Samuel Edwards, MD, MPH, Assistant Professor, Oregon Health & Science University, Staff Physician at VA Portland Health Care System
Small and medium-sized primary care practices face substantial challenges in meeting the requirements of The Medicare and CHIP Reauthorization Act (MACRA) of 2015’s Merit-Based Incentive Payment System (MIPS), an ambitious value-based payment system that adjusts Medicare payments based on clinical quality, practice improvement activities, electronic health record (EHR) capabilities, and resource use. Because of that, the Centers for Medicare and Medicaid Services (CMS) initially predicted that solo and small practices would be the groups most financially penalized by MIPS, with 87% of solo practices receiving reductions in payments. This is because the major challenge that small and medium-sized practices face is that they often don’t have the resources or infrastructure to report data or to engage in the types of quality improvement work envisioned by MIPS. Through the work and data of EvidenceNOW, we will have lessons to help all small practices succeed under value-based payment.
MIPS requires reporting on six of a possible 271 quality measures. Practices will have to decide which measures are most appropriate for their clinic, determine how to extract data on those measures from their EHRs, and then create data reports at regular intervals. Larger practices may have more robust EHR installations and staff they can dedicate to this work, while small practices usually don’t have the personnel resources or the expertise. Practices may need to make substantial capital investments in computers and data management infrastructure in order to report quality data, and for a small practice, this may not be feasible.
Another challenge is that practices may also need to invest in advanced practice change capabilities in order to conduct quality improvement, or implement complex care management. MIPS provides no upfront payment or technical assistance with these activities, so it may force even more consolidation among primary care practices and acquisition of primary care practices by hospitals.
- EvidenceNOW Cooperatives are supporting practices with two of the key challenges faced by small practices: infrastructure for data extraction and quality improvement. Consequently, practices in EvidenceNOW working to improve these capabilities should improve their chances of getting bonuses under MIPS.
- The definitions of the core EvidenceNOW measures are identical to those proposed under MIPS: aspirin, blood pressure, cholesterol and smoking cessation. Because these measures align, practices in EvidenceNOW are already focusing on improving the quality of cardiovascular preventive care for their patients, knowing that this work will also improve their ability to succeed under MIPS.
Beyond the specific support that EvidenceNOW is providing practices in the initiative, the evaluation of EvidenceNOW (ESCALATES) will also teach us what all small practices need in order to succeed in this new payment environment.
For example, we are learning:
The major challenge that small and medium-sized practices face is that they often don’t have the resources or infrastructure to report data or to engage in the types of quality improvement work envisioned by MIPS.
- Sixty-four EHRs are represented across the practices of EvidenceNOW, and their ability to extract quality measures ranges from easily generated one-click summaries, to painstaking manual chart review. So, the type of data infrastructure and EHR support practices require varies significantly. Through EvidenceNOW, we will learn about the myriad of challenges with using EHRs for generating data that is credible and meaningful for quality improvement work, how these challenges are overcome and the role practice extension plays in helping overcome such challenges.
- Since each Cooperative is using somewhat different approaches to practice facilitation, we will be able to learn what kinds of changes and external support are the most effective in transformation to achieve MIPS’ measures; these lessons can help non-EvidenceNOW practices concentrate their transformation efforts.
- Many health care professionals are burning out from current practice stress. Through EvidenceNOW, we will learn what is at the core of burnout and resiliency and we’ll be able to then help others learn how to thrive in the midst of policy changes like MIPS.
EvidenceNOW and MIPS share the goal of improving the quality of care delivered in physician practices. While MIPS aligns payment incentives with clinical quality and practice capabilities, EvidenceNOW provides the practical knowledge and support that small practices need to meet MIPS requirements. Through the EvidenceNOW initiative, we will have lessons to share that will help all small and medium-sized practices succeed.