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— Gwen Hanson, MD, Family Medicine
MACRA (Medicare Access and CHIP Reauthorization ACT) was passed in the spring of 2015; implementation is now at hand. The future will not stop.
There is no expert who does not celebrate the day-to-day work of primary care. However, it will be up to the primary care community to emerge from the next few years successfully. This will demand our most creative “ground game.”
We must defend the full range of practice models. Some will choose to enter enterprises but others will choose autonomy. The “biodiversity” of primary care is part of our heritage and must be sustained.
The premise of MACRA is value-based payment. Fundamental to the whole value basis is attribution. There are no reliable prospective tools for ensuring accurate attribution of either costs or outcomes. As we all know, patient behavior is unpredictable and ultimately self-determined. We need to be sure that the payments under MACRA are adequately adjusted to reflect the diversity of the patients we see. In addition to the attribution of costs, outcomes themselves can be unanticipated despite optimal efforts. Bad things happen despite the best laid plans.
If costs and outcomes are to be attributed to us as individuals, there must be a robust and reliable mechanism for risk adjustments for cost variability. We need to have a plan to ensure protection so we do not lapse into “cherry picking.” Physicians need a strategy to ensure that the medical conditions for each single patient are accurately and fully defined. We need to document as accurately as possible all the medical conditions of each patient so that each and every one is fully included in all models of risk adjustment.
How do you prepare for future with such uncertainty?
The best preparation for the future envisioned by MACRA will be a robust electronic healthcare record (EHR) for clinical practice. The optimal EHR will provide a detailed patient database, a well-designed interface for face-to-face and non-face-to-face patient care, and tools for effective, sustainable patient engagement.
Problem oriented charting (POC) is fundamental to a robust EHR. The current EHRs that recreate file cabinets with stored word documents will not support future practice. Information must be organized so that it can be leveraged. With POC, all conditions can be mapped to ICD codes. This ensures that billing captures every medical issue identified. Risk adjustment will depend fundamentally on the billing diagnoses. POC ensures that the conditions for each individual patient are completely identified. This provides the best security for risk adjustment within the new world of MACRA.
POC optimizes panel management. With POC, the physician is able to identify each and every patient with a given condition as various conditions are monitored for quality outcomes. POC supports panel management and allows the physician and staff to anticipate needs and improve clinical care quality. Furthermore, POC provides a more nuanced assessment of each patient with the ability capture comorbidities, other problems that make a given patient’s situation more complicated.
The EHR must support face-to-face and non face-to-face work efficiency. For face-to-face clinical care, this means easy access to important data such as laboratory results, consult notes, and so forth. Documentation itself must be easily finalized. Clinical care outputs such as prescriptions, referrals, consultations, and follow-ups must flow seamlessly from the clinical documentation with little added work.
Patient engagement will expand within the world of MACRA. Enhancements to the patient experience will improve clinical outcomes and patient satisfaction. Tools to facilitate communication and interaction, via a portal or other electronic devices, must be appealing and effective.
Change will come; MACRA payment adjustments start on January 1, 2019. Now is the time to prepare. Do you have an EHR able to power you to success in the new world of MACRA? Is it time for you find an EHR that will carry you to the new future?