PM 2017: MACRA/MIPS/APM/BPP/CJR/EPM/PSH/EC/CMS/VBP

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  • Chamberlin, Keith, MD, MBA
| Feb 07, 2017

Keith_ChamberlinThat is correct. No actual full words were spoken this year at Practice Management 2017. The entire meeting was held in abbreviations only. And there were plenty of them!

Held just outside of Dallas, Texas, at the Gaylord Resort, this was the best-attended Practice Management meeting in the history of the ASA. Why was that, I wonder? Anything to do with the fact that Medicare has totally changed how we are going to get paid? Hmmm…

Go along with me here: SGR (the Sustained Growth Rate) was replaced with MACRA, the “Medicare Access and CHIPS Reauthorization Act”. MACRA is an act passed in 2015 by Congress.

abbrevs3MACRA allows ECs (eligible clinicians) to be paid in one of two ways in the QPP (quality payment program): via MIPS (Merit-Based Incentive Payment Score), or through an APM (alternative payment model) such as an ACO (accountable care organization) that may or may not have a PSH (Perioperative Surgical Home) as part of its structure. APMs also include CJR (comprehensive joint replacement) programs, BPP (bundled payment programs), and EPMs (episodic payment models).

Now, CMS (Centers for Medicare and Medicaid Services – apparently the second “M” is silent…) has clearly decided it is time to drive all Medicare providers into a VBP (value-based payment) system and away from FFS (fee for service). CMS is doing this by making the alternative – MIPS – complex and difficult, and pairing it with a financial downside to accompany the upside. It is a budget-neutral program – in order to pay the winners, there must be losers. On the other hand, becoming part of an APM gives you a bonus every year and the chance to win prizes.

Onward. Along with learning all about MIPS, etc., we heard lectures on the Perioperative Surgical Home from many speakers including our own Zeev Kain, MD, MBA, and Stan Stead, MD, MBA. There were also talks and programs on leadership, strategic planning, out-of-network billing, and the “company model”. We heard in detail about what to expect (if you can possibly predict that) from the Trump Administration, in a talk by Lisa Liebamwicz, MD, who is the chief medical officer at the Advisory Board.

roundtablesAnd, of course, we sat at the infamous roundtables, where for two hours you had the opportunity to discuss, in depth, any one of a number of topics with experts from our specialty. Here is an interesting piece of information. What was, by far, the most heavily attended roundtable? It was a discussion about what the ASA can do for small to medium-size groups.

I must take a moment to talk about small to medium-size groups, defined as group practices with three to 50 members. Based on estimates from publicly available data, 90 percent of physicians are in group practices. Most – 52 percent – are in groups of less than 50 anesthesiologists, and 34 percent are in groups of less than 25 anesthesiologists. These numbers do not reflect whether or not the anesthesiologists are ASA members.

Until recently, the ASA has not given these smaller groups very much attention. That has changed as of this Practice Management meeting. The ASA actively listened to a focus group, and has appointed a workgroup to start planning and designing tools and processes to help small groups with all facets of practice management. Look for more about this in future ASA publications.

The PSH (Perioperative Surgical Home) was a leading agenda item. As evidence that it is becoming an important part of the surgical landscape, we now have surgeons and internists trying to develop their own versions of this “Perioperative Medicine” specialty. We have come a long way in the development of the PSH – the PSH Learning Collaborative has involved dozens of healthcare organizations that have already taken part or are part of it now.

The PSH more and more is incorporating ERAS (enhanced recovery after surgery) protocols, and Michael Schweitzer, MD, MBA, showed a slide asking which came first, ERAS or PSH? (hint: ERAS…) The PSH is becoming more important and relevant because now everyone is focusing frenetically on reducing TCC (total cost of care). We can reduce costs with clever pre-habilitation, GDFT (goal-directed fluid therapy), and great postoperative pain management that reduces LOS (length of stay).

qual_valueThere were also sessions on improving your quality and value. Benchmarking was a big topic. Comparing yourselves to each other in your own group is quality improvement. Comparing yourselves to other groups and national standards is benchmarking. That is still a process under development via AQI (Anesthesia Quality Institute) and NACOR (National Anesthesia Clinical Outcomes Registry). The benchmarking lecture was an enormous success – oh, wait – that was my lecture. I guess I should wait for someone else to make that claim.

In the past, the global attitude at Practice Management was gloomy and depressed. This year, I felt a determined hopefulness. By that, I mean we understand what is coming and when. We understand what needs to be done by when. We have developed tools and programs to help us succeed in this upcoming harsh economic environment. We have anesthesiologists working closely with CMS. We have a very robust and successful advocacy program, and we were able to protect our veterans against the original proposal to remove anesthesiologists from VA hospitals.

We are ready for the future. We can answer every bell and every call. We can jump through every hoop put in our way. Obstacles have become opportunities to show our value and expertise. It was a very, very, good meeting. You should go next year – it’s in New Orleans.

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