Tuesday Jan 23, 2018
New AAFP Resources Aim to Help With Payment, Outcomes
"There's no trick to being a humorist when you have the entire government working for you."
-- Will Rogers
As I write this post, Congress is heading towards a potential shutdown of the federal government, and the health care coverage provided for more than 9 million children through the Children's Health Insurance Program (CHIP) has become one of the primary pawns in the negotiations.
Collateral damage from this latest budget standoff could include the loss of funding for the teaching health center program, community health centers and the National Health Service Corps -- not to mention a half dozen Medicare policies whose expiration will disproportionately impact rural communities.
Congress has a unique way of adding time to the clock, and I would not be surprised if that happens again. Meanwhile, important policies that impact tens of millions of people will continue to be held hostage to the political whims of two parties who appear intent (and content) on playing a never-ending game of chicken.
The Children's Health Insurance Program is one of the most bipartisan initiatives ever enacted. Despite that bipartisan support, it is not immune to legislative trends. At some point, our legislative system will have to move from one that rewards hostage-taking and instead rewards hostage liberation, but I am not sure January 2018 is that time.
The most frustrating outcome of this process is the damage that has been done to the Teaching Health Center Graduate Medical Education (THCGME) program. The THCGME program has been one of the most successful physician workforce policies of the past eight years, with hundreds of family physicians trained and countless communities served. As the deadline for the 2018 National Resident Matching Program draws near, the failures of Congress come into greater focus.
Enough of Washington talk, I really want to tell you about some new products and services the AAFP has produced. The Academy is fortunate to have a large and diverse membership. This diversity is reflected in the practices of family physicians across the nation, but it also is reflected in our work on your behalf. The AAFP continuously strives to provide our members the resources, tools, and educational content to assist each of you in your professional journey. Today, I am going to highlight two new AAFP resources -- Making Sense of MACRA: A Guide for the Employed Physician and The EveryONE Project.
It is no secret that an increasing number of family physicians are employed. Although most physicians in other specialties are employed by hospitals or large health systems, that is not the case with family medicine. Yes, a large percentage of family physicians are employed by hospitals and health systems, but an equal percentage are employed by other physicians or physician groups.
I speak to family physicians frequently about practice transformation and payment, key elements of the Medicare Access and CHIP Reauthorization Act. One of the most frequent comments I hear is, "I am employed, so MACRA doesn't really impact me."
False. Or, at least, I believe that statement to be false.
Employed physicians should understand the payment framework of their practice for all payers, not just Medicare. Medicare clearly is the largest agitator in most practices, but understanding how you and your group is evaluated is important. Understanding how you can provide input into these decisions is essential. Learning how to best navigate this entire process should be a priority.
For better or worse, MACRA is reshaping the health care system by accelerating important practice and payment decisions at the individual physician and group level. If your practice or group is participating in an advanced alternative payment model (APM), there are several key items you should be aware of.
First, you should know and understand the set of measures by which you will be evaluated. Second, you should understand any down-side risk associated with the APM. Third, become familiar with any and all opportunities your organization has to secure shared savings. Finally, you should have, in writing, an explanation of how your group will distribute any shared savings garnered through value-based contracts.
Understanding these items will ensure that you and/or your practice receive the financial rewards consistent with your contributions to your group. Put more bluntly, don't let the financial incentives go to the C-suite or to the organization's coffers. Make certain that shared savings are returned to you and your primary care colleagues.
Now, if your group has decided to remain in the legacy Medicare fee-for-service program via the Merit-based Incentive Payment System (MIPS), here are five items you need to be aware of and monitoring:
- Final MIPS scores are attached to individual national provider identifiers (NPIs), even for those reporting as a group. So, you will have an individual MIPS score, and your group will have a MIPS score. This is important.
- In the event you change practices between the performance period and payment year, any payment adjustments follow you to your new practice.
- Your performance in MIPS may impact your salary and future contracts. Given that your MIPS score can contribute to either positive or negative payment adjustments, family physicians should be prepared to see MIPS performance scores referenced in employment contracts.
- If you are a high performer under the MIPS criteria, you will have increased leverage in contract negotiations. A strong performance in MIPS should equate to a higher salary.
- Finally, you should evaluate the performance of any potential employer. If your perspective employer continuously under-performs, you should both be aware and factor that information into your decision-making process.
This information and other helpful advice is included in Making Sense of MACRA: A Guide for Employed Physicians.
Family medicine and the AAFP have long been at the leading edge of efforts to view patients holistically. Although this has been and remains a core competency of family medicine, there is a national movement underway to better identify and incorporate into the delivery system information related to the individuals' life and community. These data elements, which range from information on housing, transportation, food security, employment, community resources, etc., are commonly referred to as social determinants of health.
Social determinants of health are "the structural determinants and conditions in which people are born, grow, live, work and age(www.thelancet.com)."
I am not an expert on social determinants of health -- far from it. However, I do recognize the importance of understanding all aspects of a patient's life and the impact those factors have on health. I also know that emerging payment models -- including value-based payment models and Medicare Advantage -- are starting to use social determinants of health in their risk-adjustment and risk-stratification methodologies. In fact, the AAFP's Advanced Primary Care Alternative Payment Model (APC-APM) proposal relies heavily on the risk-stratification of patients based on these factors.
Family physicians are uniquely qualified to treat people of all ages, ethnicities, genders and socioeconomic backgrounds. To assist you in this pursuit, the AAFP has launched The EveryONE Project. The initiative aims to provide information, resources and tools to assist family physicians in their practices. One of the most exciting resources currently available is the social determinants of health tool, which was developed in response to a request from our Congress of Delegates.
I urge you to learn more about The EveryONE Project and the outstanding resources it makes available to you and your practice. If you are interested in learning more about social determinants of health, the Kaiser Family Foundation has an outstanding issue brief(www.kff.org) on the subject.
On Jan. 10, the AAFP participated in a meeting with CMS and the Office of the National Coordinator for Health IT (ONC) to identify ways to reduce the administrative and regulatory burden placed on physicians. The meeting was led by HHS Assistant Secretary John Fleming, M.D., (a family physician and AAFP member) and included senior level staff from both organizations. CMS and ONC have developed a four-part strategy focusing on the following items:
- documentation and administrative functions;
- federal electronic health records requirements;
- usability and design of electronic health records; and
- non-federal electronic health record requirements.
CMS and ONC have developed working groups on each of these four objectives and plan to issue a request for information on administrative reform in the coming weeks. I noted via Twitter that this was "one of the best stakeholder meetings of my 20 years in Washington." There is much work to do, but I was pleased with the level of commitment CMS and ONC have made to this effort.
Posted at 10:30AM Jan 23, 2018