Bringing MACRA to Cardiologists, Ready or Not

Mary Caffrey

With the first step in the Walter E. Washington Convention Center Thursday evening, the word “MACRA” was impossible to miss. A sign bearing the acronym for Medicare Access and CHIP Reauthorization Act, the law passed in 2015 to change the way physicians are paid, was just inside the door to greet those arriving for the 66th Scientific Session of the American College of Cardiology (ACC), taking place in Washington, DC.

ACC President Richard Chazal, MD, explained its importance in his remarks at the opening session, saying MACRA “is likely to bring the most dynamic and systematic changes that we may see in our professional lifetimes,” as Medicare—a payer of great importance to cardiologists—moves from volume-based to value-based systems.

“The early years of MACRA are going pose some very real challenges to physicians accustomed to the current system,” Chazal said.

That may be an understatement.

About a half-hour earlier, a cardiologist waiting for the opening session asked what MACRA was. When told it had to do with value-based care, he scoffed, “Oh, that!” Like many physicians, he had complaints about the functionality of electronic health records (EHR), and he was not a fan of practicing in teams, except in the operating room.

Hours later, a panel of policy all-stars presented viewpoints on making MACRA work. First, Kate Goodrich, MD, MHS, director of the Center of Standards and Quality and chief medical officer at CMS, took a roomful of cardiologists through the key decision points of MACRA for 2017:

Physicians can’t afford to not know what MACRA is, because activity happening in 2017 must be submitted a year from now, to affect payment in 2019.

Goodrich acknowledged that CMS has heard provider complaints about the first-generation programs that paved the way for MACRA. It has tried to streamline the next step into value-based payment, even “rebranding” MACRA (which Congress picked) into the Quality Payment Program.

She offered examples of MIPS participation for cardiologists and discussed APMs—both existing and forthcoming—that will be especially relevant. Cardiology lends itself to Next Generation Accountable Care Organizations, but the big change will come with cardiac payment bundles, which she listed as coming in 2018.

CMS proposed cardiac payment bundles last summer, and there has been speculation about their future in the new administration. But both Goodrich and former CMS Administrator and FDA Commissioner Mark B. McClellan, MD, PhD, said while there will be changes, the underlying shift toward value-based payment will continue.

As healthcare advances, it can do more, but it costs more, too. “People are really willing to pay more for longer and better lives for their loved ones,” McClellan said. Within the context of the federal budget, healthcare spending is now crowds out other priorities. Referring to the “skinny budget” presented this week by the Trump administration, he said the proposed cuts to school nutrition programs and Meals on Wheels shouldn’t come as shock considering long-term trends.

What’s frustrating, he said, is that spending more on good nutrition at younger ages might mean spending less later for cardiovascular or diabetes care. “This is not a Democratic or Republican issue,” McClellan said, and the long-term health effects of poor diets, opioid abuse, smoking, and obesity are affecting the swing voters who decide elections.

Treating these populations requires a different approach, and the rise of value-based care came out of practices that felt they could do a better job with hard-to-treat populations if they had a different reward system. Today, McClellan said, he’s starting to see things like a cardiologist serve as the primary care doctor in a patient-centered medical home. The arrival of the new administration will bring more innovation, not less, he predicts.

“Some health plans are interested in sharing those savings with the consumers,” McClellan said. “This is all very much in process.”

William Borden, MD, an associate professor at George Washington University, said the idea of value-based care must start with good outcomes for complex patients. “If we don’t have good outcomes, we shouldn’t begin to look at the cost component.”

He described a 65-year-old woman who had made 5 emergency department visits in a year before his practice targeted her for special case management. Her care is now coordinated among 8 different providers, and, “she’s always telling her nurse care manager how much she appreciates her.”

Borden walked the group through a 2-year process of how his practice developed quality scores and calculated whether it was eligible for shared savings. One year was successful, one year fell just short. But the practice has no plans to abandon this new way of doing things. Borden believes keeping these metrics will be essential to the practice’s future, for things like contract negotiations, credentialing, or joining a new hospital.

“Society trusts us with these resources,” Borden said. “It is important for us, as physicians, to look at the cost.”
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