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Imagine being penalized for delivering good care to your frailest patients. Medicare’s quality scoring program was built for healthy outpatients, not the elderly residents of nursing homes, but it is the system doctors who round in skilled nursing facilities are forced to play. Steve Buslovich, a physician executive and geriatrician, discusses the KevinMD article “How Medicare’s MIPS impacts skilled nursing facilities and clinicians.” You’ll hear how MIPS metrics conflict with the five-star quality measures facilities must report, why tightly controlling A1C in frail elders can cause harm, and how documentation discrepancies between physicians and facilities create financial and legal risk for both. You’ll learn which nine measures actually fit post-acute long-term care, why CMS needs frailty-based quality metrics, and how AI and synced EHRs can pull data automatically so clinicians can get back to the bedside. If you practice in or operate a nursing home, this conversation names the rules of a game you didn’t choose to play.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, welcome Steve Buslovich. He’s a physician executive. Today’s KevinMD article is How Medicare’s MIPS Impacts Skilled Nursing Facilities and Clinicians. For those who aren’t familiar, MIPS stands for Medicare’s Merit-based Incentive Payment System. Steve, welcome to the show.

Steve Buslovich: Thank you, Kevin. Happy to be here. Appreciate having me.

Kevin Pho: All right. So just tell us a little bit about what you do, and then we’ll jump right into the KevinMD article that you shared with us today.

Steve Buslovich: Sure. Just a little background. I’m a geriatrician, and what I would probably label myself as a born geriatrician, always something that I’ve wanted to do.

And my background, I practice as a medical director in post-acute long-term care facilities. Started several companies, one of which was really focused on care management, institutional special needs plans, and physician EHR services. That was then subsequently acquired by PointClickCare, and I’m now in the chief medical officer of senior care position with PointClickCare working on MIPS and other related areas.

And so this is why it’s top of mind for me and many physicians out in the space.

Kevin Pho: All right. And before we get into your article, just give us a 30-second primer of what Medicare’s MIPS is.

Steve Buslovich: Yeah. MIPS is not a new initiative for Medicare, right? It’s been around for quite some time. I think it started originally in 2004. It’s really not a model that was designed for post-acute long-term care.

The honest concept behind it was, how do we transition clinicians and really evaluate them in the value-based care environment? So ultimately, how do we just go from a fee-for-service model to ensuring there’s some sort of quality outcome indicator for the services they’re providing and billing under Part B? And so the model’s really designed for community-based practices with a fairly healthy, or we’ll say healthier, population compared to those residing in senior care and long-term care communities.

The model really looks at four different areas. So number one is cost, quality, interoperability, and improvement activities. And so based on how clinicians perform under the MIPS models, ultimately that’ll predict their Medicare Part B reimbursement in future years.

And so, as most things with CMS, it starts with a carrot and then quickly moves into a stick, right? And initially there was some potential upside for reporting, and slowly and surely we’re now at the point where a practice and a licensed practitioner, physician, for example, could lose up to 9 percent of their Medicare reimbursement over the course of a year, which basically could be life or death for a practice if they’re not reporting and succeeding on their MIPS today.

Kevin Pho: Tell us about some of the metrics that MIPS measures, certainly in the nursing home context, because that’s what we’re going to be talking about today.

Steve Buslovich: So actually MIPS, like I mentioned, is not designed for nursing home concepts, so it becomes incredibly challenging for a physician group that is dedicated to serving this population to pick the right MIPS measures. There’s over 150 MIPS measures to choose from, and so it’s a little bit of a challenge, I would say, for clinicians to wrap their head around how to collect certain things. Some elements are a little bit more appropriate, things like depression screening, hemoglobin A1Cs, but others are actually a little bit elusive and incredibly challenging to collect in a long-term care environment.

One of the challenges that we face is there’s this significant disconnect between what facilities, like skilled nursing facilities in particular, are on the hook for. They have a different quality program through CMS called a five-star measure program, and those quality measures have different data elements and requirements for categories that might actually be similar to the MIPS quality measures. And so there’s this conflict that exists between what data needs to be collected for whom and how they actually intersect, and for the most part, they don’t, right? And it creates quite a conflict in the market.

Kevin Pho: So from a nursing home perspective, tell us about some of the obstacles that they’re facing in this environment that you talked about in your article.

