Tech Disconnect: Poor IT Systems Hinder MACRA Transition

The recent release of a 40-page report from the Office of the Inspector General (OIG) provided an inside look at steps the Centers for Medicare and Medicaid (CMS) is taking to implement the Medicare Access CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program (QPP). CMS has made significant progress toward implementing the QPP, however, it lacks the IT infrastructure to collect the data permitted by the MACRA final rule. This will present health care providers with additional challenges to the MACRA transition, industry experts told First Report Managed Care.

The QPP reforms are a significant shift in how Medicare calculates compensation for clinicians and requires CMS to develop a complex system for measuring, reporting, and scoring the value and quality of care. QPP will replace a number of existing programs with a 2-track system—Merit-Based Incentive Payment Systems or Advanced Alternative Payment Models—for eligible clinicians to receive incentive reimbursement payments. CMS created a transition year for the program beginning January 1, 2017 to give providers additional time to adjust to the QPP, with the first payment adjustments taking effect on January 1, 2019.

IT Infrastructure Concerns

The report identified two ongoing areas of concern for health care providers. The first vulnerability relates to CMS ability to conduct and provide technical assistance so that providers—especially solo, small practice, and rural providers—have the information and tools they need to participate in the QPP. Stakeholders have expressed concern about whether these providers—who historically have been less likely to participate in CMS quality measures—will be technically and logistically ready to participate in the QPP.

“If providers lack the knowledge, tools, or skills to participate, they will struggle to meet the QPP reporting requirements,” the report stated. “Frustrated providers may even opt not to participate in the QPP despite the payment penalty, limiting the program’s ability to meet its goals. To mitigate this risk, CMS must continue to monitor clinician readiness…to identify and address any problems early on.”

Thomas Morrow, MD, chief financial officer of Next IT, agreed that struggles with IT could lead providers to opt-out of the QPP. 

“Some predict a huge drop in Medicare acceptance which I personally agree with,” he said.
“I know if I was a practitioner with just a few hundred Medicare [patients], rather than participate and be punished, I would become rather indignant and just limit my practice. If you look at the requirements, small practices will be hard pressed to come up with the software to actually perform the work needed.”

He added, “The physicians in small practices are at the mercy of their EHR company to build the systems needed to report outcomes. They are also at a loss because learning new system updates takes time and effort and for what endpoint.”

Dedicated staff specializing in IT systems and implementation is one of the biggest areas lacking among small providers, Farzad Mostashari, MD, cofounder and CEO of Aledade, Inc, told First Report Managed Care. He noted that MACRA included the establishment of voluntary virtual groups that would allow solo and small practices to report as a group with at least one other solo or small practitioner for a performance period. 

“Unfortunately, this option is not yet available for small providers,” he said. “One of the most urgent needs for MACRA is to create a framework for what a virtual group would look like and make the concept available to providers as soon as possible.”

The second vulnerability the OIG identified was developing and testing the backend IT systems to support data reporting, scoring, and payment adjustment. 

“Building and testing the extensive IT systems necessary to support critical QPP operations will require significant and sustained effort over the forthcoming year,” the report stated. “If the complex systems underlying the QPP are not operational on schedule, the program will struggle to meet its goal of improving value and quality.” 

Lloyd Myers, RPh, vice president of Innovation at Premier Inc, acknowledged that challenges for health systems are significant, “particularly given the fact that alternative payment models, such as bundled payment, require that timely and accurate data be continuously aggregated from providers across both the acute and nonacute practice setting, where there may be a mosaic of disparate EHR systems, and required data sources that are not in the EHR.”

Furthermore, even if health systems have homogenous EHR systems, “these systems were not designed to manage performance measurement at the level of acuity needed to support the range of quality reporting, ongoing performance management, coordination of bundles, yet alone improvement, required to win under the QPP,” he said.

Data and More Data

Industry experts agreed that to make value-based care work, health care providers need data.

“Good information doesn’t solve all your problems but it is certainly a prerequisite for knowing how to manage care for patients,” Josh Seidman, PhD, MHS, senior vice president of Avalere, said. “Without the IT infrastructure it is very hard to know what is happening with patients between one setting and another. One of things that was important as we move from a fee-for-service system to a more value-based care system is the expectation that we would have the IT technology [that] would allow the sharing of information from one organization to another.” 

Dr Mostashari added that one of the biggest challenges with a lack of flexible infrastructure is not only that it “hobbles improvement efforts, it hobbles learning. Providers need IT infrastructure that can tell them what results are and how they got them, so they can repeat processes or improve them.”  

How to handle bundled payments represents another challenge for IT infrastructure, according to stakeholders. For an integrated network, it is not as difficult. 

“Integrated delivery networks typically have better IT integration than hospital systems or outpatient providers, but it does not have to be this way,” Dr Mostashari explained. “IT can enable virtual networks where the data follows the patient, and value-driven payment methods like bundled payments create financial reasons for doing so. One of the main promises of IT is to allow all providers to be patient centric without having to trap the patient in an integrated delivery network.”

Complying With MACRA: Technology Strategies Needed

Fully implementing QPP is going to require substantial structural changes for hospitals and health systems. Therefore, it is important for health systems to develop strategies for the technologies needed to comply with MACRA requirements. 

“I think health systems are really trying to help physicians and other eligible professionals to comply with the expectations of MACRA” by providing some infrastructure support, Dr Seidman explained. Areas of support needed include clinical information, data reporting, and quality improvement.

Premier Inc is bringing a full-spectrum of strategies, including cloud-based products and consulting services, to market that support and enable provider success under QPP, according to Mr Myers. 

“We believe that to succeed, providers will need to think beyond the EHR, leveraging integrated technology platforms that are capable of aggregating and organizing clinical, operational, patient, and financial data into standardized registries that can continuously measure and benchmark performance, and identify gaps in quality to enable improvement at the system, practice, and individual patient level,” he said.

Dr Mostashari empathized that IT systems need to better address the intricacies of multiple payment systems instead of simply focusing on compliance issues.

“First and foremost, health systems need to reject a compliance mindset and seeing their role as just ‘checking the box’ to comply with the letter of the law,” he said. “What they need to do is look beyond simple MACRA compliance and focus on how their technologies will help them succeed in alternative payment models, such as accountable care organizations and bundled payments. A compliance focus will always leave providers playing catch up. By adopting technologies with a focus on outcomes, providers can get ahead and prepare themselves for the increasing shift to value-based payments.”