Is there a doctor in the house?

Written by Symbria Chief Medical Officer Rajeev Kumar, MD, FACP

As the Centers for Medicare & Medicaid Services (CMS) continues to seek ways to reduce its costs and improve patient outcomes, the question of whether there will be enough physicians available and willing to practice in post-acute and long-term care (PALTC) is becoming increasingly difficult to answer. All PALTC stakeholders must work together now toward improving technology, promoting risk adjustment that considers the special characteristics of the elderly population, and developing and proposing shared risk models that will improve outcomes.

 Why now? Because doctors’ payments are threatened by a CMS Catch-22 that requires providers to meet increasingly stringent quality and performance requirements regardless of practice setting. If PALTC practitioners continue to see their revenues shrink due to factors over which they have no control, they will leave for other settings.

CMS requirement - cut costs and improve outcomes to retain revenue

In 2015, Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA created a new framework for rewarding health care providers for quality of care. A new Merit-Based Incentive Payment System (MIPS) became the comprehensive quality reporting program for most of the more than 600,000 U.S. clinicians practicing today.

MACRA also scheduled escalating cuts to physicians’ Medicare revenue (4% in 2019, increasing to 9% by 2022). However, they can earn an automatic 5% bonus to their Medicare earnings by participating in Advanced Alternative Payment Methods (APMs), such as risk-sharing accountable care organizations (ACOs) and advanced bundled payment programs (advanced BPCI).

Performance measures affect fee-for-service payments and bonuses

Physicians in the MIPS track are reimbursed largely through the traditional Medicare Part B fee-for-service structure, but CMS adjusts eligible professionals' pay based on how they score in four categories. Providers whose total MIPS score is above the so-called “performance threshold” are eligible for bonuses; those scoring below the performance threshold receive penalties.

Each of the four MIPS performance categories presents its own challenges to PALTC providers.

Advancing care information: Seamless health information transfer using electronic health records (EHRs) is required to score well on this metric. However, in addition to the lack of a functional Health Information Exchange (HIE), a challenge common to all healthcare settings, PALTC providers face additional serious issues. Nursing home and rehab center EHRs lack the capabilities physicians need to meaningfully document and receive credit under MIPS.

Cost: After a gradual ramp-up in 2017 and 2018, CMS can now weigh the cost category anywhere between 10% and 30% through 2021; beginning in 2022, cost will represent 30% of the MIPS score.

For total per capita cost (TPCC), one element of the cost calculation, CMS attributes patients to clinicians based on who provides the greatest share of primary care services. TPCC is particularly harsh for PALTC clinicians whose patients are elderly, frail, and chronically ill, a high-risk population with costs over which the doctors have virtually no control.

Quality: MIPS offers clinicians the freedom to choose quality metrics most relevant to their practices. However, unlike other practitioners, PALTC clinicians have few measures relevant to their practice, and they lack the luxury of support staff and EHRs that effectively interact with those of PALTC facilities, making compliance with MIPS quality reporting a significant hardship.

Clinical practice improvement activities: The multiple hurdles outlined above, including the lack of a meaningful interface between EHRs, support staff in the facilities, and streamlined goals for clinicians and facilities, make practice improvement activities difficult to implement in PALTC.

PALTC physicians “missing in action”

 “The problem is not the number of doctors, per se, but rather the types of doctors and where they practice,” David Grabowski, a professor of health policy at Harvard Medical School, told HBN. Noting that the shortage is particularly acute in long-term care, Grabowski cited a 2005 study in the Journal of the American Geriatrics Society, which described physicians in nursing homes as “missing in action.” Unfortunately, the landscape has not improved in the field since 2005, and when nursing home residents’ access to primary care physicians or nurse practitioners is limited, avoidable hospitalizations increase.

Ultimately, MIPS is seriously flawed as it relates to PALTC clinicians, but it remains mandatory to avoid penalties from CMS. Clearly, addressing the “MIPS disconnect” is critical to improving quality of care, increasing efficiencies, and maintaining access to care in PALTC.  Solutions may include:

  • Quality metrics and APMs relevant to PALTC, along with a robust, transparent, and reproducible risk adjustment tool that factors in patient frailty and socioeconomic attributes at a minimum.
  • Mandates requiring HIE and EHR interoperability, along with streamlined reporting processes for clinicians and facilities.
  • Incentives for primary care and PALTC practitioners to practice where the need is, and for physicians in training to choose PALTC as a career.
  • PALTC specialty designation to facilitate accurate comparisons with other specialties and appropriate risk stratification.
  • Shared risk models driven by PALTC that allow clinicians and facilities to gain-share by delivering better outcomes.

Addressing these issues and more will help reassure our elderly patients that indeed, a doctor IS in the house.