, and through the house of medicine, that a quality measures program regime is challenging… They listened to stakeholders and did a nice job there."
Nonetheless, CMS's proposal also unwittingly helps most practices solve the dilemma of whether to participate in MIPS or attempt an exemption via an Advanced Alternative Payment Model (APM).
The "advanced" qualifier appears nowhere in the MACRA legislation, Gilberg notes. "And the list of what would qualify as an advanced APM is so narrow, that virtually no physicians are going to be advanced APMs anytime soon."
So while select practices that participate in the challenging Comprehensive Primary Care Plus (CPC+) program will qualify as advanced APMs, the 95% of Medicare accountable care organizations that have invested in becoming Track 1 ACOs will be left out.
As a result of the difficulty in qualifying as an advanced APM, almost all groups will begin 2017 in MIPS.
That may not appreciably lessen practices' current burden of reporting for PQRS, the value-based modifier, and meaningful use (with clinical practice-improvement activities added to the mix).
How to Prepare
While it's still possible CMS will dial back some of its more significant requirements in its final rule, leadership's current strategy should consist of three parts:
1. Read Up
Based on strategic planning sessions Speed has attended with AMGA members groups', the first step is to process all the information that's currently available about MACRA and figure out what it means to them and to their physicians.
2. Communicate Implications to Physicians
"Quite frankly, the rank-and-file physicians aren't really paying attention, at least with our member groups," says Speed. "They're just practicing medicine with the idea that the group practice leadership will take care of the details."
The key message physicians need to hear, according to Speed, is that risk is happening.
"It's not going to be a repeat of the 1990s, when managed care came and went. Risk is now literally etched in statutory stone: MACRA. And the commercial payers typically follow Medicare, so risk is going to be interjected into all payment models."
3. Study Current Quality Programs
With a complete roadmap unavailable, the next-best guide for practices include existing programs such as PQRS, the value-based modifier, and meaningful use, for which they must still report until the end of 2016. In particular, groups will be wise to study CMS's interim (mid-year) quality and resource use reports (QRURs), released in April 2015, says Gilberg.
"It's not a perfect picture, but at least you'll get a general sense of how CMS is looking at physicians within the practice relative to both quality and resource use," Gilberg says. "Those types of measurements are likely going to be similar in the final rule."
Physicians are now reimbursed for end-of-life talks, but most still avoid the conversation. Formal training and systems may go a long way toward making advance care planning not just best practice, but standard practice.
Since Jan. 1, 2016, physicians have been able to bill Medicare for time spent discussing patients' wishes and goals for end-of-life care. Unfortunately, though most physicians say they support advanced planning conversations, most physicians avoid them.
Despite the silly talk of "death panels" and other empty political controversies surrounding advance-care planning when the Congress was debating the Affordable Care Act, physicians' associations overwhelmingly supported the historic provision in the Centers for Medicare & Medicaid Services (CMS) 2016 final rule allowing payment for these conversations.
As of early spring, however, only 14% of a national sample of physicians who regularly see patients age 65 and older had conducted and billed for these talks, according to a poll jointly released by the John A. Hartford Foundation, the California Health Care Foundation, and the Cambia Foundation. Representatives from the three organizations presented their results during an April 14 webinar.
This research is a rare attempt to quantify physicians', rather than patients', personal motivations and concerns surrounding the issue. "It is a pretty big investment to do a survey of physicians if you want to do it right and with robust methodology which we did," says Tressa Undem, a partner at PerryUndem Research/Communication. "This is not the type of survey you see every day."
Tony Back, MD, co-director of the University of Washington's Cambia Palliative Care Center of Excellence and executive director of Vital Talk, says a key takeaway from the study is the "huge disconnect" between the beliefs and actions of the same 736 physicians who said conversations about advance care planning were important (99%) and that it was their responsibility (75%), and not a family member's or another clinician's.
Barriers to end-of-life conversations identified in the study included:
Lack of time amidst competing priorities
Disagreements between patients and their families
Uncertainty about when to broach the subject
Fear of discomfort
Concern the conversation would be conflated with giving up
Training Is Paramount
Back said that the results pointed mostly to physicians' reluctance to engage in these challenging conversations.
"Those [barriers], to me, are proxies of lack of skill," he says. "The physician hasn't learned that you can break up the conversation into little chunks… how to deal with families who don't agree… [how to] deal with the issue of whether the time is right, because actually, the time is never right."
These difficulties can be diminished with training, but only 29% of the physicians surveyed have received training. The minority of physicians who've had formal training in advance care planning and end-of-life talks are the ones more likely to conduct them.
Moreover, physicians who report having explicit training in end-of-life conversations are more likely (46%) to find conversations about end-of-life care to be rewarding than those who have not (30%), and also say they feel unsure about what to say in these conversations "rarely or not too often" (60%), compared to those who have not had explicit training (52%).
Physicians who have had such talks with their own doctors also appear to be significantly more comfortable with conducting them, according to the data.
