Results from a KPMG-AMA Survey

32 Pages·2017·1.24 MB·English

Are physicians
ready for / ?
macra qpp
Results from a KPMG-AMA Survey
kpmg.com
ama-assn.org
Contents Summary
Executive Summary 2 January 1, 2017 marked the beginning of the first performance
Background and year of the Quality Payment Program (QPP) created by the
Survey Objectives 5
Medicare Access and CHIP Reauthorization Act of 2015
What is MACRA? 5
(MACRA). Beginning in 2019, the QPP will adjust payment rates
AMA and KPMG collaboration
for physicians and other eligible health care professionals for
to educate and support physicians 7
participation in 2017 under one of two payment tracks: (1) a
Survey Objectives 7
payment system with incentives or penalties for reporting and
Results 8
meeting certain quality measures, demonstrating use of a certified
Knowledge of MACRA 9
electronic health record and other measures through the Merit-
Participation 10
Based Incentive Payment System (MIPS); or, (2) a 5 percent lump
Preparation 11
sum bonus payment if the physician has a threshold portion of
Challenges 11
their revenue or patients in a qualifying Advanced Alternative
Future Participation 13
Practice Size Effect 14 Payment Model (Advanced APM). In order to help ease the
Specialty vs. Primary Care 15 transition to this new payment system, the Centers for Medicare
Practice Setting Effect 16 and Medicaid Services (CMS) created a flexible “pick your pace”
Level of Knowledge 17 reporting option for physicians. Additionally, CMS rules are likely
PQRS and Meaningful Use to exclude nearly two-thirds of all clinicians from MIPS reporting
Experience Effect 18
in 2017 (a large portion based on low volume thresholds or
Verbatim findings 19
Advanced APM participation; Advanced APMs are also excluded
Implications 20 from MIPS). Under the 2018 performance year proposed rule,
Physicians Need More Help 21 even more physicians would be excluded in performance year
Certain Challenges are Universal 21
2018 as a result of increasing the low volume threshold.
Value-Based Care Reporting
Experience Matters 22
More Alternative Payment
Models are Needed 22
Physicians are Worried
about Long-term Implications 22
Conclusion 23
There remains a significant QPP
Appendices
knowledge gap among physicians.
Methodology and demographics 24
Survey Design and Fielding 24
Respondent Demographics 24
Analysis 25
Survey Questions 26
References 30
Contributors 31
© 2017 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG
International Cooperative (“KPMG International”), a Swiss entity. All rights reserved. The KPMG name, and logo are registered trademarks or trademarks of
KPMG International. © 2017 American Medical Association, an Illinois not-for-profit corporation. The AMA name and logo are registered trademarks of the
American Medical Association. All rights reserved.
Despite efforts to ease the transition to MIPS and Some key findings from the survey of physicians involved
in practice decision-making include:
APMs, we are well into the first performance year
and little is known about physicians’ preparation – A slight majority of respondents (51 percent) were
somewhat knowledgeable about MACRA or the QPP,
and operationalization of reporting requirements.
whereas less than one in ten physicians (8 percent) felt deeply
Given increasing participation requirements for knowledgeable about QPP and its requirements. Just over four
physicians in future years, understanding where in ten physicians surveyed (41 percent) had heard of MACRA or
QPP, but did not consider themselves knowledgeable.
physicians are today with regard to readiness will
help CMS, as well as medical societies and other – S even in ten respondents have begun preparing to meet
supporting industry stakeholders, to better target the requirements of the QPP in 2017. Of those respondents,
nearly nine in ten respondents feel somewhat prepared (65
educational outreach and help physicians prepare
percent) or well prepared (23 percent) to meet requirements in
for successful participation in the QPP. Feedback 2017. Of those planning to report through MIPS in 2018, only
from physicians will also play a vital role in helping 65 percent feel prepared to meet requirements.
to guide program implementation, including
– Of those respondents expecting to participate in MIPS in 2017,
potential revisions to the CMS proposed rule for the 90 percent feel MIPS requirements are slightly burdensome
(37 percent) or very burdensome (53 percent).
second performance year in 2018.
