Tuesday, 27 September 2016 05:01

Preparing for MACRA: Options, Change, and Learning

Written by Andres Jimenez

The Medicare Access and CHIP Reauthorization (MACRA) Act of 2015 will further our industry’s progress towards value-driven care. Scheduled to take effect in 2017, recently announced options give doctors some relief, and more time to get on board. Getting physicians involved will be challenging, but some organizations such as Advocate Health System have been effective at using pay-for-performance (P4P) incentives to drive physician behavior change using principles related to social context, which also supports the most effective learning strategies for physicians.

Earlier this month, acting Centers for Medicare & Medicaid Services (CMS) Administrator Andy Slavitt announced further details regarding the first year of participation in MACRA, to include three possible starting tracks in 2017. This announcement was in reaction to feedback CMS received since its April announcement, with a goal of finalizing these next steps and providing more detail by Nov. 1. The announcement is timely, given that a Deloitte survey of 600 physicians released in July showed that about 50 percent of non-pediatric physicians surveyed did not know what MACRA was. For some, that may seem alarming, considering it will put 4 percent or more of a physician’s Medicare reimbursement at risk, but it should not be all that surprising, given what’s on physicians’ plates these days. Findings from a recent study on 57 doctors in four specialties were published in the Annals of Internal Medicine this month, revealing that almost one-half of the average physician work day is spent on the electronic health record (EHR) and other administrative desk work, while only 27 percent was spent on direct patient care. 

These findings are analogous with findings from the most recent Physician Foundation survey of 20,000 physicians, with 46 percent reporting that the EHR detracts from their efficiency. In that same survey, 81 percent of responding physicians said they were at or beyond full capacity at work. 

Why is this important? Well, it explains why many of our nation’s physicians have not heard of MACRA, and supports CMS’s efforts in providing optional tracks that buy much-needed time.

The CMS announcement provided an early preview to the four possible tracks, three of which are new and related to the Merit-Based Incentive Performance System (MIPS), and all of which are designed to help physicians avoid negative payment adjustments from care delivered in 2017. For those who are not interested in an incentive payment, Option 1 simply requires reporting of “some data” from after Jan. 1 to avoid a negative payment adjustment. Option 2 provides access to an incentive payment for participation through a reduced reporting period starting after Jan. 1. Option 3 provides access to a modest positive payment for reporting information for all of 2017. The alternative payment model (APM) option hasn’t changed from the initial announcements, and those participating in an APM will be eligible for a 5-percent incentive payment in 2019. As we await the next CMS announcement in November, those responsible for managing healthcare and supporting physicians should consider how we might maximize our efforts by accounting for their greatest challenges.

One question I’ve heard from fellow physicians is this: what will MACRA and other initiatives do to provide physicians with more time? If we can extrapolate findings from the study of 57 physicians to a nation of physicians at critical levels of frustration and burnout, I’m not sure there is much room for enthusiasm, let alone pulling physicians away from patient care to learn about MACRA. And how can we expect them to change their performance without them learning something that will impact their knowledge, attitudes, and skills, especially for those physicians lagging behind?  I suspect that the lack of time is a stronger contributor to negative performance than a physicians’ will. Considering the results from the Physician’s Practice Greater American Physician survey of 2016, which included feedback from 1,001 physicians regarding the Patient Protection and Affordable Care Act (PPACA), 71 percent of respondents said they lack adequate time for their personal life, and over half said they have a poor work-life balance. If there is no time for a personal life, what time remains for MACRA? With a bad taste resulting from many government-driven initiatives, time and attitude are major obstacles to combat as organizations prepare to support change through some sort of training initiative to make sure physicians are aware of MACRA and equipped to better perform.

This is still a message of hope, and there is substantial evidence to support the ability to garner physician buy-in centered around doing what is truly best for the patient. At the Advocate Health System, findings published in May demonstrated the ability to drive physician behavior change using pay-for-performance (P4P) incentives when using specific design principles related to behavioral economics. One principle highlighted in the study, regarding social context, builds on findings from behavioral economists indicating that individuals are greatly influenced by the perception of others. They leveraged this principle to drive behavior change via their group incentive, whereby 30 percent of their physician incentive program is impacted by group performance. 

Coincidentally, social interactions are incredibly important in the construction of new knowledge through training, motivating physicians to focus attention towards learning, and sustaining that attention to complete training. For instance, the concept of constructivist learning centers on how new information is processed by the learner, largely influenced by social interactions. Motivational theories of learning such as goal theory describe how goals, expectations, attributions, social interactions, and self-comparisons influence learning achievement. Building upon the concept of self-comparisons, instructional theories related to self-regulation ensure that training programs physicians start, are actually completed, and result in effective learning. You will find these principles incorporated into successful training programs designed for physicians, effectively producing learning and subsequent change related to MACRA and other P4P initiatives aimed at improving care.

The historical alternative to P4P has directed healthcare toward much-needed change.  Although it may take time to change the direction of such a large ship, MIPS and APMs found in MACRA are promising, and the new options should provide substantial relief to overburdened and concerned physicians. Models have emerged showing the ability of P4P programs to align incentives and produce physician buy-in, leveraging principles related to social interactions that impact change through learning. Training can improve performance by producing changes in knowledge, attitude, and skills, but not all learning is meaningful, particularly among physicians. While you prepare for MACRA, think about your best MIPS option, ensuring that your strategy incorporates proven principles for physicians – and most importantly, doesn’t waste their time.  

About the Author

Dr. Jimenez is a physician training expert, founder and CEO of ImplementHIT, a training software company offering training tools and content to deliver maximum impact in less time! Dr. Jimenez was the lead author for the American Health Information Management Association (AHIMA) ICD-10 Training program for physicians and is the former clinical director of content and training for Allscripts. To contact Dr. Jimenez please go online to: www.implementhit.com

Contact the Author

This email address is being protected from spambots. You need JavaScript enabled to view it.

Comment on this Article

This email address is being protected from spambots. You need JavaScript enabled to view it.

Last modified on Tuesday, 27 September 2016 05:25