"I think what that means is that even as a physician, you realize more clearly when you've done it yourself that you actually can do it with a patient and it won't be harmful, that you will get through it, and that actually there's some real benefit to it," Back says.
Systematizing the Process
In addition to clinician training—ideally in conjunction with community-level efforts that prime patients to think about their wishes—healthcare systems need to better systemize advance-care planning and the recording of written advance directives, the research suggests.
Specifically, only 3 in 10 respondents (29%) said that their practice or healthcare system has a formal system for assessing patients' end-of-life wishes and goals of care. And when it comes to recording that information, nearly a quarter (24%) said there was no place in their electronic health record (EHR) indicating whether a patient has an advance care plan. Among those who do have a field in their EHR for advance care planning, however, only 54% can access the plan's contents.
Correcting these problems could increase the likelihood of end-of-life conversations.
One good way to trigger the talks, says Back, is through EHR prompts that ask physicians whether they'd be surprised if the patient died within a year. "Those are a group of patients that are at very high risk for having some kind of complication where this conversation would be critically important," he says.
But physicians needn't wait until patients are seriously ill to begin the conversation. In particular, patients should appoint a surrogate decision-maker to whom the medical team can turn if patients can't speak for themselves. "And there's a best practice of having these conversations recorded in the chart in a way that's easily accessible and portable, so that these wishes could be transferred between different institutions," Back says.
The CMS benefit is designed to include these varying circumstances. Specifically, CPT code 99497 covers a discussion of advance directives with the patient, a family member, or surrogate for up to 30 minutes. An additional 30 minutes of discussion takes the add-on code of 99498. These services can be offered and billed as part of Medicare's annual wellness visit.
Medicare will pay a standard amount of $86 for 99497 in a doctor's office and $80 for the service in a hospital, and up to $75 for 99498.
From Best Practice to Standard Practice
A main goal of the research and investments surrounding advance care planning are to make these conversations not just best practice, but standard practice, says Terry Fulmer, RN, president of The John A. Hartford Foundation.
"It wasn't too many years ago when it would be very uncomfortable to ask about organ donations. So think about it if you say to somebody 'If your teenager gets in a car crash can we harvest their organs to save other lives?'" Fulmer says. "How much more sensitive can you get than that? Just like that, where currently we have something on a driver's license… we will get to this because people want it."
Finally, although physicians are well positioned to help this vision become reality, various members of healthcare teams can and likely already contribute to this ongoing dialogue with patients.
As a result, the next phase of research by these three groups will involve focus groups with nurse practitioners, social workers, and others. That work should be underway immediately and results may be available in June.
CMS’s new primary care payment model represents an opportunity for physicians practices experienced in care redesign to be compensated for those efforts. It signals to all groups that it’s time to get serious about improving outcomes.
Major physician groups are applauding the Centers for Medicare & Medicaid Services’ announcement last week about its Comprehensive Primary Care Plus (CPC+) payment model, the new-and-improved successor to its CPC program.
On April 19, CMS conducted a webinar to describe how the program will affect participating practices. Laura Sessums, MD, the CMS Division of Advanced Primary Care director, said “CPC+ will offer practices many benefits: the ability to provide enhanced care for patients and improve their outcomes, engagement in a robust learning community of other practices working hard on care delivery redesign, and involvement with payers providing aligned payment, quality measurement, and payer data sharing.”
While many details about the five-year, multi-payer program remain forthcoming, Shari Erickson, vice president of government affairs and medical practice at the ACP, has already been getting calls from members (especially those participating in the soon-to-sunset CPC program) looking to learn more. “They want to know how they can encourage their local payers to become engaged or continue to be engaged with CMS on this project,” she says.
With room for 5,000 practices (2,500 in each track) to enroll in CPC+, Erickson expects that many groups experienced with medical-home related initiatives will dive in.
Applicants must meet minimum requirements to be in the running at all. “To participate in CPC+, practices must enter the model with some experience in care delivery redesign beyond that seen in traditional primary care,” Sessums said.
“This experience will be critical to ensuring the practices have the capability to do the work of the model and achieve its aims. We expect that practices applying to either of the two tracks will have some experience with improving patient access to care, with defining their patient population as a whole, and quality improvement.”
Practices in both tracks will be expected to carry out five primary care functions or “corridors of action,” Sessmus said; Track 2 practices will do so more intensively:
Access and continuity
Comprehensiveness and coordination
Patient and caregiver engagement
Planned care and population health
More information about these functions should be available on the CPC+ website later this week.
Readying for Value-Based Pay
Medical groups that have not yet gained proficiency in these elements, however, can still benefit from studying CPC+ specifics, Erickson says.
“For those practices that maybe aren’t able or ready to get into this project, it paints a clearer picture of what they can expect from Medicare as MACRA rolls out,” she says. “Even if this project isn’t determined initially to be an alternative payment model, it gives us a pretty good idea what CMS is thinking should be in an APM, particularly for primary care.”