– R espondents indicated that the time required to report is
In order to better understand physician preparation and
the most significant challenge today and expect that time
positioning for QPP, KPMG and the American Medical
for reporting will continue to be a challenge in subsequent
Association surveyed 1,000 practicing physicians in the United
years. Respondents also emphasized challenges with
States who have some awareness of MACRA and are involved
understanding requirements, understanding MIPS scoring,
in practice decision-making related to QPP. Respondents
and the cost of reporting.
were from a variety of practice sizes, practice settings,
specialties, and geographic regions. Although other surveys
– P revious experience in other programs, including PQRS
have explored the extent to which physicians are generally
and Meaningful Use, appears to have contributed to
familiar with MACRA, our survey focused on those physicians
physician readiness for QPP; thus, getting experience now
who have some knowledge of MACRA and are involved in
in QPP at some level has the potential to set physicians up to
practice decision-making in order to better understand gaps in
potentially be more successful in the future than those with no
understanding, early views and attitudes about the roll-out of the
experience. However, it is particularly concerning that only 25
program, and physician plans for QPP participation. This is not
percent of physicians with prior reporting program experience
to say that awareness among physicians is not still a challenge.
feel well prepared for the QPP.
There remains a significant QPP knowledge gap among
physicians. In this respect, the findings of this survey can assist – However, even those who feel prepared still don’t fully
in indicating a glide path for more widespread QPP adoption in understand the financial ramifications of the program. In
the future. short, they may be prepared to “check the box” of reporting
requirements, but may lack the long-term strategic financial
vision to succeed in 2018 and beyond. Only 8 percent of
respondents feel they are “very prepared” for long-term
90%
financial success, while 58 percent feel slightly prepared and
26 percent feel not at all prepared.
of respondents feel MIPS
requirements are slightly burdensome or
very burdensome.
© 2017 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG
International Cooperative (“KPMG International”), a Swiss entity. All rights reserved. The KPMG name, and logo are registered trademarks or trademarks of
KAPmMerGic Iannt eMrneadtiicoanla Al.s ©so 2c0ia1t7io Anm. Aellr ircigahnt Ms reedsiecravl eAds.sociation, an Illinois not-for-profit corporation. The AMA name and logo are registered trademarks of the Are physicians ready for macra/qpp 3
Summary
(continued)
The findings of the survey largely support a number of
widely held assumptions about physician knowledge of
and preparedness for QPP requirements:
– S ome challenges are universal regardless of practice size,
specialty, or previous value-based payment experience,
particularly the time required and the complexity of
reporting.
– P hysicians, especially those in small practices, need more
help in preparing.
– P hysicians want more alternative payment model options
available to them.
– P hysicians with value-based payment reporting
experience are more prepared and more confident about
how they will perform under MIPS.
– P hysicians remain deeply concerned about long-term
financial ramifications of QPP.
These findings have significant implications for physicians, as
well as a number of other industry stakeholders as the QPP
enters its second year. Policymakers must consider the existing
challenges when crafting future policies and QPP requirements.
CMS and professional medical societies, including the AMA, can
use these findings to develop educational and training resources
for physicians, including by targeting efforts to specific subsets
of the population that appear to need the most help.
This survey provides valuable insights into physician
understanding of and preparedness for the QPP. Although
some groups of physicians (larger practices, multi-specialty
practices, and those with experience in value-based reporting
programs) appear somewhat more prepared and optimistic
about their performance in MIPS, a majority of physicians
across practice sizes, practice settings, and specialties need
more time to transition their practices to the new system.
Additionally, physicians and the broader health care system
need more alternative payment models to allow those who
are ready to move more aggressively toward value-based care
models that hold physicians accountable for the quality and
cost of care they provide. CMS should consider the findings of
this survey and others when crafting policies on participation
requirements, implementation timelines, and other program
specific regulations.
