Editor’s note: The American College of Surgeons (ACS) Board of Governors (B/G) has conducted an annual survey of its members for more than 20 years. The purpose of the survey is to provide a means of communicating the Governors’ concerns to the College leadership. The 2016 ACS Governors Survey, conducted in August 2016, had an 84 percent (230/274) response rate.
The following article focuses on surgeons’ perceptions of the payment reforms that are being implemented through the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA).
After more than a decade and a half of debate, Congress repealed the flawed sustainable growth rate (SGR) formula that had been used to calculate Medicare reimbursement for physician services with the passage of MACRA in 2015. This legislation replaces the SGR with the Quality Payment Program (QPP), which is designed to encourage and reward the provision of value-based care. MACRA’s emphasis on quality is appealing to surgeons, especially Fellows of the ACS, which was founded for purposes of improving patient care and setting standards for the quality of care given in hospitals.
QPP overview
Physicians may participate in the QPP either through participation in an Advanced Alternative Payment Model (APM) or the Merit-based Incentive Payment System (MIPS). Because APMs for surgery are largely still in development, most participating surgeons will use MIPS for Medicare reimbursement—at least initially—but likely will need to conform with APMs as they are implemented to achieve proper reimbursement.
MIPS has four components, three of which are analogous to existing Centers for Medicare & Medicaid Services (CMS) quality programs: Quality, which is similar to the Physician Quality Reporting System (PQRS); Advancing Care Information (ACI), which builds on the Electronic Health Record (EHR) Incentive Program (also known as meaningful use); and Cost, which is similar to the Value-based Modifier (VM). The fourth component, Clinical Practice Improvement Activities (IA), is new.
The QPP is designed to allow these activities to be phased in gradually. Participation in these various exercises initially can prevent reductions of payments and, over time, successful participation in the program can lead to increased payments. The entire program is budget neutral with regard to CMS payments.
Each year, the Communications Pillar of the ACS B/G conducts a survey of the Governors in an effort to engage the Fellows with the ACS leadership and to take the pulse of surgeons. This process is a resource to gauge the concerns, feelings, and interests of the Fellows.
The 2016 survey contained 11 questions pertaining to MACRA, with particular emphasis on surgeons’ preparedness to enter into APMs. The queries investigated the surgeons’ knowledge about their practice and/or hospital’s depth of activity with outcome metrics, integrated care, benchmarking efforts, and contract and risk management.
Use of quality and performance measures
Not surprisingly, many surgeons are in practices that use transparent benchmarking tools to track surgical quality, safety, and outcomes. In all, 77 percent of respondents said their practices use benchmarking, clinical quality forums, or improvement projects (not including morbidity and mortality conferences), which track effectiveness improvement. Another 20 percent indicated that their practices do not use these tools, and 3 percent indicated that they were unaware of whether their practices do so (see Figure 1).
Figure 1. Tracking effectiveness:
Does your practice use benchmarking, clinical quality forums, or improvement projects (not including morbidity and mortality conferences) that track effectiveness improvement to improve patient care?
Full-time academic surgeons were most likely to report (67 percent) that their hospital leadership used transparent benchmarking to track surgical quality, safety, and outcomes on a quarterly basis. Full-time hospital-employed surgeons were a close second at 64 percent. Among the respondents in private practice, 44 percent reported using quality benchmarking instruments, but 19 percent were unsure whether their practices participated in these programs (see Figure 2).
Figure 2. Transparent benchmarking:
Does your hospital leadership use transparent benchmarking to track surgical quality, safety, and outcomes on a quarterly basis?
When asked whether the surgeons’ practices used benchmarking, clinical quality forums, or improvement projects to track effectiveness of efforts to improve patient care, the numbers are even better. In fact, 89 percent of full-time academic surgeons reported that their institutions used these programs to improve patient care, and 75 percent of full-time hospital-employed surgeons indicated that their practices did so. Private practices lagged in this area, with only 55 percent reaching this goal (see Figure 3).
Figure 3. Tracking effectiveness (by type of practice):
Does your practice use benchmarking, clinical quality forums, or improvement projects (not including morbidity and mortality conferences) that track effectiveness improvement to improve patient care?
In addition, just 40 percent of academic surgeons and 39 percent of hospital-employed surgeons reported that their practice revenue is based on outcome metrics, meaning that at least 10 percent of their revenues come from achieving performance metrics. Among surgeons in private practice, the percentage is much lower—14 percent (see Figure 4).
Figure 4. Practice revenue:
Is your practice revenue based on outcome metrics, meaning that at least 10 percent of your revenue comes from achieving performance metrics?
Risk-based contracting
As the APMs evolve, it is anticipated that physican payments will increasingly be tied to outcome metrics as well as risk-based contracts. For most physicians, this evolution will force them to look differently at their practice activities and the health care delivery system as a whole. Most physicians are familiar with fee-for-service reimbursement policies and procedures.
Risk analysis requires that surgeons use a new approach to thinking about health care delivery, including participation in risk pools and revenue reserves. Participation in Accountable Care Organizations (ACOs), which will likely be a central component of some APMs, has taught physicians about managing groups of patients and dealing with risks. Bundled payments and the ACO experience work hand in hand. Many experts anticipate that bundling and ACOs represent the future direction of health care in the U.S.
The survey results show that very few private practice respondents (12 percent) are involved with risk-based contracts, meaning that at least 10 percent of their revenue is from ACOs or consists of bundled payments for managed care. Furthermore, only 36 percent of full-time hospital-employed surgeons and 32 percent of full-time academic practice surgeons are involved in these types of contracts (see Figure 5).
