Practice Transformation Networks – Moving MACRA forward.

Regional Insights: Lisa Letourneau

Lisa Letourneau (MD, MPH) is the Executive Director for Maine Quality Counts, a Regional Health Improvement Collaborative (RHIC). Lisa also leads the Northern New England Practice Transformation Network, supporting more than 1,100 clinicians in Maine, New Hampshire and Vermont in their practice transformation efforts.

The role of the Northern New England Practice Transformation Network (NNE-PTN) is both bold and straightforward: we help providers to identify, adopt and implement meaningful changes that will transform both the way they provide care – and the quality of care they provide. Despite the fact that we bring new ideas that require time, energy and a certain amount of faith on the part of our constituents, our provider-partners are remarkably receptive. To honor their faith and patience, we’re very deliberate in how we communicate our recommendations, taking care to acknowledge the different roles within practices – and to deliver the specifics they need to achieve success.

And now, with MACRA implementation just months away – and 962 pages of draft rules to unravel – knowing our audience has never been more important. Yes. Those 962 pages are important. But they don’t all apply to everyone. That’s where we come in.

Until recently, a lot of the information flow about MACRA has been by and for policymakers. Because that audience is so well served, we pull the lessons we need from that dialog – and from the draft rules – and distill those aspects that are important to our audience: practices.

As a PTN, much of our communication is directed to practice leaders – the administrators, managers and medical directors tasked with running the day-to-day operations of a busy medical practice. These are the people who are responsible for identifying and implementing practice-wide change. And as such, they’ll need to have enough of a grasp on MACRA to make sense of the rules, to be aware of the challenges of implementation, and to identify and seize upon the opportunities the law affords.

Once these practice leaders have a handle on the details, they’ll need to actually integrate MACRA in their practices, highlighting and promoting its features to everyone from staff to practitioners – at every level.

Granted, the rules aren’t yet final. But they will be – in a matter of months. And in medical practices, where it’s been demonstrated that changes take as many as 18 years (you read that right) to become fully integrated, it’s important to get started now. Here’s how:

1) Educate yourself. Learn as much about MACRA as you can, attend additional webinars, including CMS and professional membership organization webinars, and look to NRHI as a resource.

2) Engage fellow providers and practice staff. If you don’t have everyone on board, it’s tough to move forward. The practices that perform the best in PCMH and other practice transformation work, are those who engage their entire team in the process.

When providing information on MACRA it’s critical to think about who the audience is. Help our customers – who are largely practices and practice leaders – to understand the different roles and help them build an understanding of MACRA that is appropriate to them. With MACRA, work with the concept of developing a cascading communication plan starting at the highest level, all the way through the practice to the front line level. Historically in medicine it takes 18 years to see change in practice, so it’s important we help providers understand the need for urgency and that we boil this down to the most essential points.

As a PTN the first point of contact is often practice managers. Consider what they need to know, then think about what they need to share with their providers. We can support practice management to be leaders by helping them make the connections between the vision of MACRA and what is done daily in practice.

Help practices understand what their path will be – will they be in MIPs or Advanced APM? We know there are relatively few options to qualify for an Advanced APM including having enough patients to qualify; it is expected that most providers will be in MIPS.

3) Connect with local, regional and national leaders who are participating in ACOs. We encourage clinicians to connect and learn from them, their recommendations about what to be focusing on.

4) Understand current performance, using PQRS, QRUR, and other reporting. It’s vitally important not to let the lack of complete or perfect data be the enemy of good enough data to understand your current state. While the first MIPS payment year is 2019, the first Performance Year is 2017 and providers still need to report PQRS by the first quarter of 2017 for the care they provided in 2016.

Within MIPS there are 4 key components: cost, quality, Advancing Care Information (ACI), and Clinical Practice Improvement Activities (CPIAs). Providers should be thinking about what they know about their current cost and quality performance:

  • On claims-QRUR and clinical performance: What is a practice’s ability right now to pull their electronic clinical quality measures and what do they know about their performance on the electronic quality measures? Advise providers to receive CMS 2014 QRUR (Quality Resource Utilization Report) if they have not yet done so.
  • Practices will need their 2015 Office of the National Coordinator for Health Information Technology (ONC) certificate for advancing care information.
  • As a practice, think about what could you currently do to improve performance in one of these areas that may also qualify as a quality improvement activity
  • Determine where the practice really is in terms of access. What can you do, even over the next six months? For example, Care transitions—what are they really doing to track admissions, are they using Health Information Exchanges to be notified in timely way of ED visits, admissions and discharges? Are high risk patients getting timely care?
  • Determine how providers can use current CMS payment models to support some of these activities, such as chronic condition management FFS visits. Don’t forget about all these other things we have been working on for years, which are tied to success in some of the MIPS quality improvement activities. For example, are Medicare Annual Wellness Visits being utilized? Existing Medicare Transitional Care Management codes to decrease readmissions and Chronic Care Management codes are vastly underutilized in most primary care practices. Focus on being conscious of what you’re doing to provide good care and not making changes across the board.