Article Figures & Data
Figures
- Figure 1.
Examples of the Heart of Virginia Healthcare (HVH) focus-group questions. Abbreviation: MACRA, Medicare Access and CHIP Reauthorization Act.
Tables
- Table 1.
Characteristics of Primary Care Practice Sample, Heart of Virginia Healthcare, 2018 (n = 16)
Practice ID Practice Size (Number of Providers*) Practice Specialty Mix MUA PCMH ACO Medicare Payment Mix % Number of Participants per Focus-Group† Independent practice (8) I1 2 to 5 Single specialty Yes No No 10 2 I2 2 to 5 Single specialty Yes No No 8 10 I3 2 to 5 Single specialty Yes No Yes 20 6 I4 2 to 5 Single specialty Yes Yes Yes 30 5 I5 11 to 15 Single specialty Yes Yes Yes 16 5 I6 6 to 10 Multispecialty No No Yes 8 3 I7 11 to 15 Single specialty Yes No No 23 2 I8 6 to 10 Single specialty Yes No No 25 7 Total 40 Hospital-owned/health system (8) H1 2 to 5 Single specialty No Yes No 30 3 H2 2 to 5 Single specialty No Yes Yes 35 8 H3 2 to 5 Single specialty Yes Yes Yes 57 1 H4 6 to 10 Single specialty No Yes Yes 30 4 H5 2 to 5 Single specialty No Yes Yes 30 1 H6 6 to 10 Single specialty Yes Yes Yes 33 6 H7 2 to 5 Single specialty Yes No Yes 10 3 H8 2 to 5 Multispecialty Yes No Yes 10 4 Total 30 - Table 2.
MACRA Awareness and Analytic Themes by Practice Ownership, Heart of Virginia Healthcare, 2018 (n = 16)
Practice Ownership Independent Hospital Owned and Health-System Affiliated MACRA Awareness [I8]: “Already reported [MACRA measures].”
[I7]: “Well, we’re done with this year. You know, deadline [for MACRA reporting] is passed. We did score the maximum number of points that we could score this year.”
[I4]: “Yes, [MACRA reporting is through the advanced payment model], I’m qualified for the bonus payments next year.”[H2]: “I must admit, I am not as knowledgeable as I probably should be [about MACRA]. I have not delved all that much into the stuff about MIPS and MACRA.”
[H5]: “How we are doing [MACRA processes] that is confusing to me, but I do know that that is part of the reason why we have all of these boxes we have to click and document, and reminders, alerts that pop-up.”
[H7]: “I hear about it [MACRA] at meetings.”
[H8]: “That [MACRA] sounds like, our quality initiatives are based on that.”Analytic Themes “Highly involved and knowledgeable” “Distanced and Bureaucratic” N = 16 (independent = 8; hospital-owned and health system affiliated = 8).
MACRA, Medicare Access and CHIP Reauthorization Act.
- Table 3.
Steps Taken toward MACRA, Variation by Practice Ownership, Heart of Virginia Healthcare, 2018 (n=16)
Practice Ownership Independent Hospital Owned and Health-System Affiliated Steps toward MACRA [I1]: “It’s [MACRA reporting] through our EHR. We have to do an annual risk analysis. And it has to be uploaded and sent to the EHR to verify that we did it. Yes, they send us alerts going, Hey, where are you. This needs to be done. Or this needs to be uploaded.”
[I6]: “We are building templates in our EMR that captures all the tick marks [related to MACRA] you have got to meet for meaningful use. So, we are working on that right now.”
[I3]: “I think if you know how to use your EHR system, it makes it better [for MACRA quality measure reporting]. Because if you are afraid of it, and don’t know how to use it, and you know, as with anything, you walk into it saying, Oh, I don’t want to do that [extract quality measures and report]. I don’t know how to do that. But if you are understanding the complexity and you know how to use it, it works for you instead of not working. ”[H7a]: “They [corporate] will tell us what to do, and we will do it, ‘Yes, sir.’ [We will try] to the best of our ability [to comply with MACRA requirements”
[H7b]: “To the best of our ability. I don’t expect them [corporate] to give us the freedom to either participate or not participate in MIPS.”
[H5]: “It’s [MACRA preparations] coming from above [corporate], yes. We have not, the three of us, come up with our plan. It comes down…That is one thing that we don’t have to worry about. Now we end up with unnecessary work sometimes.”
[H3]: “I’m sure they [corporate] have, I can’t answer that 100%, from an organizational standpoint, I feel like that they [corporate] will have us prepare for whatever we need.”
[H6]: “We also, the health system has a list of board approved goals that come down from the health office that are recommendations, goals that we target [for MACRA] so we try to meet.”
[H1]: “But in order, [larger health system] to just, is wanting us to kind of wait on it [on MACRA] until it rolls out to all the care centers. Because I guess they’re [corporate] going to be giving out their own, you know plan for that. Right now, we haven’t really done anything toward it, because [larger health system] doesn’t want us to yet.”Analytic Themes “Focus is on the EHR capability for MACRA reporting” “Corporate Dependency” n = 16 (Independent = 8; Hospital owned and health-system affiliated = 8).
MACRA, Medicare Access and CHIP Reauthorization Act; EHR, electronic health record.