Figure 5. Risk-based contracts:
Is your practice involved in risk-based contracts, meaning that at least 10 percent of your revenues are from ACOs or are bundled payments for managed care?
As the QPP evolves, more health care providers will likely move into Advanced APMs, which means surgeons will need to consider a range of new questions about their practices, including whether their practices assess the patient population for risk-based contracting. The B/G survey showed most do not assess patients for risk-based contracting. Hospital-employed surgeons were more likely to report engaging in this practice (26 percent) than surgeons in other practice arrangements. The reason that hospital-based surgeons are more likely to use risk-based contracts is most likely secondary to hospitals being required to assess population-based problems and their risks by different agencies, including The Joint Commission, state departments of health, and so on.
We asked the Governors whether their practices have reserves that can handle risks associated with APMs. Only 36 percent of respondents at academic medical centers indicated their practices could handle the risks, while 29 percent of hospital-employed physicians indicated their facilities had reserves to handle risks associated with APMs (see Figure 6).
Figure 6. Reserves:
Does your practice have reserves to withstand annual cycles of payment and the “downside” risks of APMs in the area of staff compensation and business continuation?
The survey also asked respondents whether their practices participate in risk-based contract governance committees. Not many participate in these committees—just 13 percent of surgeons in academic practices, 18 percent of those in full-time hospital-based practices, and 2 percent in private practices responded in the affirmative. Furthermore, 41 percent of surgeons in academic practice said they did not know whether their institutions participated in these committees (see Figure 7).
Figure 7. Risk-based contract governance committees:
Do surgeons in your practice participate in risk-based contract governance committees?
Moreover, not many surgeons reported that their practices have reserves to withstand annual cycles of payment and the downside risks of APMs in terms of staff compensation and business continuity. Among surgeons in academic practice, 36 percent said their practices had these reserves, whereas only 29 percent of hospital-based surgeons and 14 percent of private practitioners indicated they would have enough money set aside to withstand these fluctuations (see Figure 6).
Integrated care
For MACRA to reach its ultimate goals of improving care while reducing costs, integration of care is essential. To address this aspect of MACRA preparedness, the Governors were asked whether their practices are involved with other specialty service lines and if they participate in medical homes. When asked whether their practice works with primary care physicians in a medical home recognized by insurance companies or other payors, just 28 percent of surgeons in academic practice, 39 percent in hospital-based practice, and 19 percent in private practice responded in the affirmative (see Figure 8). Furthermore, less than 40 percent of respondents’ practices were involved with medical homes (39 percent for hospital-employed surgeons), but on a brighter side, academic surgeons (70 percent) and hospital-employed surgeons (57 percent) have practices with clinical service lines aligned with other specialties (see Figure 9).
Figure 8. Medical homes:
Does your practice work with primary care physicians in a medical home recognized by insurance companies or other payors?
Figure 9. Clinical service lines:
Is your practice based on well-established clinical service lines aligned with other specialties?
Conclusion and resources
MACRA is a bipartisan legislation developed with input from numerous stakeholders. In spite of uncertainties in Washington, DC, it is clear that pay for performance and value-based purchasing—key concepts that drive MACRA and the QPP—are here to stay.
The Governor’s survey revealed that many surgeons are exposed to value metrics and are interested in taking steps to improve quality of care and their performance. However, many Governors are unfamiliar with how MACRA and the QPP define achieving these goals and the steps they will need to take to qualify for positive payment adjustments in the future.
As surgeons, we are trained to evaluate and adapt. Like other health care professionals, surgeons adopt new processes and procedures at different rates. The key is to avoid being in the “late adopter” group. Just as it took a while for many surgeons and other physicians to adjust to PQRS requirements, taking on the challenge of implementing MACRA will require effort and time. Fortunately, CMS is implementing the QPP incrementally through a series of steps or phases to acclimate physicians and their organizations to the new system over time. For example, the MIPS requirements for 2017, which will affect payment in 2019, are not very rigorous.* The good news for ACS Fellows is that the College offers numerous resources to help surgeons of varying levels of expertise with quality measurement to succeed under the QPP.
The ACS leadership and the Division of Advocacy and Health Policy have taken proactive steps to educate Fellows on compliance with MACRA. The ACS has created a QPP Resource Center. This resource comprises informational videos about QPP, which provide basic information about the program, options for participation, and other information available to members of the organization. Over time, the College will be adding tools to help surgeons maximize their success and minimize stress as QPP is phased in. Visit the Resource Center often to check for updates.
In addition to the ACS, other available resources include a Medscape web page, which contains multiple-part online sessions concerning MACRA and its options. This resource is free.
CMS also is posting information concerning MACRA on its website. This resource goes into great depth. Links take the reader to all of the options with their specific components. Traversing the CMS website does take some time and the additional links may appear endless. However, as a resource, the CMS site is complete.
Of course, along with these free resources, consultants are available to instruct you and your organization about MACRA for a fee. How involved surgeons want to get depends on their interest in the different options. If you are a member of a large surgical group or multispecialty group or hospital system, a dedicated team with information technology support should be considered.
How ready are surgeons for MACRA? The results of the Governor’s survey show we have work to do. As surgeons, we are programmed to adjust. Striving to provide quality care is ingrained in us. The hard part of change is just getting started. Fortunately, the College is in our corner and ready to help. Start or continue your MACRA journey using the ACS resources that are just a few clicks away.
*Coffron MR and Bailey PV. QPP in 2017: Navigating the transition year. Bull Am Coll Surg. 2017;102(4):22-28.
