Let’s Find What Works

In April, Texas Medical Association (TMA) leaders delivered 50 specific recommendations on how Congress should fix Medicare and the Medicare Access and CHIP Reauthorization Act (MACRA). The 21-page document was the result of a meeting between TMA leaders and U.S. Representative Kevin Brady (R-The Woodlands), Chair of the House Ways and Means Committee, and Michael Burgess, MD (R-Lewisville), Chair of the House Health Sub-committee. The document lists recommendations to increase physicians’ Medicare payment, reduce paperwork hassles, measure quality with metrics that are meaningful to physician and patients, and push health information technology vendors to shoulder their share of the administrative burden.

Above I have reproduced Fig. 1 from the document. It shows that while hospitals, nursing homes, and other Medicare providers get annual fee updates based on increases in the cost of providing services, physicians have been subject to flawed fee schedule update formulas since the early 1990’s, which are still far less than the rate at which their costs are increasing. The compounded results mean that physician payment is currently 25% below what it was in 2001.

With the gutting of the bonus payments originally possible in MIPS, the small upwards fee adjustments available under MIPS can’t adjust for this, and the cost of complying with the Quality Payment Program (QPP) is exacerbating the problem. Under the Alternative Payment Model (APM) track, there’s no real possibility that shared savings can increase enough each year to offset the downward trend. For many years it has been assumed that cutting payments to physicians would limit Medicare spending and thus Medicare growth, but clearly that hasn’t happened. What has happened is that in Texas, 37% of physicians now refuse to take Medicare or limit the number of new Medicare patients they accept. As a result, access to certain types of care for Medicare beneficiaries has been reduced, and Medicare costs have actually increased. Meanwhile the Medicare-eligible population will continue to grow simply because of our aging population.

When the QPP was designed, the goal was to reduce cost while maintaining or improving quality. Unfortunately, to quote the report, “ . . both cost and quality measures, as currently implemented, result in serious attribution problems, so that physicians frequently are assigned responsibility for cost or outcomes that are unrelated to any care that they have provided.” That is absolutely true. I explained this in exhaustive detail in a blog about my Quality and Resource Use Report (QRUR) from 2015, which was in effect, analyzing how well a fish could ride a bicycle.

MIPS

The TMA report summarizes issues pertaining to MIPS, which includes the fact that success in meeting MIPS requirements depends upon the provider’s EHR and its ability to exchange health information. Physicians end up with costly technology that is not user friendly or sufficiently standardized. The TMA also expressed its concern about the cost of the interface and maintenance fees that EHR vendors charge physicians, and advocates for the use of standards like FHIR for data exchange. In a nutshell, MIPS costs a lot for the physician to implement and doesn’t identify high quality care.  That’s mostly because the quality measures available don’t actually measure anything to do with quality of medical care provided – and now CMS wants to move toward “population based” measures that aren’t based on patient care at all, but the health of the community. It’s a grand idea, and a great argument for supporting community gardens, local church ministries, and healthier school lunch programs – but not a way to measure an individual physician’s care.

Quality Measures

The report points out that for most physicians, MIPS quality measures apply only to a subset of their patients, which may be too small for any statistical reliability. “Furthermore, TMA has heard from many physicians who do not find MIPS quality measures meaningful to their practice or who cannot find applicable measures.”

QPP Participation

TMA recommends CMS replace MIPS reporting requirements and payment adjustments with a program that is voluntary and that doesn’t impose penalties. I think that means, “go back to business as usual.” They recommend that quality measures be aligned across all payers to reduce administrative burden, and that physician performance measurement use meaningful and accurate metrics with, “medically appropriate exceptions and exclusions, including proper risk adjustment to both cost and quality measures to eliminate the impact of social determinants of health and other cultural or socioeconomic variables.” Wow. That surely would be the goal, but given how hard it has been to get groups to agree on something as basic as a Hemoglobin A1C target, I can just imagine the challenges to creating social risk adjustments.

Among its other recommendations were that the QPP quality and cost performance metrics:

  • Use QPP quality and cost metrics that capture only those activities that are under the physician’s control and have been shown to improve quality of care, enhance access to care, and/or reduce the cost of care.
  • Do not require QPP data unless it can be submitted automatically through EHR and/or registry vendors at no cost and with no manual entry required.

I can’t argue with any of their conclusions regarding the weaknesses of MIPS, quality reporting, or the misbehavior of EHR vendors. I can write volumes about these topics from the perspective of a registry. If anyone were to hand me a check for 0.001% of the money spent annually on the care of chronic wounds, using US Wound Registry data, we could analyze what interventions actually reduce the cost of it. But, no one is going to do that. So, I am worried how we will improve quality and curtail improper use of resources through a voluntary program. Medicare will be bankrupt in 2026. The current program isn’t working. How can we fix it?

I agree with the TMA’s assessment of the flaws of MACRA. What is a path forward that will stop improper use of Medicare resources JUST IN THE FIELD OF WOUND CARE, never mind any other area? HOW CAN WE IDENTIFY PRACTICES THAT IMPROVE QUALITY AND REDUCE COST, JUST IN THE FIELD OF WOUND CARE?  The US Wound Registry has initial results for our quality projects, and ideas of how to expand them, but we are swimming upstream. Currently, at least on the outpatient side, no one gets paid to provide cost effective care- we get paid to provide MORE care. We don’t even get paid for better outcomes. Unless you are reporting risk stratified healing rates, we’ve proven that facilities are not truthfully reporting those.  Medicare may be spending $95 Billion a year treating chronic wounds, but nothing to understand the value of that care.

We do agree that automatic submission of data through the EHR with no manual data entry is the way forward. We could do that tomorrow. However, right now, Medicare isn’t ready for any sort of fix, but if you are a private payer, and you want to know how we are improving adherence to evidence based practices, improving honestly reported wound healing rates, improving the appropriate use of advanced therapeutics, reducing amputation rates, and reducing disparities in the outcome of diabetic foot ulcers, venous ulcers, pressure ulcers and dehisced surgical wounds, email me. We’d like to look at total cost of care via claims. We think we are reducing it. We have a lot of data in our registry.  Medicare is spending as much as $95 Billion a year on this problem – what about you? We think driving quality reduces cost. Let’s find out.

To read the Texas Medical Association Report: IMPROVING AND SIMPLIFYING THE MEDICARE QUALITY PAYMENT PROGRAM Recommendations to Support Physicians in Their Move to Value-Based Care and Alternative Payment Models- follow this link:

https://www.texmed.org/uploadedFiles/Current/Images/TMT_Images/TMA%20MACRA%20Working%20Paper%20-%20April%202018.pdf

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