If MACRA Fails, It Will Be a Failure of IT, Not Doctors or Regulators

The following is a guest blog by Steve Daniels, president of Able Health.

There has been a whole lot of mudslinging over the last month between regulators and healthcare providers over MACRA, which shifts Medicare payments further toward pay-for-performance starting January 1. On the one hand, CMS Acting Administrator Andy Slavitt is clear that CMS is ready for change. “We need to get out of the mode of paying physicians just to run tests and prescribe medicines,” he told a Senate Finance Committee hearing. Meanwhile, Dr. Thomas Eppes of the American Medical Association has called MACRA a “quantum shift” and pushed for a delay.

Yes, the Medicare Quality Payment Program instituted by MACRA should—and will—evolve based on comments made on the proposed rule. But the reality is the program provides enormous opportunity for providers to increase bonus payments, while streamlining reporting requirements across a patchwork of outdated and duplicative programs. And it’s worth noting that the potential penalties under the Merit-Based Incentive Payment System (MIPS) over the next four years are actually lower than the sum of the penalties of the programs it is replacing.

To meet MACRA goals, it will take a well-prepared team of providers and administrators—empowered by data and well-designed tools. Doctors can’t be solely responsible for achieving patient outcomes, reducing costs and documenting it all for CMS as they go. Unfortunately, the history of health IT has not been kind—or affordable—to doctors. And today, the health IT stack has a new challenge—keeping pace with the proliferation of value-based programs, from accessing data all the way through enabling new clinical practice.

We must move from a mindset of meeting Meaningful Use checkboxes toward supporting a more effective way of operating. And in the modern world of software-as-as-service, there’s no good reason left that IT needs to cost providers millions of dollars. We can do better. As things stand, if MACRA fails, it will be a failure of IT, not doctors or regulators.

Gathering all the data

For value-based care to work, patient data needs to be made available for providers to coordinate with each other, as well as to payers, to properly evaluate performance based on all known information. Those still blocking or jacking up prices for data access are complicit in obstructing the vision of a learning value-based system.

It is time to remove technical barriers through modern and open data standards like FHIR, as well as rules and unreasonable fees that prevent parties from accessing data when they need it. Thankfully, the Advancing Care Information performance category will reflect the emphasis on information exchange set forth in Meaningful Use Stage 3.

Calculating performance flexibly

The new era of performance-based pay requires continuous monitoring of quality and cost, with the ability to track progress across multiple programs on an ongoing basis. To measure quality today, we often use static algorithms hard-coded by EHRs vendors and health system IT departments, conforming to standards set by NCQA or CMS.

But providers need tools that are tailored not just to one or two programs like Meaningful Use and PQRS, but across the organization’s full range of value-based programs as these program continue to expand, evolve, and proliferate. With efforts to standardize IT for quality measures stalling, vendors need to focus less on one-size-fits-all quality measure calculations and more on flexible systems that enable measures to be rapidly constructed and customized to move with the trends. Expect change to be the norm.

Informing new behaviors

With so many health IT professionals focused on gathering and reporting data, it is not surprising that design has taken a back seat so far. But this year, not a single population health vendor earned an “A” rating from Chilmark, due to poor user engagement and clinical workflow. This is no longer acceptable. The challenge of enabling the new clinical and administrative behaviors associated with value-based care is too vast. User experience must be top of mind for any IT implementation, with representative users involved from the start. We have seen the impact of poor user experience in the fee-for-service system, from frustrated clinicians to alarming patient safety issues.

Design is even more important when the challenge is not just documenting billing codes but also achieving health outcomes for patients across a care team. Don’t bombard clinicians with notifications and force clumsy form-filling. Instead, employ best practices from cognitive psychology to inform professionals with lightweight and intelligent touchpoints. Automate documentation and interpretation of data wherever possible.

A new era of health IT

Whether or not it’s delayed, the Quality Payment Program is coming. And the healthcare industry is moving inexorably toward value-based care. Will health IT step up to the challenge of building toward a value-based future that is accessible to all providers? Or will we sit back and wait for the next list of requirements?

About Steve Daniels
Steve Daniels is the President of Able Health, which helps providers succeed under MACRA and value-based programs. Formerly the design lead for IBM Watson for healthcare and a lifelong patient advocate, he is passionate about the role of open data exchange and intuitive experience design in fostering a continuously improving healthcare system. Find him on Twitter and LinkedIn.

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  • It is disappointing to see such an unbalanced view of things presented these days. Especially after all the lessons we’ve learned from previous programs. There will be plenty of blame to go around when this program stumbles; some undeserved, some deserved.

  • I’m especially interested in the issues of data sharing, which have a huge affect on the quality of patient care. I’d add to it the need to be able to transmit provider’s orders to another institution; for instance, a doctor in one system has his patient go into a hospital in another system and the only ways to transmit orders are by phone or fax; and frequently that breaks down. Imagine that in an ER, where a patient in bad need of treatment has to wait for hours for the orders to be chased down. Just as bad, when the hospital (in one system) and the doctor (in another) can’t readily share data for that patient with all sorts of waste or other problems resulting from that failure. Finally, the hospital and ambulatory system that won’t spend the money to share data and orders with major lab facilities, causing all sorts of delays in getting results, and making those results in image form only, not available to portal access and not available to do analysis on. All of which reduce the quality of patient care.

  • Mike,
    We like to share all the different viewpoints. If you’d like to write the counterpoint to this article, I’d be happy to share it as well. A look into various viewpoints helps us understand what’s going on and how to improve things.

  • Without a doubt, I blame regulators. They forced a policy market that made it very complex to innovate and enter the market. Constant changes to the program, ever increasing complexity, and mandatory certification has hammered innovation. IT vendors are on a hamster wheel to catch up to all these changes. It would have been MUCH better to let the real market work with nudges from regulators, not the nanny state, one-size-fits-none rules.
    Imagine if we had a “leave us alone” or “custom IT option” for MACRA. All we want it to NOT be penalized and let us innovate and work directly with vendors to make IT work for actual providers, not what Washington DC thinks.

  • MACRA and the ever-changing Quality Payment Program have always had one end goal in mind, interoperability.

    If Health IT Vendors can focus on interoperability alone, then the hours won't be wasted. Interfaces and telemedicine are the way of the future. If we can create data sharing programs to connect providers and EHRs directly to devices, the quality of care, and the quality of life for patients could dramatically improve across the United States.

    All too often providers must treat patients in the dark. Why? Because patients don't know what tests have been performed and may not be aware of all prior diagnoses. Without complete and accurate information, providers must repeat tests, multiple times, which costs insurance companies, our government, and self-pay patients much more than they should be paying.

    Interoperability is key to improving the quality of health and cost savings across the US.

  • Taylor,
    Has that always been their goal or SHOULD it have always been their goal? I think it’s the later. If that was the end goal, then they’ve executed very poorly in achieving that goal.

  • John,

    Since the very beginning of the EHR incentive program, the goal has been to create a data sharing network for all patient information and records. While I do agree with you that things could have been implemented better, I think “very poorly” is a strong statement regarding the program execution. As with everything new, there were several hiccups and much greater resistance than expected from participants. From a healthcare IT and healthcare admin standpoint, it’s an almost impossible task to make providers and clinicians do anything they don’t want to do.

  • Taylor,
    That’s true unless you dangle $36 billion in front of them. It was amazing how irrational the market became with all of that government money dangling in front of them.

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