© 2017 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG
International Cooperative (“KPMG International”), a Swiss entity. All rights reserved. The KPMG name, and logo are registered trademarks or trademarks of
4 Are physicians ready for macra/qpp KAPmMerGic Iannt eMrneadtiicoanla Al.s ©so 2c0ia1t7io Anm. Aellr ircigahnt Ms reedsiecravl eAds.sociation, an Illinois not-for-profit corporation. The AMA name and logo are registered trademarks of the
Background and
survey objectives
What is MACRA?
The Medicare Access and CHIP Reauthorization Act of
2015 (MACRA) was signed into law on April 16, 2015,
repealing the sustainable growth rate (SGR) formula used
to determine physician payment updates in Medicare
and replacing it with a stable 0.5 percent payment
update until 2019. Compensation of physicians and other
eligible professionals in payment year 2019 will be based
upon their performance in 2017 in one of two available
participation options under the QPP:
1.
Merit Based Incentive Payment System (MIPS),
a payment system with incentive payments or
penalties for reporting or failing to report certain
quality and efficiency measures; or,
2.
An Advanced Alternative Payment Model
(Advanced APM), a 5 percent bonus payment,
and exclusion from MIPS, if the physician meets a
threshold based on the portion of their revenue or
patients covered under a qualifying Advanced APM.
© 2017 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG
International Cooperative (“KPMG International”), a Swiss entity. All rights reserved. The KPMG name, and logo are registered trademarks or trademarks of
KAPmMerGic Iannt eMrneadtiicoanla Al.s ©so 2c0ia1t7io Anm. Aellr ircigahnt Ms reedsiecravl eAds.sociation, an Illinois not-for-profit corporation. The AMA name and logo are registered trademarks of the Are physicians ready for macra/qpp 5
Background and objectives
(continued)
CMS announced in May 2017 that more physicians would While CMS has assumed that these reporting options will help
be excluded from MIPS reporting in 2017 (over 800,000 ease the transition to MIPS, little is known about physician
clinicians) than originally projected (738,000 to 780,000), preparation and operationalization of program requirements for
representing nearly two-thirds of all clinicians.i Under QPP. With more physicians and other clinicians expected to
the 2018 performance year proposed rule, even more enter the QPP in future years, understanding where physicians
physicians would be excluded in performance year 2018 are today with regard to readiness will help CMS, medical
as a result of increasing the low volume threshold. But associations and other supporting industry stakeholders better
significant challenges remain for those clinicians required target educational outreach that helps physicians and other
to participate in MIPS in 2017 and beyond. clinicians prepare for success. Feedback from physicians will
also play a vital role in helping to guide future rulemaking for the
In order to address some of these challenges of complying and
QPP, including for the second performance year in 2018.
succeeding under MIPS, CMS established flexibility in reporting
requirements for the first performance year (2017). In this
transitional year, physicians can avoid any payment penalty in
While CMS has assumed that
2019 by choosing one of the following reporting paths:
these reporting options will help
MIPS testing
Report some data at any point in Calendar Year 2017 to
ease the transition to MIPS,
demonstrate capability by reporting on one quality measure, or
one improvement activity, or the set of required ACI measures.
little is known about physician
There is no minimum reporting period. There is no negative
adjustment in 2019.
preparation and operationalization
Partial MIPS reporting
of program requirements for QPP.
Submit partial MIPS data for at least 90 consecutive days in
Calendar Year 2017. Report on 1 or more quality measure, or
1 or more improvement activities, or the set of required ACI
measures. There is no negative adjustment in 2019 and the
potential for some positive adjustment of less than 4 percent
in 2019.
Full MIPS reporting
Meet all reporting requirements for at least 90 consecutive
days in Calendar Year 2017. There is no negative adjustment in
2019 and there is the maximum opportunity for positive 2019
adjustments. Exceptional performances are eligible for additional
positive adjustment of up to 10 percent.