According to this week’s webinar, CMS has not yet determined how CPC+ and MACRA will intersect.
Nonetheless, practices that haven’t begun readying themselves for value-based reimbursement in general need to start, according to Pamela Ballou-Nelson, RN, MSHP, PhD, PCMH, CCE, a senior consultant with the Medical Group Management Association.
“All of the payers are going to be moving to some sort of value-based model of reimbursement, and it will be based on clinician efficiency, which will be both quality oriented for patient outcomes and also dependent upon clinical improvements,” she says.
Truly improving outcomes and reducing hospitalizations for patients will hinge not just on what happens inside the practice, but also beyond, Ballou-Nelson says. In particular, practices will need to get better at activating patients to adopt healthy behaviors and collaborating with community resources to address social determinants of health.
CPC+ does indeed focus heavily on meeting patients’ social and behavioral health needs. In fact, Track 2 practices will be required to have a process to link patients to community resources, Sessums said.
In reality, this work may be harder than it sounds, notes Ballou-Nelson. She gives an example of a community in Chicago whose bus company provided residents with free transportation to doctors’ appointments, but the service went unused and was on the verge of being discontinued until a practice finally began asking patients why they weren’t using it.
It turned out that patients with mobility problems or carrying oxygen needed additional help getting from door to door. When the practice placed volunteers on the bus to assist patients, uptake soared and the patients stopped missing appointments.
Optimism Around Vendor Engagement
Time is also up for practices that purchased cheap electronic health record systems while waiting to see whether the trend would stick, Ballou-Nelson says. At a minimum, practices need to invest in EHRs that are interoperable and capable of tracking the data that their contracts require.
Using an EHR is required for participation in either track of CPC+, though only Track 2 practices will have to submit a letter of support from a healthcare IT vendor that outlines its commitment to boost advanced healthcare IT capabilities to increase practices’ comprehensiveness of care.
CMS does not prescribe how that HIT enhancement be achieved, however, only that it meets the needs of the practice team to achieve the CPC+ objectives.
“That seems encouraging because one of the frustrations our members have had with EHRs as a whole is that many of the vendors have needed to build their EHRs to meet regulatory requirements of Meaningful Use and documentation requirements of E/M coding,” the ACP’s Erickson says. “And with all of that work [vendors] don’t really make any space, so to speak, to more specifically build out what practices need on the ground based on the way practices actually function.”
While new data confirms that the stability of the physician workforce is as precarious as ever, a multi-specialty group's CMO explains how reducing burnout is an achievable goal.
Physician burnout is threatening to engulf the provider workforce, a Mayo Clinic study published this month suggests.
By analyzing physician surveys in conjunction with payroll records, investigators found that for every point increase in the seven-point scale of emotional exhaustion, one of three domains measured by the Maslach Burnout Inventory, there was a 40% greater likelihood a physician would cut back his or her work hours over the next 24 months.
They found a similar relationship for every one-point decrease in the five-point scale measuring professional satisfaction.
And contrary to stereotypes, this trend was not linked to a greater proportion of women physicians or younger physicians reducing professional work effort, Tait Shanafelt, MD, professor of medicine at Mayo Clinic and lead author of the study, told me. "Rather, it was primarily due to an increased proportion of men, particularly male physicians over age 55, reducing professional work effort."
The Cost of Ignoring Alarms
Compounded with a predicted physician shortage and not counting the 89% of respondents to a 2015 Cejka Search survey wanting to change jobs, cut back, or leave medicine, these findings obviously aren't good news for healthcare leaders.
"These results have important repercussions for healthcare organizations seeking to maintain a productive and engaged physician workforce," says Shanafelt. "Burnout is, in large part, a system issue. Organizational efforts to address the problem must address the drivers of burnout, including problems with excessive workload, inefficiency in the practice environment, loss of flexibility and control over work, and barriers to healthy work-life integration."
It's not uncommon, however, for leaders to regard burnout as an emotional issue rather than a business one, according to Karen Weiner, MD, chief medical officer at Oregon Medical Group. This mindset is seemingly unique to healthcare.
"In any other industry, if we were to pull together the CEOs and say, 'you are burning out your primary revenue generators faster than you can replace them,' it would be an all-hands-on-deck emergency situation where every technology, every innovation is focused on sustainability models for that valuable and limited resource," says Weiner. "In medicine, that's where CEOs and leadership needs to be."
The Mayo study may help leaders get there. "If you want to quantify your risk for losing physicians in the coming year, run the Maslach Burnout Inventory on your physicians. You can translate that to an ROI if you want to, if you need to, to direct resources toward improving burnout."
The cost to replace a physician, Weiner notes, ranges from $250,000 to $500,000.
An Outdated Culture
As a physician and leader, Weiner knows first-hand how this exercise can impact an organization. In 2013, when she was on the board of directors and practicing full-time at Oregon Medical Group, morale was at an all-time low.
"We were at a crisis point where we had a lot of angry, frustrated physicians," Weiner says. Perhaps not surprisingly, the MBI revealed that 58% of the group's physicians were experiencing burnout.
