Thread by @Farzad_MD

1/ Our national quality/value program (MACRA) is broken

Most people just complain about its shortcomings, but @Travis_Broome comes up with an elegant, grounded way to fix its biggest flaws

Apply behavioral economics, use virtual groups, lay path to APMs ajmc.com/view/macra-has…

2/ MACRA was a true milestone, and a concept that I still support- instead of artificially capping medical inflation (and then not having the guts to actually see doc pay cuts) lets create 2 paths- a "pay for performance" base and an incentivized alternative payment model track.

3/ But 3 seemingly technical details fundamentally sapped the potential impact of this huge bill.

classic behavioral economics- the impact of an incentive is not just proportional to its size, but also its cost, uncertainty, and delay

MACRA stunk on all counts here.

4/ A lot has been said about the burden of data collection-

As I discussed with @GistHealthcare (gisthealthcaredaily.libsyn.com/monday-june-14…) exceptional physicians might still find meaning in quality measurement (as you might in suffering) but the payments don't come close to costs right now.

5/ Best recent paper with tons of terrific data is from @DhruvKhullar

"It cost practices $12 811 per physician to participate in MIPS.. a general surgeon receiving a PERFECT 2018 MIPS score could a reward of ~$2,000... in 2020"

Crazy.

But...why???

jamanetwork.com/journals/jama-…

6/ Docs are ranked against each other; quality payments for high performers were supposed to come from low performers.

@CMSGov didn't have confidence in calling "low performers" -> Nobody got "dinged" -> Nobody gets rewarded either.

Low rewards. delayed. uncertain.

#Trifeca

7/ OK, some people say that's fine. We don't need the MIPS/P4P part to work.

In fact, the whole goal of MACRA was to move docs into advanced alternative payment models. Over there, they get 5% bump automatically, and an opportunity to make a lot more in global risk

same issues

8/ As Travis points out, the 5% AAPM bonus is scheduled to go away. And it's crazy delayed.

A doc who joins an AAPM for 2022 will make that decision this month.

They won't receive their bonus until August of 2024!, a full 3 years after they made the decision to participate. 🤦

9/ We are behind schedule on AAPM uptake (CMS closing new ACO participation in 2 of last 3 years didn't help)

So the paper recommends extending the AAPM bonuses for another 3 years, and making bonus payments no later than 3 months after participation in an AAPM begins.

And...

10/ Here's the elegant part of the policy solution. Make the solution to the MIPS problem the pathway to the AAPM goal
*Use the "virtual group" concept THATS IN THE LEGISLATION (pushed by smart folks like @LenMNichols @RonWyden) but not really used

We proposed details in '16

11/ Grouping practices addresses a huge problem with practice-level quality measurement- small sample sizes.

here's a classic paper from @EveKerrMD @hltqualdoc: ncbi.nlm.nih.gov/pmc/articles/P…

and a more recent one for oncology practices by @NancyKeatingMD jamanetwork.com/journals/jaman…

12/ The idea of creating virtual groups isn't new.

@CareFirst twist on PCMH-group small practices into “Panels,” to create a larger patient population base, encourage peer consultation across practices as well as competition within and across panels.

link.springer.com/article/10.100…

13/ But..."I don't want to be lumped in with other practices I didn't choose!"

That can be a feature not a bug...if you allow practices to "graduate" whenever they want into a risk-taking ACO with other practices of their choosing (APM path!)

(@CareFirst doesn't allow this yet)

14/ You see how that works?

In MIPS, you create the precursor to the organizational structures PCPs need to move to their AAPMs

Instead of the QM smorgasbord, Travis suggests that CMS could extend this approach to the AAPM models that are best for specialists- eg "bundles lite"