Only physicians who do NOT participate in any of the reporting
paths in 2017 will be subject to penalties in 2019. CMS has
proposed that physicians will again be able to avoid a negative
payment adjustment in 2018 by doing less than full reporting
in the second performance year—CMS estimated in its latest
proposed rule that 94 percent of participants will receive a
positive or neutral payment adjustment in 2018.
© 2017 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG
International Cooperative (“KPMG International”), a Swiss entity. All rights reserved. The KPMG name, and logo are registered trademarks or trademarks of
6 Are physicians ready for macra/qpp KAPmMerGic Iannt eMrneadtiicoanla Al.s ©so 2c0ia1t7io Anm. Aellr ircigahnt Ms reedsiecravl eAds.sociation, an Illinois not-for-profit corporation. The AMA name and logo are registered trademarks of the
Background and objectives
(continued)
AMA and KPMG collaboration to
educate and support physicians Survey Objectives
The Payment Model Evaluator (PME), designed and built by
KPMG and the AMA in 2016, has been an effective web-based
tool for exploring awareness of and preparation for MACRA.ii
The PME, includes a brief self-assessment for physicians and
A number of core questions drove
their staff to determine the financial impact of the QPP on their
practice alongside educational and actionable resources to development of the survey:
prepare for the QPP. The tool was offered free of charge to all
physicians and their practice administrators. 1 H ow knowledgeable are physicians
In order to better understand physician preparation and about the QPP, in particular MIPS and its
positioning for QPP, in the spring of 2017 KPMG and AMA program requirements?
surveyed 1,000 practicing physicians in the United States who
have been involved in practice decision-making related to QPP.
2 To what extent have physicians prepared
Although previous surveys have explored the extent to which
for the requirements of MIPS and
physicians are generally familiar with MACRA, this survey
operationalized changes within their
only included physicians who have heard of MACRA and are
practices to meet requirements in 2017?
practice decision-makers in order to better understand gaps in
understanding, early views and attitudes about the roll-out of the
program, and physician plans for the program in the future. For 3 O f those physicians participating in
additional details about the survey methods and demographics, MIPS in 2017, what level of reporting
see Appendix A. are they planning to do under the “pick
In addition to building on the work in the PME, the survey your pace” options? How do they plan
augments the growing body of experiential knowledge gathered to participate in 2018 and future years?
through feedback received during physician focus groups that
informed creation of the PME, as well as feedback received
4 W hat are the most significant challenges
by the AMA from the broader physician community, including
for physicians participating in MIPS in
through previous work with the RAND Corporation.iii The AMA
the first year?
will use the results of the survey to develop additional physician
educational tools that meet the diverse needs of physicians in
practices that vary by care setting, size, experience with value- 5 W hat areas do physicians need more
based care, and level of knowledge. help in, and what role can CMS and
medical associations play in filling
knowledge gaps?
6 H ow many physicians feel prepared for
long-term success under QPP?
7 W hat changes should CMS consider
to improve the program in 2018 and
beyond?
© 2017 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG
International Cooperative (“KPMG International”), a Swiss entity. All rights reserved. The KPMG name, and logo are registered trademarks or trademarks of
KAPmMerGic Iannt eMrneadtiicoanla Al.s ©so 2c0ia1t7io Anm. Aellr ircigahnt Ms reedsiecravl eAds.sociation, an Illinois not-for-profit corporation. The AMA name and logo are registered trademarks of the Are physicians ready for macra/qpp 7
Results
A slight majority of respondents (51 percent) were somewhat knowledgeable
about MACRA or the QPP, whereas less than one in ten physicians (8 percent)
felt deeply knowledgeable about QPP and its requirements. Just over four in ten
physicians surveyed (41 percent) had heard of MACRA or QPP, but did not consider
themselves knowledgeable.
