The plethora of health care changes, both local and national, delayed my letter to you, but for the better. Let me tell you why. The much ballyhooed Medicare Access and CHIP Reauthorization Act (MACRA) of 2015’s final rule was released Friday, October 14, 2016 (see Executive Summary). This officially confirms the Centers for Medicare and Medicaid Services’ (CMS) stated pivot away from fee for service (FFS) payments toward those tied to quality.
The good news is we have flexibility. In what is called “Transitional Year 1, 2017,” institutions have several options, which I have tongue-in-cheek labeled:
- “Nada” – Risk a 4 percent cut to Medicare payments
- “Test the waters” – No penalty, with small chance of bonuses
- “All-in” – Submit 90 days to one year’s worth of data and potentially get bonus payments
- “Alternative lifestyle” – Avoid the Merit-Based Incentive Payments (MIPS) completely by entering into an Alternative Payment Model (APM) (i.e., Comprehensive Primary Care Plus (CPC+), Next Generation Accountable Care Organization (ACO) model, etc.)
Since the proposed rule was published earlier this year, CMS engaged professional societies, providers, and other health care organizations for feedback. My initial read of the final rule points to increased flexibility and hopeful ease of reporting within the system. What’s more, Andy Slavitt, the acting administrator for CMS, said that the agency continues to take additional steps to aid small practices to:
- Reduce the time and cost to participate
- Exclude more small practices (the new policy will exclude an estimated 380,000 clinicians), increasing the availability of advanced APM to small practices
- Allow practices to begin participation at their own pace
- Change one of the qualifications for participation in advanced APMs to be practice-based as an alternative to total cost-based
Slavitt stated, “Due to these changes, we estimate that small physicians will have the same level of participation as that of other practice sizes.”
The Journey to Value (#J2V) Manifesto
Warning: Opinions expressed are solely my own and do not necessarily express the views or opinions of others.
Background: Whatever your status, specialty, techno status (philia or phobia), political views, or year of graduation, one thing that we can all agree on is that health care is changing. The pros, cons, and politics of it are far more than can be discussed in this newsletter. As an academic health care organization, our long-term growth and future will be determined by how we position ourselves as a HIGH QUALITY, LOW COST provider of health care services in El Paso, Texas.
To recap, last year, the U.S. Senate passed MACRA legislation 92-8 in the most contentious political atmosphere in generations. The message is clear; a pivot away from FFS is happening. Whether it be as a Next Generation ACO Model, CPC+, or a host of other innovation payment programs in the private and public payer space, health care payments in the future will be based on the terms of quality and value.
Where are we now? Every year, CMS provides us a Quality and Resource Use Report (QRUR), shown below. This document compares us to peer organizations on quality and cost. Those in the top-right quadrant are eligible to receive bonus payments, while those in the bottom-left quadrant are assessed a penalty. Due to a host of reasons, as an organization, we have always focused on avoiding penalties and staying within one standard deviation (SD) of the national average for quality and cost (the yellow zone). With MACRA, however, in an attempt to stay cost neutral, the lines are now blurred. Health care organizations at the bottom of the MACRA scale will be penalized to pay for incentives that organizations at the top of the MACRA scale will earn. So, although MACRA starts slowly, over time it will ramp up; winners take from the losers. It is imperative that we be a WINNER in our region.
What’s happening in El Paso? Historically, arguments that have limited our opportunities for change have been:
- “We don’t do it like that” or “We have always done it this way”
- “This isn’t Houston and Dallas”
While those were once statements of fact, they no longer hold and are dangerous schools of thought. There are presently a minimum of four groups in El Paso that are contemplating strategic clinical alignment in order to take part in ACO or CPC+ arrangements. There are already several provider groups in El Paso that are engaged in risk-based and quality-based contracts that, over the last few years, brought in millions of dollars. Moreover, as part of MACRA, CMS outlines an option for smaller groups to remain competitive – virtual groups. This will force and incentivize groups to align, coordinate, and cooperate in order to avoid penalties and compete with larger groups for a fixed pot of incentives. As El Paso grows in population and economy, private groups such as Privia and Komedix are making in-roads to offer patients with the ability to pay for alternative clinical options to compete with the status quo.
What do I believe we have to do? We have made, and continue to make changes. Our faculty numbers are growing, and our mission of education is strong and growing. We made, and continue to make investments in health care technology to give us the ability to measure ourselves transparently, and then manage the change (my view on health care technology – https://youtu.be/75jLiWzeO9U). These investments have allowed us to attest to Meaningful Use (MU) at a 90 percent rate over the last few years. We have many of the best physicians in El Paso. However, this is not enough. A fundamental change in how we take care of patients is needed to ensure we remain competitive over the coming years. In my mind, some of these changes include:
- Acting as a UNIFIED, multi-specialty practice and NOT a loose alignment of clinical entities.
