Hundreds of medical providers gathered in Portland Thursday to discuss primary-care centered health, changes in how the government pays for quality, and a drastic overhaul that’s reshaping healthcare across the country – and that won’t be affected by the rancorous debate now unfolding over the fate of the Affordable Care Act.
The Medicare Access and Chip Reauthorization Act, or MACRA, was passed in 2015, with the goal of reforming a significant portion of government-funded health coverage. Unlike the proposed Senate health bill, which focuses on private insurance and Medicaid, MACRA, will affect the more than 750,000 Oregonians enrolled in Medicare, mostly people over age 65, but also some younger residents with disabilities and qualifying conditions. Nationwide, more than 55 million Americans are affected.
“Many people think that the repeal of the Affordable Care Act is going to make MACRA go away, but that’s absolutely not the case. These are two separate complete programs by statute,” Carol Vargo, director of physician practice sustainability with the American Medical Administration, told the crowd of medical providers and healthcare administrators that gathered to learn about the program, which had a release of 2018 rules earlier this week.
MACRA was adopted with the support of the AMA and in many ways supports initiatives that the ACA brought to Medicaid and Oregon’s CCOs, Vargo said. It puts a heavy emphasis on using data analysis to drive the types of care provided, and to identify patients who may need extra support. It also moves toward rewarding medical providers for outcomes – how healthy somebody is – rather than inputs – how many visits or tests that patient received.
But with more than a thousand pages of governing rules, and many small practices so focused on getting through the day and the week, not the years ahead, getting the medical establishment up to speed on these changes to Medicare can be a challenge, Vargo acknowledge.
Much like the ACA’s focus on primary care, quality ratings, and costs, MACRA seeks to overhaul how physicians are paid in order to lower costs to the government and improve health outcomes.
Hospitals, as the largest employers of physicians in the state, are at the center of this effort to reinvent care and payment systems. Dr. Jim Guyn, senior vice president for population health with Bend-based St. Charles Health System; Dr. Everett Newcomb II, chief operating officer at Legacy Health; and Dr. Ralph Yates, chief medical officer at Salem Health, all took a deep dive into their ongoing efforts to adapt to MACRA in a panel discussion at the conference, which was sponsored by the Oregon Medical Association and Oregon Health Care Quality Corporation.
“We do have to move away from the way things were. When you’re a fairly isolated healthcare system, as we are, we’ve been able to pretty well dictate what we want. Insurance companies had to play ball with us,” Guyn said. “Our CEO, Joe Sluka, has made a determination that that is not the future. The future is in value-based arrangements and risk arrangements, and that’s where things are definitely going to go.”
Electronic records management systems may be key to this effort – but first they have to be set up and used correctly, Guyn said. For example, St. Charles currently has separate systems for inpatient and outpatient care that do not effectively communicate with one another – and these systems are distinct from records kept by non-St. Charles physicians, pharmacies, and so forth.
“We are still missing the piece that has to do with the longitudinal history of what happens to patients,” he said. “We don’t know they were at the E up the road a few times, or that they have a prescription from another provider. The only one that knows that is the payer” – that is, the insurance company, Medicare, or Medicaid.
If all of the data could be combined, the implications would be enormous. Data could be used to identify which patients are at highest risk for health problems, to give them the support they need. It could identify which orthopedists or cardiologists cost less and are more effective in there are. It could save money and improve health outcomes, Guyn said.
Newcomb at Legacy said he shared Guyn’s assessment of the data challenge.
“When you take an isolated cardiology practice over here, and an isolated practice over there, how do you share the best practices across them?” Newcomb asked.
Some physicians who work with Legacy are directly employed by the health system, but a large majority are independently affiliated. But using common platforms regardless of employer, and between healthcare systems, does provide a partial fix, he said.
“I don’t know that there is a total solution,” Newcomb continued. “One of the advantages of being in Portland proper is that all the hospitals and health systems are on the same platform.”
OHSU, Providence, Legacy, Salem, Adventist and others all use the EPIC software suite for tracking medical records and billing
“By having that common platform, at least for the hospitals and providers on the staffs of those hospitals, we can go in and through a piece of EPIC called Care Everywhere, if somebody was in the E yesterday and how they are in your clinic, you can go in and get some basic clinical data,” Newcomb said. “It’s not ideal, but it’s certainly a lot better than having to sit on the phone for 20 minutes and trying to call everybody to get some data about what happened yesterday.”
He also acknowledged that even among systems that have adopted EPIC, not all records move easily back and forth – and many systems do not use EPIC at all.
Yates said he concurred that medical records are crucial to gathering data and tracking patients, but in his remarks on MACRA he focused more heavily on how care is delivered within the Salem Health system, rather than on its use of data.
“It has to start with primary care,” Yates said. ““There’s no reason heart failure should be pushed to cardiologists. There’s no reason diabetes should be managed by endocrinologists, not with the skill sets we have today. The question is, how.“
At Salem Health, the answer increasingly involves what Yates called the expanded care team model. In a clinic centered around primary care, for example, a doctor of pharmacy, a licensed social worker and a care coordinator might all be embedded alongside physicians.
Clinicians see more patients per day than in a typical setting, then engage in what’s called a “warm handoff” to the other specialists in the office. The doctor of pharmacy may work to understand the full balance of medications a patient is taking for complex health problems and make final decisions about new prescription treatments. The social worker can help with mental health needs and social needs around complex conditions. The care coordinator makes sure patients have the transportation to get to appointments and pharmacies, and other support to stay on track with their medical plans.
This MACRA-driven approach mirrors efforts described earlier this month in Salem, at CCO Oregon’s Social Determinants of Health Conference. There, officials at Portland-based Rosewood Family Health Center also described a “warm handoff” approach to integrating mental health providers, dieticians and other experts alongside primary care providers.
Echoing the MACRA focus on data-driven efforts to improve care and lower prices, organizations like Kaiser Permanente and Providence Health & Services shared their efforts to gather data about what works best at the earlier conference, as well.
And despite threats to the Affordable Care Act, and uncertainty about how Congressional actions could reshape Oregon’s attempts to overhaul its healthcare system, speakers at The Oregon MACRA Playbook Conference remained focused on the ways MACRA will advance some of the key goals of the ACA.
“Savings are there within the system, we have to design a model that’s more efficient,” Yates said. “We must change how we are delivering care.”
Reach Courtney Sherwood at [email protected].