We surveyed 1,000
Seven in ten respondents have begun preparing to meet the requirements of the
physicians who are
QPP in 2017. Of those respondents, nearly nine in ten respondents feel somewhat
involved in practice prepared (65 percent) or well prepared (23 percent) to meet requirements in 2017. Of
those planning to report through MIPS in 2018, only 65 percent feel prepared to meet
decision-making and
requirements. This difference may be related to the yearly process of changes to the
have at least some physician fee schedule.
knowledge of MACRA
Of those respondents expecting to participate in MIPS in 2017, 90 percent feel MIPS
or QPP. Several requirements are slightly burdensome (37 percent) or very burdensome (53
percent).
significant findings
are further explored in Respondents indicated that the time required to report is the most significant
challenge today and time for reporting will continue to be a challenge in subsequent
subsequent sections.
years. Respondents also emphasized challenges with understanding requirements,
understanding MIPS scoring, and the cost of reporting.
Previous experience in other programs, including PQRS and Meaningful Use,
appears to have contributed to physician readiness for QPP; thus, getting
experience now in QPP at some level has the potential to set physicians up to
potentially be more successful in the future than those who do not have experience.
However, it is particularly concerning that only 25 percent of physicians with prior
reporting program experience feel well prepared for the QPP.
However, even those who feel prepared don’t fully understand the financial
ramifications of the program. In short, they may be prepared to “check the box”
of reporting requirements, but they may lack the long-term strategic financial vision
to succeed in 2018 and beyond. Only 8 percent of respondents feel they are “very
prepared” for long-term financial success, while 58 percent feel slightly prepared and
26 percent feel not at all prepared.
51%
Just over one-
half of respondents were somewhat
knowledgeable about MACRA or
the QPP.
© 2017 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG
International Cooperative (“KPMG International”), a Swiss entity. All rights reserved. The KPMG name, and logo are registered trademarks or trademarks of
8 Are physicians ready for macra/qpp KAPmMerGic Iannt eMrneadtiicoanla Al.s ©so 2c0ia1t7io Anm. Aellr ircigahnt Ms reedsiecravl eAds.sociation, an Illinois not-for-profit corporation. The AMA name and logo are registered trademarks of the
Knowledge of macra
A majority of the 1,000 physicians surveyed (those involved reform initiatives because they are more likely to be employed
in practice decision-making) were somewhat knowledgeable and less involved in decision-making. The screening conducted
(51 percent) or deeply knowledgeable (8 percent) of MACRA in this survey may have removed those in larger practices less
or QPP; however 41 percent of those surveyed said they likely to know about MACRA, indicating that physicians in larger
had heard of QPP, but would not consider themselves practices may have more value-based care experience and
knowledgeable. knowledge.
Physicians in larger practices (more than 10 physicians) were Respondents in multi-specialty group practices were more
more likely to feel deeply knowledgeable of MACRA or QPP (11 likely to feel deeply knowledgeable (11 percent) than those in
percent) than their counterparts in smaller practices (6 percent single-specialty group practices (8 percent), solo practices (7
for solo practitioners, 9 percent for those in practices of 2 to percent), or hospitals (8 percent) (see Figure 2). Specialists and
4, and 5 percent for those in practices of 5 to 10 physicians) primary care physicians were approximately equally likely to
(see Figure 1). Previous surveys, including the AMA Physician feel deeply (9 percent and 7 percent, respectively) or somewhat
Practice Benchmark Survey,iv have found that physicians in knowledgeable (50 percent and 51 percent, respectively) about
larger practice sometimes have less knowledge of payment MACRA or QPP.