- Showing dedication to the measurement of clinical quality (however it is measured) and deliberate responsibility lines to monitor and improve areas where we fall short.
- Ensuring that we engage and integrate our clinical information sets with our partners; there is no way to manage a complicated group of patients if we do not know when they go to the emergency room, urgent care, or a community pharmacy.
- Empowering all members of the health care team — CMAs, LVNs, RNs, NPs, PAs, care coordinators, and case managers — so that care is given to a patient by whoever is responsible for that care. The world in which a physician manages 1,000 patients is in transition. Instead, the health care team will manage 10,000 patients with only the sickest and those requiring interventions seeing a physician.
- Aligning clinician compensation to incentivize value of care over quantity of services.
Many of these things, we are already doing as an organization, either through Clinical Information Systems (CIS) projects — EMR, Enli Care Manager, Clinical Worklist, and a host of things that the CIS team does tirelessly to ensure the infrastructure exists. Equally important is the work multiple clinics are doing in various Healthcare Effectiveness Data and Information Set (HEDIS) projects collaboratively with the Office of Clinical Informatics (OCI). The Transforming Clinical Practice Initiative (TCPI – see OCI updates below) is an exciting next step in our #J2V, as it will help us align our technology with our clinical process and the measurement thereof. At the end of the day, as they say, “This isn’t rocket science,” but it will take the willingness to change and a dedication to be transparent about the things we do well, and those we do not do well. We require the ability to measure everything — both clinical and business measures — and then use this data to identify processes that require change. It is imperative that changes sync with the best interests of our patients: patient experience and patient engagement. For the naysayers who don’t believe it can be done, our current MU success rate is 91 percent, with only a handful of providers missing just a few measures to get to 100 percent success.
The Digital Health team stands poised and willing to work with all departments and clinicians to ensure we make this transition successfully. It will not be easy. It will not be seamless. There will be bumps in the road, but I believe we are the best multi-specialty group in West Texas. Working together, I am confident we can make our #J2V show this.
OCI updates: The TCPI has begun! OCI is excited to partner with Vizient and other academic health centers across the country (Emory, University of Florida, Yale, and Moffitt Cancer Center) on our #J2V —large-scale practice transformation to align with value and quality. We are in the benchmarking and assessment stage presently. As this process moves forward, updates will be provided.
As MU phases out and is replaced by MIPS scoring, OCI is happy to announce that this year, the institution has passed 90 percent compliance at the earliest time of the year-ever! Thank you to all the providers and staff who assisted in making this the best MU year so far!
CIS updates: We are all looking forward to the upcoming town halls in all the clinical departments. The main purpose of the town hall is listen to YOU, the clinical end user. CIS hopes to gather feedback so the team can improve how we serve you, our customers. The goal is to implement and update tools needed in the clinical areas, and identify what our customers’ priorities are over the next year.
The PACS system, used primarily by the surgical sub-specialties, is undergoing an upgrade. We expect this upgrade will be completed by November 28, 2016. When the upgrade is complete, the PACS system will allow users to access clinical images taken at Texas Tech Physicians of El Paso from Apple and Android (Samsung) devices without having to be on a laptop, and equally important — with zero administrative rights required on the users’ devices.
So, What (Else) Is New?
Digital health rotations: Medical students at the Paul L. Foster School of Medicine began to do elective rotations with CIS and the OCI as part of a Digital Health rotation. The rotation is broken into two weeks with each group. During the rotation, the students learn about the clinical systems used at Texas Tech University Health Sciences Center El Paso (TTUHSC El Paso), as well as the policies, processes, and vision related to digital health. Nursing informatics students from TTUHSC (Lubbock) have also begun to do rotations and capstone projects with the Digital Health team. We are very excited about continued collaboration and positive engagement with all spaces on our campus and beyond.
Texas Tech Physicians of El Paso (TTP El Paso) at Transmountain: The TTP El Paso at Transmountain Cerner project is officially live. There are a few interfaces that are still being worked on, and training for the physicians at TTP El Paso at Transmountain will start this week. Future integration into University Medical Center (UMC) of El Paso and The Hospitals of Providence (THOP) is being re-assessed due to delays from our clinical partners. Providers working at TTP El Paso at Transmountain will be the first in El Paso to utilize Electronic Prescription of Controlled Substances (EPCS). No more triplicate scripts for them!
Digital Health Bytes
- 7 MIPS must-knows – Read here
- Telehealth hits mainstream – Read here
- Uber for health care – Read here
- The end is near – Read here
- The future of payment in Texas – Read here
Please feel free to contact me with any questions regarding our role in the digital transformation of health care.