"We had implemented our electronic medical record [system], and that really highlighted all of the dysfunction we had in our group. The culture that we had developed over the decades prior had worked well [until] then, but the environment was changing and our culture wasn't conducive to being able to meet the needs of the changing market."
With that impetus to change, the physician-owned group took several measures to update its culture, including articulating a new vision and generating the group's first physician compact, which stated "the new rules of engagement," Weiner says.
"In retrospect, the biggest deficit in our group was lack of community, that we did not have the collaboration that we needed to get anything done," she says.
But once the physicians jointly agreed on the group's new vision, which is to collaborate to provide the highest quality of patient-centered care, their unity became more powerful than the problem. "Once collaboration was in place, everything [else] was doable," Weiner says.
When the group conducted follow-up burnout surveys two years later, the incidence of burnout had dropped significantly, she notes, but there was more work to be done.
"In our progress, we've achieved collaboration and we're trying to remove barriers to providing care because that's always a frustration to physicians and it's not good for patient care. So removing the waste in the system makes everybody's work more rewarding," she says. "It's ongoing. It's small, incremental improvements."
Part-Time Is Better Than No-Time
It's important to note, though, that some of these adjustments involve the very consequence that the Mayo study illuminated: Giving depleted physicians the ability to work less. As of today, Oregon Medical Group has several physicians who work one day per week in the walk-in clinic or jobshare as part of a primary care team.
"An organization has to understand that it has to be flexible—not just flexible—but they have to develop models that work to salvage people," Weiner says. "That resource is so valuable that we have to make it work. And that's what we've done. We have quite a few physicians that would have been gone otherwise that are contributing to care in the community."
Shanafelt agrees that having a part-time physician is better than a physician leaving medicine altogether. "Organizations that provide physicians the flexibility to adjust work-effort to preserve meaning and satisfaction may have a competitive advantage in recruiting and retaining physicians," he adds.
"There is a societal imperative, however, to provide physicians a better option than choosing between reducing clinical work or burning out. Large numbers of physicians reducing their professional effort due to burnout would exacerbate the already substantial projected U.S. physician workforce shortage as well as impact continuity of care for patients," Shanafelt says.
The elephant in the room is the idea of offloading non-physician work to others, specifically, APRNs.
In addition to the cultural changes required to implement team-based care, there are practical ones, especially regarding standardization. "You can't offload work from physicians unless that work is standardized," says Weiner, "because you have to be able to know what work you're giving away and making sure that work is getting done."
And you can't standardize work without physician engagement, Weiner adds. And you can't create physician engagement without collaboration.
And without leadership committed to understanding how physicians are balancing their work and life responsibilities, you can't get the fight against burnout even started.
Failure to do so could snuff the life out of the fledgling MSSP program, which includes fewer than 500 total members, but represents nine out of every 10 ACOs.
That's the claim of 22 organizations, including the American Medical Association, Medical Group Management Association, American Medical Group Association, American College of Physicians, and various specialty societies that signed a joint letter to CMS Acting Administrator Andy Slavitt on March 25.
Although the groups support the transition to regional benchmarks, they asked CMS to revisit several details. "While we recognize and appreciate CMS's efforts in this notice of proposed rulemaking to improve program methodologies to retain and attract [accountable care organizations] ACOs, we emphasize the critical need for the agency to further modify the program to address other critical issues such as quality measurement, risk adjustment and unstable assignment to ensure a successful future for this program," they write.
Expansion from One-Size-Fits-All If CMS takes these comments to heart, the implications would be substantial, according to Suzanne Falk, MGMA associate director of government affairs.
"The program right now just isn't having the kind of numbers behind it to justify expanding it, which is what CMS is trying to do as we move toward an alternative payment model environment," she says. In 2014, about a quarter of Track 1 ACOs earned shared savings, she notes, and nearly half generated losses.
"These benchmarking changes are really critical and they do definitely improve by incorporating in those regional cost data, creating a more accurate picture. But they're still sticking with kind of that one-size-fits-all approach that misses the mark. And because the program is voluntary, we really need that to be flexible in order to attract new and different types of ACOs," Falk says.
Finalize, with modification, blending ACO historical and regional cost data into ACO benchmarks
Provide ACOs with maximum flexibility and choices related to transitioning to benchmarks that comprise a component of regional cost data
Focus on comparing ACO performance relative to fee-for-service Medicare by excluding ACO assigned beneficiaries (for all ACOs in the region) from the regional beneficiary population
Honor the current policy that accounts for savings in rebased benchmarks, rather than punish ACOs that worked hard to earn savings in previous agreements
Modify and enhance the proposal to reopen ACO determinations to include greater opportunities for ACOs, especially when CMS errors are the cause, and shorten the timeframe from four to two years
Overall, these requests urge CMS to be less aggressive and more flexible in the way it implements new benchmarks. Because of the considerable investment of time and money involved in becoming an ACO, medical groups need assurance that the effort will be worthwhile.
