Regardless of their size, specialty or level of preparedness, medical practices are concerned that the implementation of Medicare’s Quality Payment Program (QPP) will be burdensome and time consuming, according to a new survey conducted by the AMA and the KPMG consulting firm.
“It’s a big challenge all the way across” practice types, said Carol Vargo, director of physician practice sustainability at the AMA, who said this finding was the survey’s “big takeaway.”
The AMA and KPMG surveyed 1,000 practicing U.S. physicians involved in their practice’s decision making regarding the implementation of the QPP, whose two pathway options include the Merit-based Incentive Payment System (MIPS) or the adoption of an Advanced Alternative Payment Model (APM). The survey was conducted between April 25 and May 1, prior to the recent release of proposed QPP updates to the program by the Centers for Medicare and Medicaid Services (CMS).
The survey is seen as a baseline to measure MACRA implementation progress and a tool to help guide education efforts and policy decisions.
Vargo noted that doctors understand the need to move toward value-based payments, but said “it isn’t smart to do that if physicians aren’t ready.”
The AMA is working to provide a “glide path” for physicians to transition to value-based care, she said. This includes launching an educational campaign, “One patient, one measure, no penalty,” which provides physicians with resources to guide physicians on meeting the minimum requirements for this year.
“Our resources include a step-by-step video on minimum reporting requirements to avoid a penalty in 2019 and a payment model evaluator that offers a brief assessment of where a practice stands,” AMA President David O. Barbe, MD, said in a statement. “In just 10 steps, physicians can successfully meet the standard under MACRA.”
To learn more about CMS’ “pick your pace options,” listen to this recent ReachMD interview with Kate Goodrich, MD, CMS’ chief medical officer and director of its Center for Clinical Standards and Quality.
Concerns about reporting’s burdens
Widely held concerns identified by the KPMG-AMA survey include the time required to accurately capture and report performance data, understanding QPP requirements and the mechanics of reporting, the cost of performance reporting, and the organizational infrastructure needed to report performance.
Fifty-one percent of respondents said they were somewhat knowledgeable about the QPP and the law that created it, the Medicare Access and CHIP Reauthorization Act (MACRA). But only 8 percent described themselves as “deeply knowledgeable,” and 41 percent said they knew about the QPP but wouldn’t consider themselves knowledgeable.
“There’s a huge knowledge gap,” said Vargo, who was speaking at the National Alternative Payment Model and Accountable Care Organization Summit in Arlington, Virginia, where the results of the survey were released.
Participation in QPP will affect Medicare Part B payments in 2019. So, most physicians surveyed plan to participate—but the levels of readiness and participation vary greatly.
Of physicians surveyed, 56 percent plan to participate in MIPS, 18 percent expect to be a qualifying participant (QP) in an APM, 7 percent plan to participate in an APM but not meet the QP standard, 8 percent don’t plan on participating this year, and 12 percent don’t know yet if or how they may participate.
Physicians were given three “pick your pace” options for MIPS implementation:
- Full reporting, the most strenuous category in which participants can qualify for bonuses of 4 percent or more.
- Partial reporting, which includes fewer requirements, a shorter reporting period and an opportunity to qualify for bonuses of up to 4 percent.
- A test option, which only requires reporting one measure, from one patient, at any time before Dec. 31.
Of those expecting to participate in MIPS, 74 percent plan to do so through a group rather than as an individual. Thirty percent plan to do full reporting, while 25 percent intend to take the partial reporting option and another 30 percent plan to use the one measure-one patient option. Two percent plan to be in a MIPS APM and 12 percent are unsure what level their practice will participate in.
Those who’ve reported before are readier now
Participation in the CMS Physician Quality Reporting System (PQRS) or attesting to meeting requirements for Stage 2 of the electronic health records (EHR) Meaningful Use program were linked to physician QPP readiness.
Nearly 70 percent of those surveyed have begun QPP preparations, 17 percent have not yet begun, and 13 percent are unsure if there practice has begun preparations. Of those who have started to prepare, 23 percent consider themselves well prepared and 65 percent somewhat prepared.
The survey found wide variations in knowledge and preparedness between practice sizes, settings and specialties.
Ross White, a manager at KPMG’s Center for Healthcare Regulatory Insight, spoke at the ACO Summit and noted that physicians in middle-sized practices, those with eleven to 49 physicians, were among the most knowledgeable about MACRA and QPP.
It was speculated that physicians in smaller practices may be overwhelmed or weren’t participating in the program, while those in practices with more than 50 doctors might be too separated from the decision-making process.
“To be completely disengaged is not a good thing” for physicians who are not in decision-making roles, Vargo said.
While 7 percent of solo practitioners considered themselves very knowledgeable and 49 percent somewhat knowledgeable about MACRA and the QPP, 49 percent of hospital-based physicians reported not being knowledgeable.
Small practices in general were looking for help in transitioning. But, overall, 83 percent of physicians surveyed believed their practice needed more education. Among the topics prioritized by respondents were MIPS reporting requirements, QPP financial impacts, MIPS scoring methodology and clinical transformation strategies.
This was despite 45 percent of survey respondents reporting that they have already receives some QPP education or training from their practice, hospital, or health system with 22 percent attending a session sponsored by a medical society.
“Given the gaps in knowledge and uncertainty about how best to prepare for success, there is considerable opportunity for CMS, medical societies, and other interested stakeholders to help better educate and prepare all physicians,” the survey report concluded.
S. Lawrence Kocot, national leader of KPMG’s Center for Health Regulatory Insight, agreed.
“CMS can’t do it alone,” Kocot said, adding that stakeholders need to step up and help educate physicians and other stakeholders.
Vargo said physicians understand the overarching issues behind the QPP, but given how busy they are with their current practice, their chief question is, “What do I need to know today?”
Checking the box
The survey found that only 8 percent of physicians believe they are well prepared for long-term financial success with the QPP.
Vargo added that even those who are “ready to play the game” have significant concerns about the goals of the program and that this “check-the-box notion” won’t get the health care system where it needs to be in terms of overall cost and quality improvement..
Vargo was reminded of a 2015 report on the effects of health care payment models that the AMA produced with RAND Corp. Physicians at the time expressed concerns about whether pay-for-performance measures truly reflected differences in patient care and that, in one program, there was concern that bonuses were distributed arbitrarily.
“I got a bonus check. And other specialists didn’t,” said one physician quoted in the report. “Yeah, it was like the tooth fairy. I woke up, and there was check under my pillow.”
Vargo said there can sometimes be a “large disconnect” between policymakers, system administrators and front-line clinicians, but she said CMS has been a “very good listening partner” in the MACRA rule-making journey.
Mara McDermott, vice president of federal affairs for CAPG, a Los Angeles-based organization representing 300 multispecialty medical groups and independent practice associations, agreed. She said former acting CMS Administrator Andy Slavitt under Barack Obama and Seema Verma, appointed by Donald Trump, have shown flexibility and have “tried to meet physicians where they are” in this journey.
That flexibility, while needed, also can make answering individual physician questions much more difficult, McDermott said. That is because it’s hard now to provide specific guidance without knowing exactly where the physician is on the QPP path.