Steve Buslovich: Sure. So for example, let’s just take wounds as a quality measure. There are two quality measures on the facility side that relate to short-stay quality measures and long-stay quality measures related to wound development. And so the way a physician or a practice provider would document according to MIPS really has to do with reviewing where the wound originated and ultimately its progression.

The way a facility has to document a wound is based on an MDS, minimum data set, which is a federally required comprehensive nursing assessment of the individual. For every resident, an MDS has to be collected routinely. That document ultimately looks at staging of the wound. And so there could be conflict between what a physician or a practice provider is documenting even related to simple things such as wounds, which you would think should be consistent. They could actually create problems for the nursing facility if there’s discrepancy. And so, that’s one example.

Another example could be immunization, right? Immunizations are provided by the facility staff, the nursing staff, to the resident, and it’s tracked in the facility’s electronic health record. That data doesn’t necessarily port over reliably to a third-party EHR that the practice provider could be on. And so there’s this discrepancy between even when quality is delivered, where that data resides isn’t necessarily accessible for both parties, and it creates a challenge.

Kevin Pho: So what are some of the threats to nursing homes if you can’t reconcile the data or if the data isn’t as good as it should be? Are there financial threats the nursing home has to face?

Steve Buslovich: Well, so for example, the five-star quality measures substantially impact the building’s perception. There’s financial implications because ultimately there are penalties. Certain states have their own quality measures that are similar to Medicare’s five-star quality measures. And so if you’re not performing well and there’s conflict in the documentation, it can affect your star ratings. And your star ratings then affect your ability to participate in Medicare reimbursement and value-based purchasing.

It also has legal implications, right? We all know there’s quite a litigious environment. And so, if there’s ever a litigious issue and there’s discrepancy in the documentation, that doesn’t help either party, neither the practice group and definitely not the facility, who’s usually the target of these things.

Kevin Pho: So what I’m hearing is that there are just so many different scorecards that both physicians and the facilities have to keep track of. Already there is going to be a resource limitation, and it’s hard to administratively keep track of all of these metrics, right? So how are nursing homes managing this environment?

Steve Buslovich: I think for the most part, they’re doing it manually, and it’s really challenging with our staffing crisis out there to be able to have dedicated staff to pay attention to all of these things. I think it’s going to get worse before it gets better. So some of the things that we’ve been discussing with CMS, and there’s some really great people at CMS that are in the field that do understand this problem. However, there are many others who aren’t aware of the magnitude of this issue, particularly since this is a smaller subset of the population, but it contributes and consumes quite a bit of the expenditure percentage, right, in the market.

And so ultimately I think I’m trying to create much more visibility, because for those practice providers that are dedicated to the space, and we need more of them, by the way, I think everybody wants to be a good partner for the building, and the buildings want to ensure that their documentation is aligned.

So CMS is looking at it, but I think we need a little bit more advocacy there to accelerate some of this, we’ll call it, administrative burden. On the point-of-care side, where we ultimately are trying to help is we create a dedicated EHR for practice providers, for practice groups dedicated to the space, so that the data is synced. So ultimately they’re not trying to collect data manually, and so when that data is synced, those diagnoses, those quality measures and conditions are synced with the facility’s records. So ultimately it becomes similar to like a hospital type of environment where everything is aligned, and that reduces the likelihood that ultimately something will be missed or there will be parallel documentation efforts across both parties where they don’t align.

Kevin Pho: Tell us a scenario, an ideal scenario where your solution would be in play and everything worked as it should. So I know that you briefly explained your solution, but on a clinical scenario, what exactly would that look like?

Steve Buslovich: So I think it’s partly technology and, I would say, mostly a CMS correction, right? I think ultimately there’s a need for data elements to be standardized. If CMS would create quality measures that actually pertain to a geriatric population more accurately, it would make everybody’s lives easier, and it would feel a lot less of a burden to the practitioners. Because what we really need to do and continue to focus on is, how do we get the clinicians back to the bedside?

There’s a huge shortage of geriatricians. There’s a shortage of internists and, obviously, nurses, right? So my goal is ultimately, how do we use technology to automate some of the data collection? AI is a great example of how we can facilitate and accelerate some of that information so there’s less administrative burden on the medical team and the nursing team to essentially sift through manual data and try to connect dots for reporting purposes.