Upping Participation and Retention
To boost participation, "we really need to incorporate flexibility in the way that they approach and reward different types of savings, whether that's improving on past savings or just being a consistent low spender relative to your region or nation," Falk says.
"What they really need to do is create a pathway to recognize past savings specifically, and to incorporate more flexibility into the benchmarking overall."
These elements are also integral to preventing more MSSP dropouts, according to Yul D. Ejnes, MD, a past chair of the ACP board of regents and member of a Rhode Island MSSP group practice. While the general premise of moving to regional benchmarks should help high-performing groups continue to achieve incentives, he notes that the nuances need to be friendlier for smaller players as well.
"The dropout rate is a concern," Ejnes says, especially given that some of the ACOs that have dropped out are groups that are known to provide high-value care. So that if the model can't work for them, how's it going to work for some of the less able groups?"
A MACRA Must
Perhaps one of the biggest factors for healthcare organizations contemplating participating in the MSSP is whether these ACOs will qualify as an alternative payment model under MACRA, the Medicare Access and Children's Health Insurance Program Reauthorization Act.
Though the question is not addressed in CMS's proposed rule, the commenters explicitly call on the agency, in their letter, "to allow physicians participating in all MSSP ACOs to qualify for MACRA APM incentive payments, provided they meet the threshold levels of revenue or patient participation required by the law."
Ejnes and Falk agree that this provision is a must.
"We're all kind of waiting on the edge of our seats here for the proposed rule that deals with the implementation of MACRA," Falk says. On behalf of MGMA members on the fence in deciding whether being part of an ACO will benefit them, the group is sending a firm message to CMS: "Given how large a component the MSSP is to the ACO program, you really need to incorporate that as qualified APMs under MACRA or you're going to totally just kick the wind out of the sails of the entire ACO program," Falk says.
Two physician leaders share key lessons learned about how organizations can partner with physicians to foster leadership best practice among aspiring clinical administrators.
Many scientists believe that the rapid expansion of a very hot, dense, single point in space nearly 14 billion years ago spurred the formation of the 100-billion-galaxy-universe we know today.
When Sutter Medical Group merged with three affiliate groups in January 2011—exploding its physician count from 353 to 514 almost overnight—the Northern California organization experienced a Big Bang of its own.
And as if coping with the four-way culture collision and related aftermath didn’t create enough of a leadership challenge for the newly formed multispecialty group, a year into the merger, there was another change.
Samuel J. Santoro, DO, FACOG, who had been serving as the group’s board member, OB/GYN department chair, and division vice president, accepted the position of chief executive officer for one of SMG’s affiliate groups.
“While this was an amazing opportunity for Sam, it really highlighted our vulnerability in the medical group,” Lee Anne Wong, MD, SMG’s director of recruitment and retention, told attendees at the American Medical Group Association’s annual conference earlier this month. “We had several excellent physician leaders who wore several hats each. We didn’t have an identified pipeline of individuals who were ready, willing, and able to fill those empty seats. And we didn’t have a good way of identifying future potential leaders.”
Wong and her colleague, Sue Gotelli, director of physician leadership development for Sutter Health, the system to which SMG belongs, shared their story at the conference believing many organizations across the country would relate.
“I think a lot of people have had the same experience with rapid growth of medical groups and mergers and acquisitions,” Gotelli told me by phone after the conference. “What people realize is that the bigger the group, the more structure you need to keep it running well, both from a management perspective and a leadership perspective.”
As the Sutter team worked to address its difficulties with physician leadership development and succession, the lessons learned were of somewhat cosmic proportions as well. I’ve narrowed them down to five themes:
1. Physician Leader Roles Have Multiplied
Physicians have more opportunities to get involved in leadership or administrative medicine today than in years past, Gotelli says, thanks in part to the healthcare industry’s intensifying focus on population health management.
“Payment models are changing and looking at how we treat populations of patients with specific clinical conditions, so there’s a need for a lot of service line leaders,” she says. “There’s also a big movement in patient safety and [need] for clinical quality leaders such as chief medical officers, which a lot of physicians aspire to. Some physicians are actually interested in operations and roles are opening up for them as well.”
2. Succession Planning Can Begin at Recruitment
Along with expansion of leadership opportunities, the timeframe in which physicians can begin their leadership track has also widened. Increasingly, physicians interviewing for jobs right out of training express interest in opportunities to grow and develop as leaders, says Wong, a practicing pediatrician and recruitment leader.
“I don’t think the obstacles that were true a generation ago are true now for incoming new practicing physicians,” Gotelli adds. “I think they’re actually interested in leadership. They want to have a bigger voice. And we have a need for leaders at all levels.”
3. Leaders Are Made, Not Born
Among many more seasoned physicians, however, participating in the administrative side of medicine isn’t something they’ve contemplated—and they often feel unprepared to pursue opportunities that arise, according to Gotelli.