- Table 4.
Impact of the Quality Payment Program (QPP) on Practices' Finance, Workflow, and Patient Care - Heart of Virginia Healthcare, 2018 (n = 16)
Financial Impact Workflow Impact Patient Care Impact Impact of MACRA [I1]: “Probably not a huge amount of [positive] impact [on practice’s finance] because, right now, it’s just Medicare and Medicaid.”
[I7]: “Sure. I didn’t have an [administrative staff] 10 years ago. Or at least [admin. staff] wasn’t doing this job [MACRA related work] 10 years ago.”[I1]: “Probably not make a big difference in workflow [and workload]. Because so much of it is captured by the EHR.”
[I6]: “We are trying not to let it have a [negative] impact on our workflow [because of the way we chart].”
[H8a]: “Well, I would say there’s a lot of those things that the [MACRA related] documentation slows you down because you think you’ve documented but it’s not going into whatever little box that they want checked.”
[H8b]: “Yes, it’s [MACRA processes] added a big burden to the nurses because there’s a lot of more, a lot more stuff they have to do in the rooming process, boxes that have to be checked and questions that have to be asked and all of that stuff has added a lot of time to the rooming process.”[I1]: “I don’t think it’s [quality payment program] going to improve [our patient care].”
[I7]: “Is it [the impact of MIPS] measurable? I don’t know that can measure it [improvement in patient care]. I think we all have our opinions about that.”
[H8]: “I don’t think [QPP will improve our patient care] so because I think it’s being done [now] but it’s just not necessarily being [a priority before]…So essentially, this stuff [MACRA measures] was kind of being done it’s just being tracked now and it’s more of a priority [now].”Analytic Themes “Mixed perceptions toward the impact of the QPP on practices’ finance, workflow, and patient care.” n = 16 (I, independent practice = 8; H, hospital-owned practice = 8).
MACRA, Medicare Access and CHIP Reauthorization Act; EHR, electronic health record; MIPS, merit incentive payment system.
- Table 5.
MACRA Awareness and Steps Taken with MACRA by the Accountable Care Organization Practices - Heart of Virginia Healthcare, 2018 (n = 16)
ACO Practices [I7]: “Well, we’re done with this year. You know, [the MACRA reporting] deadline is passed.”
[I3]: “We are a Track I ACO, so we will be reporting as MIPS, and then we have to report separately advancing care initiatives. So, last year we reported through the ACO, because that was their first reporting year. We will be reporting again through the ACO.”
[H4]: “We already track that [quality measures related to MACRA], yes that comes from the corporate. We’re an ACO, [larger organization] is an ACO so that’s being, yes [to receiving support].”
[I5]: “We’re working with our ACO to help us through the Next Gen process. But we’ve been able to adapt pretty quickly and develop good workflows around the other [MACRA related quality] measures.”
[I4]: “Starting early [for ACO practices] with the realization that things were going to be different and be ready for change, whether we try to resist.”Analytic Themes Practices part of an Accountable Care Organization are more proactive. n = 16 (I, independent practice = 8; H, hospital-owned practice = 8).
MACRA, Medicare Access and CHIP Reauthorization Act; ACO accountable care organization.
Practice Ownership Independent Hospital Owned Challenges with MACRA Capability of the EHR
[I7]: “So that’s where the pain portion is, is with the EHR.”
[I2]: “Once you ask the computer to go ahead and start manipulating the data, now you’ve got a problem.” Lack of Financial Resources
[I7a]: “So, is there a cost [related to MACRA]? Absolutely there is a cost. And do docs see less patients? The answer is yes. They do see less patients than they used to.”
[I7b]: “We wear multiple hats here in our independent practice. We have to be very creative in how we [do things], and [be] resourceful with our employees. So, having resources that are knowledgeable and reputable, that could benefit. You know, it was me going through these steps and preparing for MIPS.”Time Scarcity
[I2]: “One to three hours every night, and I do spend one to three hours [on] MACRA.”[I2]: “Yes, because you can see 100 patients a day. It’s going back and charting on what their issue is. Because, you can see the patients, you can take care of them but there is so much documentation that they’re going to require until we see a revamping of that, of the whole system. I think it’s going to have to come.”[H4]: “Well, we’re, also have [third party organization]. Have you heard of [third party organization]? We have an outside consultant that’s helping run this whole deal. So yes, so [larger organization] hired them to.” Analytic Themes “Independent practices have more challenges with MACRA reporting” n = 16 (independent = 8; hospital owned and health-system affiliated = 8).
MACRA, Medicare Access and CHIP Reauthorization Act; EHR, electronic health record.
Topic Question MACRA Awareness Are you aware of MACRA? Have you heard about MACRA, the government calls it “Quality Payment Program, QPP?” What do you know about MACRA? Steps taken toward MACRA What steps has your practice taken towards MACRA? What did your practice do to get ready for MACRA? Can you describe the steps taken for MACRA to get ready? Impact of MACRA What overall impact do you think the quality payment program will have on your practice? a. Any financial impact on your practice? b. Any impact on your practice workflow? c. Any impact on your practice’s patient care? MACRA, Medicare Access and CHIP Reauthorization Act.
