Hartford Business Journal

8 Hartford Business Journal • August 15, 2016 www.HartfordBusiness.com Many docs wary of Medicare reimbursement shift By John Stearns jstearns@HartfordBusiness.com M ACRA almost spells macramé, which is ironic given that the acronym for the new Medicare reim- bursement rules doctors are facing seems to have more than a few physicians' stomachs tied up in knots. The Medicare Access and CHIP Reauthorization Act that Congress passed last year, better known as MACRA, represents a major change in how doctors will be paid for treating Medicare patients. The Centers for Medicare & Medicaid Services is looking at quality and cost in the new system, said Mat- thew Katz, CEO and executive vice president of the Con- necticut State Medical Society. "If you save the system money, you get added payment," he said. "If you cost the system money, compared to a bench- mark, you lose some money. That's essentially the structure." Today, doctors are paid a fee for service. That doesn't go entirely away under MACRA, but more of a doctor's pay will be tied to care quality and outcomes based on metrics, some already in place but not mandated, that some area doctors say are complicated and sometimes irrelevant to patient care. Their reimbursement could rise or fall based on those performance measures. Connecticut doctors interviewed for this story, who were recommended by the medical society as represent- ing a cross-section of practices, all support the need for cost savings, but not in ways they say could harm the doctor-patient relationship and care. They don't like the prospects of being penalized financially for missing benchmarks that may not apply to every patient. Some advocate delaying implementation of MACRA and others fear it could hurt solo and small practices, forcing them out of business or to join larger groups with more resources to deal with the system. The first reporting requirements under MACRA, for which public comment has ended and final rules are expected to be published in November, begin in Janu- ary. In theory, the 2017 program year will see the shift to MACRA, with payment adjustments applied beginning in 2019, the medical society said. Despite the significant changes looming since MACRA was signed into law last year, accounting and consulting firm Deloitte found that half the 600 doctors it surveyed recently about MACRA had never heard of it. Sarah Thomas, managing director for research in the Deloitte Center for Health Solutions in Washington, D.C., said she wasn't surprised by that finding, but "I was surprised that even doctors with a large share of Medicare patients didn't know it." That highlights the need for educating doctors quickly about the law — no small feat considering its complexity. "If we do not educate, we're going to have a mess on our hands — and that needs to happen and needs to happen immediately," Katz said. New rules Between 4 and 9 percent of a provider's Medicare reim- bursement in the next few years will be based on two new reimbursement structures in MACRA from which physi- cians will choose: The merit-based incentive payment sys- tem, or MIPS; and alternative payment models, or APMs. In MIPS, performance and "composite scores" will be based on four categories: quality, resource use, meaning- ful use of electronic medical records and clinical practice improvement activities (CPI), according to an American Medical Association summary. CPI is new and the other three, which some doctors say lack evidence supporting their benefit, will have different and changing weightings in the scores. For missing performance thresholds, there will be maxi- mum penalties of up to 4 percent in 2019, 5 percent in 2020, 7 percent in 2021, and 9 percent in 2022 and beyond, AMA said. Exceeding the performance threshold, physicians can earn bonuses on a sliding scale, with the highest bonus at least as high as the highest penalty for that year, AMA added. Under APM, most providers will also be subject to MIPS, but will receive favorable scoring — with correspondingly higher reimbursement rates, according to a summary by Portland, Maine-based Network for Regional Healthcare Improvement (NRHI). Providers participating in the most advanced APMs (including accountable care organizations, patient-centered medical homes and bundled-payment models) may be designated as qualifying APM participants (QPs), which are not subject to MIPS. They may be eligible for annual 5 percent lump-sum bonus payments from 2019 through 2024 and other benefits, NRHI said. FOCUS HEALTH CARE Q&A Greater Hartford cancer care moves toward performance-based model On July 1, the Center for Medicare and Medicaid Services (CMS) launched a new five-year trial program that aims to make Medicare patient cancer treatment more coordinated and cost effective. Rocky Hill-based Starling Physicians, which formed last year through the merger of two physician groups with more than 250 providers, is among 195 physician groups nationwide — includ- ing three in Connecticut — that were officially accepted into the Oncology Care Model (OCM) program. In exchange for their efforts, participating physician groups will receive a $160 monthly payment from CMS for each patient treated under the program. They will also have the chance to earn perfor- mance-based payments tied to cost savings and quality measures. OCM is one of many CMS initiatives that are pushing providers away from the long-dominant fee-for-service model and towards population-based or "accountable care" contracts. The Q&A talks about the OCM program with Tracy King, Star- ling's chief integration officer. Q: Why did Starling apply to join the OCM program? A: Starling has always endeav- ored to provide whole-patient- centered care to oncol- ogy patients. The CMS OCM model recognizes the resources required to make oncology care truly comprehensive and provides some of those resources so practices like Starling can make the invest- ments in technology and personnel to fully develop a compre- hensive care delivery model. This program helps us more fully realize our goal of providing comprehen- sive, whole-patient-centered care. Q: What sorts of patients will you be seeing under this program? A: This program is for patients with traditional Medi- care coverage. In addition to our historic standard of care, which follows evidence-based clinical guidelines and pairs each patient with a physician/ advanced-practice nurse team, the OCM program will allow us to expand our team with nurse navigators and social workers to address patients' compre- hensive medical and psychoso- cial care needs while they are receiving cancer treatment with Starling Physicians. We are in discussions with health plans that cover other patients to expand this model to support those patients as well. Q: Starling was formed last year through the merger of Grove Hill Medical Centers and Connecticut Multispe- cialty Group. Does the fact that you are larger help you as you enter this new initiative? A: Overall, the combined size of Starling will allow us to make the investments needed to provide more comprehensive, whole-patient-centered care for the populations we serve. Starling has a larger geographic footprint now and serves multiple hos- pitals with multiple specialties. Our oncology division exists with- in a larger, multispe- cialty group that is finding ways to make these kind of investments in all of our clinical areas. Our size allows us to serve more of our patients with our own providers, when they need the help of a specialist or in the hospital. However, in the OCM pro- gram nationally, we are one of the smaller programs, and that's because this is a big commitment. Q: How does CMS' push toward coordinated, popula- tion-based care compare to what you are seeing from com- mercial payers? A: The OCM is more compre- hensive and better defined than some of the commercial pro- grams we've discussed with the commercial payers. Many of them are moving in this direction at this time, and we're encouraging them to do so. The OCM requires medical prac- tices to analyze patients' needs and their medical issues very closely, so we can best under- stand the population we care for. We think that the OCM model, or some variation on that model, should be the model of care for all patients receiving cancer treatment, based on clinical-evi- dence, with highly personalized attention to patients' clinical and psychosocial needs. n TRACY KING Chief integration officer, Starling Physicians Dr. Timothy Chartier, a Mohs micrographic surgeon and partner with one other doctor in Dermatology Surgical Associates LLC in Farmington and Glastonbury, believes the Medicare Access and CHIP Reauthorization Act of 2015 will have a negative impact on many small practices in the state. Continued H B J P H O T O | J O H N S T E A R N S

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