“They stumble a little bit until they realize there is actually science behind leadership development, that there are known things people can do and practice to get good at it,” she adds. “And when they really understand this is not something you’re just born with, that you can work on it, I find physicians to be great students who can put [leadership] concepts into application very quickly.”
To help aspiring leaders foster these skills, Sutter Health offers formal leadership education that focuses on ‘four Es’ of development: exploration, experience, exposure, and education.
“One of the best ways organizations can help physicians or any leaders grow and develop in their leadership roles is to give them experiences to put their leadership skills to action,” Gotelli says. “I think organizations that take this seriously are looking at proactively creating opportunities for people to get exposure and experience.”
4. Best Practices Aren’t Just for Medicine
Physician leaders need not just skills development, but also ongoing support and resources. When clinicians become medical directors or service line leaders, they need precise job descriptions, information about how to perform tasks, names of people available to help, and more, according to Wong.
One way SMG began better supporting its was with the creation of a monthly ‘bounce it off’ session, during which division vice presidents and medical directors gathered to talk about what was going well with their roles and where they needed help.
“We are used to talking about clinical best practice, but we don’t always talk about leadership best practice,” Wong says. These sessions, more formally renamed Sutter Medical Group Leadership Meetings, provide leaders with not just networking opportunities, but also teambuilding opportunities.
Importantly, the meetings help physician leaders recognize they’re not alone. “I think sometimes in our leadership roles we feel like we have to have all the answers, and rarely do we have all the answers,” Wong notes.
5. Money Matters, to a Point
Although Wong and Gotelli’s presentation didn’t address compensation for leadership work specifically, audience members, many of whom were physicians, were curious about whether Sutter’s physician leaders got paid for their administrative work.
The answer, according to Gotelli, is yes, but the amount isn’t necessarily representative of leaders’ full efforts. “It’s very important to offer financial incentive,” she says. “And I agree with [physicians] who say it’s sometimes a thankless job. Especially for folks that are in subspecialties where the compensation is a little higher, it’s difficult to attract them to leadership roles because they’ll invariably lose money doing it.”
Most of the physician leaders at SMG maintain a full clinical practice and receive additional compensation relative to a 0.2 to 0.4 full-time equivalent, Gotelli says. “It’s very, very difficult to keep all those balls in the air, and another thing we need to do better is to compensate physicians adequately for the time they’re spending on leadership roles,” she says.
What truly motivates almost all of the physician leaders she’s worked with, however, is the ability to impact greater numbers of patients by being a leader than through one-on-one care alone.
“Most successful physician leaders I’ve seen have had some sort of aha moment,” Gotelli says. “It’s a bit of a leap of faith. You can’t really explain it to someone until they experience it.”
The final rule on payment reform under MACRA may be weeks away, but providers are bracing for it as they mull two new payment tracks and await clarification on several key terms found in the legislation.
It’s going to be huge. “It’s changing how we measure and deliver care going forward. It’s almost revolutionary,” says Darryl Drevna, director of regulatory and public policy for the American Medical Group Association.
What is ‘it?’
We’re talking about MACRA, the Medicare Access and Children’s Health Insurance Program Reauthorization Act. The bipartisan law passed last April to finally end the 17-year tyranny of the Sustainable Growth Rate formula for physician reimbursement under Medicare.
I chatted with Drevna and his colleague, Chet Speed, JD, LLM, vice president of public policy for AMGA, at the association’s annual conference (where MACRA was a hot topic) earlier this month and again by phone this week.
To backtrack briefly, when MACRA first passed through the House and Senate, major medical groups including the AMGA, the American Medical Association, the Medical Group Management Association, and the American Academy of Family Physicians cheered the demise of the SGR, and welcomed the financial stability offered by MACRA.
A few months after the law’s passage, I spoke with Dennis M. Dimitri, MD, president of the Massachusetts Medical Society, about the impact MACRA would have on physicians within my home state. His comments were mostly enthusiastic. “We no longer have the threat of 20% to 30% cuts in payment hanging over our heads,” he told me. “We have finally and completely replaced the flawed SGR formula.”
When I revisited with Dimitri on the topic from a national standpoint the other day, the practicing family physician added a crucial note to his original sentiment: “The devil will be in the details.”
2017 Reporting Period Poses Problems
We have a general idea of what MACRA’s two new payment tracks will entail:
The Merit-Based Payment Incentive System (MIPS)—aka ‘a new and improved fee-for-service’
Alternative Payment Models (APMs)—aka ‘ACOs on steroids’
But the Centers for Medicare & Medicaid Services (CMS) isn’t expected to release its proposed rule with the specifics until later this spring.
That’s a problem—even for the large medical groups best-positioned to bear risk, according to Speed. He notes that AMGA members generally reap at least $500 million in annual revenue and mostly have strong infrastructures in place.
“I’d say one-fourth of our members have already taken risk and they’re good at it and happy with it,” he says. “But for the three-fourths that haven’t really dabbled in risk, they’re the ones that are looking at the 2019 date and saying, ‘Wow, that’s not a whole lot of time to get ready.’”
