TCT 2017: Physician's 5 key points for aligning incentives under MACRA

CMS recently finalized its rule for the second year of the Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program (QPP), which continues the move toward value-based reimbursement and away from volume-based models.

With healthcare systems still adjusting to the new policies, the Society for Cardiovascular Angiography and Interventions hosted an hour-long session Oct. 31 during the Transcatheter Cardiovascular Therapeutics conference in Denver titled “Cath Lab Economics and Payments: Mastering MACRA.” Herbert D. Aronow, MD, MPH, closed the session with a presentation on how to align financial incentives between physicians, hospital administrators and other stakeholders, and how collaboration could lead to success under MACRA.

Here are five key takeaways from Aronow’s presentation and post-session interview with Cardiovascular Business. Aronow is the director of interventional cardiology at the Cardiovascular Institute of Rhode Island Hospital, The Miriam Hospital and Newport Hospital.

1. Physicians and administrators need to be on the same page.

“Although it’s one of the most important relationships to align, it can be one of the more difficult,” Aronow said. “There’s sometimes the perception on the part of physicians that administrators don’t understand or care about patients, that maybe they only care about the bottom line. I’m not saying that’s right, but the perception is out there. And there’s a perception amongst some administrators about physicians, that they don’t understand we can’t provide things that we can’t afford. Somewhere there’s a happy medium.

“We each live in our own respective habitats and they differ. Physicians like to be in the cath lab, not in meetings. We have access to different types of information and we do process information differently at times and we manage conflict differently.”

Aronow said physicians and administrators must work together to define roles, each with sufficient authority to make decisions and enact necessary changes. But there must be a line of communication so each side understands the business and clinical aspects of care decisions.

“I think it is incredibly important that there is a physician in every practice or division who can champion MACRA,” Aronow said. “Many physicians find it difficult to understand and all administrators will need some clinical insight into the decisions that will be made.”

2. Individual economic incentives are a powerful tool, but so is patient-centered gainsharing.

Rather than spend incentive earnings on bonuses for staff members, Aronow suggested a way to spend the money that both medical team members and administrators could support.

“Money saved could go into new equipment or more staff if it’s needed or renovation of the physical plant—all the things that might make the program better or the experience better for the patient,” he said. “That motivates the providers. I think that when there’s a quid pro quo it’s more likely that we’ll see change. It’s not selfish, it’s really selfless. It’s all about the patient.”

3. Valuable care is a combination of good clinical outcomes and low costs.

So, how to cut costs?

“Maybe that will come through reducing the number of barely indicated procedures, maybe it will come from reducing costs per case and it will certainly come from improving efficiency,” Aronow said.

In addition, hospitals will need to engage in quality improvement initiatives and participate in Certified Electronic Health Record Technology to maximize payments—and avoid penalties—in other areas under the QPP.

4. Despite the emphasis on cost, it could be problematic to assess physicians by the amount of resources they spend.

“I know there’s an effort on the way at many hospitals to look at resource use in the cath lab,” Aronow said. “Some operators are more expensive than others when performing the ‘same’ procedures. The truth is that they’re not always the same procedures; it might be that there are physicians performing more complex procedures and using more equipment to do that.

“Just like anything else we look at, when we look at mortality for example, you’re going to risk-adjust. I think if we moved in that direction … we’ll need to be sophisticated about adjusting for factors that drive costs and not just look at unadjusted cost for a given type of procedure.”

5. Health systems should act now—even if performance metrics are still being defined or may change in the coming years.

“MACRA is a moving target right now. There are many aspects of it that are uncertain,” Aronow said. “But what is certain is that we’re all going to need to work together to reduce costs and improve quality, so I don’t think that we need to wait to find out exactly how we need to do it to begin working on what we all know we need to do.”