Fig.1 Level of physician knowledge of macra/qpp by practice size
1 6% 48% 45%
2-4 9% 49% 42%
5-10 5% 49% 46%
11-24 11% 55% 34%
25-49 11% 61% 28%
50+ 11% 49% 40%
4 4 4
in-depth knowledge somewhat knowledgeable not knowledgeable
Fig.2 Level of physician knowledge of MACRA/QPP by practice setting
Single specialty
8% 50% 41%
group practice
Multi-specialty
11% 54% 35%
group practice
Solo practice 7% 49% 44%
Hospital 8% 44% 49%
4 4 4
in-depth knowledge somewhat knowledgeable not knowledgeable
© 2017 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG
International Cooperative (“KPMG International”), a Swiss entity. All rights reserved. The KPMG name, and logo are registered trademarks or trademarks of
KAPmMerGic Iannt eMrneadtiicoanla Al.s ©so 2c0ia1t7io Anm. Aellr ircigahnt Ms reedsiecravl eAds.sociation, an Illinois not-for-profit corporation. The AMA name and logo are registered trademarks of the Are physicians ready for macra/qpp 9
Results
(continued)
Participation
A majority of physicians surveyed (56 percent) expect to 2 percent expect to report as a MIPS APM in 2017; and 12
participate in MIPS in 2017, while just under 2 in 10 physicians percent do not know what level of reporting their practice will
expect to meet the definition of Qualifying APM Participant do in 2017. The quality performance category is the one most
(QP) and be exempt from MIPS reporting. Another 7 percent likely to be used (76 percent) by physicians planning to report
expect to participate in an APM, but not meet the QP standard; only one measure in 2017. Nearly three-quarters (74 percent) of
8 percent do not expect to participate; and 12 percent do not MIPS participatin1g2 p%hysicians plan to report as a group, rather
know whether and how they will participate in 2017. than as an individual; and three-fifths of all MIPS participants
plan to use their electronic health record, (EHR), qualified
Of the nearly 1 in 10 physicians not planning to participate in 8%
registry, or qualified clinical data registry (QCDR) to report
MIPS in 2017, nearly half (49 percent) had voluntarily chosen not
performance in 2017, with 91 percent planning to report quality
to participate; while the other half expected to be exempted as
throug7h% their EHR or QCDR.
a result of the low volume threshold for revenue (26 percent)
56%
or patients (24 percent). [Note: the survey was fielded prior to Physicians expecting to be exempted from MIPS reporting as
physicians and practices receiving formal notification from CMS a result of Advanced APM participation were most likely to be
about whether they would be required to participate in MIPS in part of an organization in the Next Generation ACO model (54
2017]. percent); M18e%dicare Shared Savings Program (MSSP) Tracks 2
or 3 (50 percent); or Comprehensive Primary Care Plus (CPC+)
Of those physicians planning to participate in MIPS, 3 in 10 plan
(35 percent) [Note: some respondents indicated participation in
to report the minimum possible (one measure) in 2017; one-
multiple Advanced APMs, resulting in a total greater than 100
quarter plan to report partially (more than one measure) in 2017;
percent].
3 in 10 plan to opt for MIPS full reporting in 2017;
12% 12%
2%
30%
8%
Fig.3 QPP Fig.4 MIPS
7%
participation 56% 25% participation level
in 2017° for physicians†
18%
30%
1 1 1 1
Participate in MIPS Advanced APM MIPS testing Full MIPS reporting
1 1 1 1
MIPS APM Not expecting to participate Partial MIPS reporting MIPS APM
1 1
Don’t know Don’t know
° Excludes 8% of resp1o2n%dents not planning to participate in QPP †Among those planning to participate in MIPS in 2017
2%
30%
25%
30%
© 2017 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG
International Cooperative (“KPMG International”), a Swiss entity. All rights reserved. The KPMG name, and logo are registered trademarks or trademarks of
10 Are physicians ready for macra/qpp KAPmMerGic Iannt eMrneadtiicoanla Al.s ©so 2c0ia1t7io Anm. Aellr ircigahnt Ms reedsiecravl eAds.sociation, an Illinois not-for-profit corporation. The AMA name and logo are registered trademarks of the