Part of the trouble with the timeline, experts note, is that the financial rewards and penalties to be issued beginning in January 2019 will be based on data medical groups submit starting in 2017. So if CMS’s final rule regarding MACRA drops in November 2016 as expected, groups will have just 30 to 45 days to learn exactly what they’ll be measured on and start working toward those measures, Drevna explains.
The MMS is one group that is advocating for more time, Dimitri says. It is “pushing to try and move that 2017 data collection date off a bit because we aren’t sure that practices are really going to be prepared to do that, given that the rules aren’t available yet.”
What Does ‘More Than Nominal Risk’ Mean, Anyway?
During a U.S. House Energy Subcommittee on Health hearing last week, Patrick Conway, MD, deputy administrator for Innovation and Quality and Chief Medical Officer at CMS, acknowledged that the agency has yet to define several key terms found in the MACRA legislation.
In particular, the law states that to qualify as an APM, a medical group will have to take on “more than nominal downside risk.” That final definition will matter a great deal to AMGA members, says Speed, particularly surrounding the question of whether Track 1 ACOs will qualify.
“Track 1 ACOs don’t take downside risk; that’s why most of the ACOs are Track 1,” Speed says. “But the argument may be that ACOs say we’ve invested in some cases multimillion dollars in developing the infrastructure to be an ACO, and those payments we’ve made are not reimbursed, so in essence those are a risk.”
Other eagerly awaited details surround the design of the multiple APMs that will exist. Although CMS has actively engaged various medical societies in developing measures that will be relevant to different specialties and practice types, the American Academy of Dermatology Association (AADA) submitted a statement of record on March 17 urging “a gradual, phased-in approach to the MIPS and APM provisions in MACRA, that recognizes the unique challenges of specialty care.”
Choose Your Adventure (Both Look Dicey)
Despite the multitude of unknowns, physician practices are tasked to decide whether they’ll set out (switching in ensuing years is allowed) on the MIPS or APM path. While many organizations, such as the AAFP and various specialty societies, have made the public commitment to help their members navigate the entire MACRA journey, MMS’ Dimitri admits the work is daunting.
“What we are struggling to try and do as a medical society is help our physicians understand what these alternatives would mean for them—MIPS versus APMs—and what will work best for the practices of physicians and the patients that are being taken care of in those practices,” he says.
As for AMGA membership, made up of mostly large multi-specialty group practices, the MIPS or APM question remains widely unanswered, Speed says.
“To be brutally honest, most of them have not decided,” he says. “I think from our members’ perspective, they want to be an APM because it gets them out of a fairly rigorous MIPS measurement regime, and also there’s a 5% bonus to their Part B reimbursement—that’s a significant incentive. The way the APM provision is drafted, though, it’s a fairly high hill to climb to become an APM.”
What’s more, though MIPS may more closely resemble the FFS world physicians are used to, its pay-for-performance methodology (to be tracked by consolidating three existing quality reporting programs and adding a fourth surrounding practice improvement activities) presents its own set of hazards.
“It’s interesting,” notes Speed. “APM is obviously [a] risk, but MIPS is also. It’s a very aggressive risk-taking schedule. It’s 4% plus or minus in 2019, and by 2022 you could have a swing of 18% on your Part B revenues. That is a risk no matter what you say.”
Small Groups May Seek Help
As a result, there’s industry suspicion that MACRA will drive increased affiliations between small physician groups and larger organizations.
“We’ve heard anecdotally that smaller practices look at MIPS and say, ‘I can’t do that,’ and look at APMs and say, ‘I can’t be that,’” says Speed, suggesting they may seek safe harbor by becoming more closely integrated with larger groups, hospitals, and health systems. Large organizations appear to already be figuring some of these prospective relationships, which may or may not amount to full-blown sales and acquisitions, into their business strategies, he adds.
Although the MACRA legislation does set aside a collective $100 million in funding and technical support for practices that are small or located in rural or medically underserved areas, money for which the MMS helped advocate, Dimitri agrees that more partnerships may ensue.
“One of the things we may see is that a number of physician practices may try to figure out ways to be virtually organized in fashions that allow them to put together the resources to be able to deal with these complex needs,” he says.
More Challenges, Questions Ahead
Judging from the recent subcommittee hearing, Congressional sentiment appears strong to see that CMS implement MACRA in line with its intent, which is primarily, as the title of the bill says, to ensure Medicare access.
“I think [members of Congress] view this as a really strong step forward,” AMGA’s Speed says. “I think they want CMS to implement it the way they want it to be implemented. At the same time, I think they’re beginning to hear from their doctor constituents that it may not be as easy as they thought it might be.”
Patient experience experts from the Cleveland Clinic make the business case for meaningfully connecting with patients, also known as consumers.
How to give patients a better experience is no longer the mystery it was a decade or so ago. Hospitals and providers are more aware than ever that communication matters, that empathy matters, that even serving lasagna that patients actually want to eat can make all the difference in how a person feels about a hospital stay or medical encounter.