Kevin Pho: So you mentioned that CMS’s metrics, they’re not currently aligned with what nursing homes optimally need. So specifically, if you were in charge of CMS, and if you were in charge of this, what changes would you make?

Steve Buslovich: I think the models right now look at very disease-specific elements, and those elements don’t necessarily make sense for a medically complex population. So if you think about disease-based quality measures, well, my patients have 15 chronic conditions, so then there are 15 data elements I have to track, which may conflict with the overall likelihood of achieving best possible clinical outcomes. So for example, hemoglobin A1C monitoring, right?

If we tightly control diabetes in a frail population, patients get hurt, right? And we know this from the literature. CMS doesn’t necessarily understand whether this particular individual is frail or how frail they are. And so depending on their frailty, depending on their advance directives and goals of care, the clinical management may be patient-centric but doesn’t align with the quality measure model.

And so you’re often looking at things like age cutoffs for immunizations, right? Or things like breast cancer screenings. But we’re missing the frailty evaluation of what is the physiological state of that individual and what is their life expectancy and goals of care.

If their life expectancy is less than 10 years, that really changes the paradigm, and that’s, by the way, the majority of the population. That changes the paradigm of how we approach our medical treatment plan and align that with patient family expectations and their preferences, right? And so I think if I was CMS, I would develop more frailty-based quality measures that take into account true patient-centered risk and risk-stratify the population according to their physiological risk for decline and ultimately mortality, to then drive which quality measures are much more appropriate, right?

Right now it’s a one-shoe-fits-all, and I’m sure you’ve seen this in practice. It’s ultimately, we’re chasing an attribute as opposed to doing the right thing for the patient based on their risk profile. And so I would look at also quality measures that make more sense, like not only completion of advance care planning, but aligning advance care planning conversations with their level of risk, for example.

I think things like rehospitalizations and wound development are probably appropriate measures, but I think many of them are subjective or could be gamed, and they don’t necessarily reflect true quality. So those are some of the things, if I had a magic wand, I would definitely try to advocate for.

Kevin Pho: Today we’re of course talking about one of your solutions to better align clinician documentation with what the facility needs to best optimize their performance under the MIPS program. Now, from the practicing clinicians’ standpoints and other geriatricians who round in nursing homes, is there anything that they could do on an individual basis to address this problem, or is this something purely on the technical side? Is there anything that individual physicians can do?

Steve Buslovich: I think this is a very complicated model, and as CMS moves to more of a value pathway MIPS model, I think educating themselves on what quality measures are most appropriate, I think there’s about nine, to be honest, would likely increase their ability to succeed on their MIPS in the post-acute long-term care environment. I think most clinicians are unaware and uneducated in terms of how the data collection and the reporting work, right? You just need to understand how to play the game. We didn’t create the game. We just need to understand the rules, and most clinicians don’t understand the rules, and they are complicated.

So my advice to them is, pick the quality measures that make sense, that you’re most likely to succeed with, so that in the very least you’re not writing a check back to CMS. And I think that, besides a data problem, it’s a choice. The practice chooses which quality measures they’re going to be reporting on, and just my advice would be: choose wisely.

Kevin Pho: We’re talking to Steve Buslovich. He’s a physician executive, and today’s KevinMD article is How Medicare’s MIPS Impacts Skilled Nursing Facilities and Clinicians. Steve, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Steve Buslovich: Some take-home messages. I would say that I think it’s really exciting to think about how the use of AI can accelerate some of this data collection and reporting capabilities. I would say it’s super important to choose your partners wisely, your technology partners, particularly in their access to data, how AI models are built to be applied to the population, the cohort you’re managing.

And that is really where I think, where PointClickCare is investing heavily, is figuring out how to tie the ecosystem together so as patients transition from community to hospital to post-acute and vice versa, how does that data flow? How do we enhance data elements, particularly around quality measure collection, in those transitions of care, and how does AI accelerate that function and reduce the administrative burden for clinicians?

I think that is my personal goal to try to accomplish over the near future, and really appreciate you taking the time to talk to me today.

Kevin Pho: Steve, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Steve Buslovich: Thank you.