Author + information
- Jagmeet P. Singh, MD, DPhil, Deputy Editor, JACC: Clinical Electrophysiology∗ ()
- ↵∗Address correspondence to:
Dr. Jagmeet P. Singh, Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114.
It goes without saying that the existing modus operandi and the trajectory of escalating health care costs are untenable. Evidently, much is still lacking within our system in the United States, pertinent to the quality of care we give, the efficiency in its delivery, and the use of resources. In the recent past, there has been a considerable amount of dialogue and continued incentives toward the adoption and dissemination of value-based care. To this end, payment reform strategies have been in play to align payments with “the value” of care delivered, especially since existing fee-for-service (FFS) models promote incentives for overutilization. Recent legislation embedded within MACRA formalizes the shift away from FFS, while enforcing a greater deal of accountability on health care providers.
So What is MACRA?
Over a year ago the Medicare Access and CHIP Reauthorization Act (MACRA) was approved by Congress. This was enacted in part to address the reality that the FFS model is unsustainable, because Medicare spending over many previous years has continuously exceeded economic growth. In the past, to balance this equation, FFS payments were linked to a sustainable growth rate (SGR) formula, suggesting the need for recurring annual reimbursement cuts. Although the SGR cuts were never implemented, thanks to repeated “doc fix” legislation, the SGR created much angst and uncertainty. MACRA has created a more permanent fix by transferring responsibility for “value” to hospitals and practicing clinicians. MACRA brings with it new payment models, the adoption of which will be mandatory, unlike prior reform attempts that were usually voluntary with inconsistent participation.
Under MACRA, there are 2 reimbursement paths to avoid paying penalties. This includes: 1) the Merit-based Incentive Payment System (MIPS) or 2) the Alternative Payment Model (APM). The first performance period will be initiated on January 1, 2017, and the first adjustments made to physician pay will take effect on January 1, 2019. Through the MIPS path, in 2019, physicians will be able to earn plus or minus 4% of reimbursement, with the potential of going as high as 9% by 2022. Notably, physician pay will be on the basis of weighted ratings related to 4 key components: quality (50%), advancing care information (25%), clinical practice improvement (15%), and resource use (10%). On the other hand, the APM model will allow physicians to earn an annual bonus of 5% from 2019 to 2024, while being exempt from MIPS. However, to be able to qualify for APMs, practices will need to meet 3 prerequisites: 1) be engaged in the use of electronic health records technology; 2) participate in quality measures akin to MIPS; and 3) assume some degree of financial risk.
So How Does This Work Fiscally?
Several hundred thousands of eligible clinicians will participate in MIPS. CMS intends to keep this budget neutral through rewarding high-performing physicians at the expense of those that may not do as well. So, although we may all be in it together, we are competing for a piece of the pie from rival practices and hospitals around the country. APMs, on the other hand, are not budget-neutral, as the incentive here is to improve cost-savings while enhancing patient-centered care. This does require the appropriate infra-structure, as well as the willingness to take some risk. Having said that, there is some flexibility to the extent of participation in the first year, but a bare minimum is expected of all. Notably, nonparticipants by the end of 2017 will face a pay cut of 4% by 2019.
Are There Any Uncertainties?
Yes, there is little evidence to confirm that this will all work. The extent to which these metrics are related to clinical outcomes is uncertain, and we do not know if the burden of the administrative effort in reporting will offset the expenses of implementing these changes. Moreover, it is quite possible that physicians providing low-cost care may not be the ones providing high-value care. Importantly, referring physicians also may not always have the ability to “assess value” of the rendered subspecialty care. Another big problem is that cardiology, and especially cardiac electrophysiology, is highly specialized care. If you examine MACRA, it is a very generalized initiative and caters to all, inclusive of primary care. It will need continuous tweaking, and the sooner we get engaged, the more influence we will have on the evolution of this transformative change in the practice of everyday medicine. The question does come up whether the changing political landscape will set back the clock, causing us to drift back to our old ways. In general, legislators from both parties have supported payment reform historically, and MACRA in itself received bipartisan support. This new payment structure directly linked to performance, while focused on value and accountability, is here to stay.
How Should the Electrophysiology Physician Acclimate?
As a subspecialty, the adaptive process will be challenging. We have to be engaged in the development of these new health care delivery models and ensure: 1) that they are patient-centric; and 2) that we are not penalized for providing appropriate care, some of which may be expensive and high-tech. There is an element of urgency in getting actively involved in this growing collaborative effort to make certain that some of the redirected care does not result in constrained access to specialized care. We need to not only partake in the process of increasing transparency, but also clarify the incentives at the individual physician level. Some of this will involve educating our non–electrophysiology (EP) colleagues to facilitate uniformity in the approach to appropriate testing and therapeutic interventions.
The writing is probably on the wall, that similar to bundled payment strategies for coronary artery bypass surgery, acute myocardial infarctions, and heart failure management (1–3), atrial fibrillation (AF) as a disease substrate is not too far away. Should we as a subspecialty play the lead role in coordinating the inpatient, outpatient, and procedural care for these patients? Whether initially this will be “a bundle” around procedural management, that is, a single bundled payment for an AF ablation (irrespective of the number of repeat procedures), or one focused around readmissions and hospitalizations for AF, either in the immediate 30-day periprocedural period or 1-year period, remains to be determined. The same could be said about device therapy in patients with heart failure. Because penalties on hospitals for readmissions will be shared by all, EPs, with their knowledge of device diagnostics and remote monitoring, will need to be more readily engaged in preventative strategies as well as be a part of algorithms to triage patients appropriately to urgent care clinics to avoid readmissions.
A low-hanging fruit for the picking is the adoption of TeleHealth. This may help in improving access to care, improving clinical outcomes, and reducing costs. This could include virtual visits (between clinician and patient via video) or virtual consults (between a clinician and a referring clinician) (4). Additionally, eVisits and eConsults are gaining considerable traction. Specific patient care–related questions can be requested via a peer-to-peer asynchronous eConsult. In our experience at Massachusetts General Hospital, these help trim down the unnecessary use of specialists for clinical questions that may be fairly straightforward (5). This, in turn, enhances the referral process and times for more clinically complex patients. Some of these questions can pertain to interpreting an electrocardiogram or a Holter result, discussing treatment options, providing disease management guidance (e.g. extent of rate control), or asking about the value of additional testing to either obviate or facilitate a subsequent EP visit.
We clearly need to better integrate with our non-EP colleagues (within cardiology and beyond). We can do this through helping develop protocols to facilitate evidence-based care that also allow for an appropriate amount of flexibility to keep the care patient-centric. The care teams we help develop must be multidisciplinary enough that they can provide oversight and care over the course of the entire patient journey. Importantly, providing continuous access for our patients to receive clinical care and mechanisms to deal with urgent situations to prevent readmissions need to be intrinsic to this equation.
Last, this really should not be about whether we as physicians will receive a penalty or a bonus, but about enhancing patient care. We need to work together and be focused on delivering high quality, value-based patient care, geared to improving patient outcomes. In the midst of a changing political landscape and prevailing uncertainty of the current status of health care reform, some changes are here to stay. MACRA seems to be one.
Dr. Singh has served as a consultant for Biotronik, Boston Scientific, Medtronic, St. Jude Medical & Liva Nova Group, Respicardia Inc., and Impulse Dynamics.
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