But with competing priorities such as patient safety, quality, and other elements that visibly impact the bottom line, the 'why' for investing in strategies such as leadership rounding, communication training, behavioral interviewing, score transparency, and promoting a culture that makes those measures effective can still be a tough sell, according to a pair of conference speakers.
Lori Kondas, MBA, senior director for the office of patient experience at the Cleveland Clinic, and Joshua Miller, DO, FACP, medical director of the Cleveland Clinic Willoughby Hills Family Health Center and associate medical director of Cleveland Clinic regional operations referred to the urgency and importance of making these commitments as 'the burning platform.'
Why Patient Experience Matters
"Patient experience" as a buzzword dates back to the early millennium, when the Centers for Medicare & Medicaid Services began publicly publishing Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores for individual hospitals on its Hospital Compare website in 2008. In 2012, the stakes got even higher when a portion of hospital reimbursement became tied to HCAHPS performance.
While the penalties for sub-par performances have increased slowly, however, the dollars now are substantial. By 2017, HCAHPS scores will determine up to 2% of a hospital or health system's Medicare payments.
"The risk for not giving patients a good experience financially now becomes very high, so hospitals or practices that don't stand behind the fact that we need to take care of our patients both behaviorally and clinically stand to lose a significant amount of money," Kondas says.
What's more, there are several other ways patient experience indirectly, but cumulatively influences the bottom line, notes Miller. The industry's shift toward value-based care is only one.
"We'll sit down with our doctors and say, 'We really care about this.' We'll talk about narrow networks, how [payers] will drop physicians and things of that nature potentially on scores, so we need to start paying attention to it now or we're going to pay later because of it, either from a malpractice suit or other financial consequence," Miller says.
Meanwhile, the healthcare industry must also accept being in the midst of the age of consumerism, adds Kondas. "It really is patient experience overall that drives people toward where they choose. With that increasing amount of transparency that we talked about, patients can see what others think about you," she said.
"It's sort of like TripAdvisor. You can go anywhere and learn about a healthcare system—and not just about what the quality of care was, but how [consumers] were treated."
Cleveland Clinic's Turnaround
At the Clinic—a large, nonprofit, multispecialty academic health system made up of nine (soon to be 10) hospitals and conducting nearly 6 million patient visits per year—leaders started feeling the heat in 2008 when faced with HCAHPS scores well below the 50th percentile in several categories, particularly surrounding communication.
This wake-up call spurred the Cleveland Clinic to get serious about patient experience, leading not only to increases in system-wide training on communication and service, but also to the creation of the Clinic's first annual Patient Experience Empathy & Innovation Summit in 2010. Over the course of the past eight years of intense focus, the system's scores have steadily climbed.
Incidentally, I participated as a panelist in a discussion about healthcare social media at the 2011 Summit. Since then, the national event has truly taken off, Kondas told me after her presentation, now drawing more than 2,000 attendees—a roughly 10-fold increase since its inception.
The Challenge of Buy-in
Nonetheless, despite the growing interest in the topic, getting leadership buy-in to invest in patient experience—regarded by some as the "soft and fuzzy" side of medicine—is not a given, according to Kondas. "How do you help people who have an eye for the bottom line, an eye for resources, to really believe this is something worth focusing on?"
The predicament seemed to resonate with attendees. Based on a quick poll of the audience, made up of roughly equal parts physicians and administrators, about 75%, rated their organizations' cultural readiness to prioritize patient experience at a modest 5 out of 10.
Granted, it's not always leadership that needs to be sold on patient experience. Some reticence can be attributed to physician attitudes. In another informal poll of the room, Miller asked, "How many of you have physicians at your organizations who say, 'the scores aren't real'?"
"The scores are real," Miller said while looking out over the raised hands rippling through the room. "It's what the patient thinks and feels."
Miller went on to describe some of his own experiences with patient feedback and the importance of addressing comments and complaints. A patient who is angry about a long wait before an appointment, for example, is more likely to be distracted by that frustration and less engaged in talking over medical concerns with the provider, potentially snowballing into poor adherence, which may in turn contribute to a preventable hospitalization, to name just one plausible scenario.
Since 2011, Cleveland Clinic caregivers have learned how to handle these situations with a course in relationship-centered communication. "We tell the doctors it's almost like an MBA for communication," Miller says. "It's to give them more tools in their tool belt."
But these types of tools cannot be simply ordered from a supply catalog. They take time, commitment, resources, and follow-through to work effectively—a steep investment for which the returns can be tough to measure, at least immediately.
In the long run, however, caregivers who practice empathy are more efficient, according to Miller. Organizations engaged in patient experience, hiring not just for clinical skill but also behavior, see lower rates of costly turnover, notes Kondas. Patients who feel heard are less likely to sue, research has shown.
Ultimately, the business case boils down to this: "If you want patients to come to your hospital, you better make them happy," Kondas says.