28 minute read
INSIDE LOOK
from CCC- April/May 2022
by ensembleiq
The Medicare Access and CHIP Reauthorization Act of 2015 was a game changer for payments to Medicare clinicians by the Centers for Medicare & Medicaid Services (CMS). Most notably, it replaced CMS’ Sustainable Growth Rate payment system with the Quality Payment Program (QPP). Officially launched in 2017, the QPP rewards high-value, high-quality clinicians with payment increases while lowering payments to those who don’t meet defined performance standards. Its objectives include:
• Improving Medicare beneficiaries’ health and care. • Lowering costs to the Medicare program. • Educating, engaging, and empowering patients as members of their care teams. • Advancing the use of health-care information between providers and patients. • Maximizing QPP participation with education, outreach, easy-touse program tools, and support tailored to practices’ needs.
Based on practice size, specialty, location, or patient population, clinicians and practices can choose from the Merit-based Incentive Payment System (MIPS), geared for those that provide services to Medicare patients, or the Advanced Alternative Payment Models, designed for those that provide high-quality, high-value care with a focus on a specific population, clinical condition, or care episode.
In April 2021, MinuteClinic submitted its first annual MIPS report. Since its inception in 1999, MinuteClinic, which now has more than 1,100 retail medical clinics across 35 states and the District of Columbia, has emphasized the quality, accessibility, and cost-effectiveness of the care it offers, making the decision to participate in MIPS a natural one.
MinuteClinic’s Anne Pohnert, MSN, BSN, RN, FNP-BC, director of clinical quality, and Tammy Todd, MSN, BSN, RN, CRNP, CPHQ, senior clinical quality manager, spearheaded the MinuteClinic MIPS integration project. Their experiences should be instructional for other organizations and practices who want to take part in MIPS and the QPP.
Convenient Care Clinician: How did MinuteClinic lay the groundwork for participating in MIPS?
Anne Pohnert: We’ve had a quality metrics program for years, and part of evolving is understanding how to stretch the boundaries of quality measurement and improvement. We had met thresholds for certain aspects of previous iterations of the CMS program for individual providers. We’d been tracking CMS changes along with the requirements for submission as part of our quality approach. And so, as we came to understand the specifics of MIPS and saw an opportunity to submit and test ourselves, we talked with our external partners at Epic [a tech company that offers a suite of products for medical center operations, including electronic record-keeping] about what it would take to pull it together and who would be the right person for project manager. Fortunately, Tammy, our quality data and reporting expert, was ready to step in and lead the project.
CCC: What are the essential keys to success with MIPS?
Tammy Todd: Because it’s such a broad and complex project, you have to build a very strong project team and connect the key partners. There’s the clinical aspect—you need to be able to interpret the clinical elements that are required—but there’s also the technical aspect around submitting data. We have an internal IT team as well as an external Epic electronic health record support team who supported the project.
Anne Pohnert: Another essential is building your understanding of CMS and all the requirements. Tammy did a great job of reviewing the QPP resources, attending webinars and learning everything possible about the program. It helps for one person on the team to develop the expertise and oversee the entire process.
Tammy Todd: CMS resources are so vast, so supportive, and so easy to access. The Electronic Clinical Quality Improvement Resource Center site at ecqi.healthit.gov really offers robust educational resources on the technical component, as well as resources for the health provider to learn more. This site is an excellent resource, as well as qpp.cms.gov.
At a Glance
• MinuteClinic’s Anne Pohnert, MSN,
BSN, RN, FNP-BC, and Tammy Todd,
MSN, BSN, RN, CRNP, CPHQ, share their experiences with the Merit-based
Incentive Payment System (MIPS).
• MIPS is one of two options under CMS’
Quality Payment Program
CCC: Who did you draw on within MinuteClinic and Epic to put together your dream team?
Tammy Todd: It’s essential to have leadership sponsorship and commitment to the project. Our executive sponsors included the president of MinuteClinic, the chief nurse practitioner officer, the medical director for quality and patient safety, and the senior director for payer relations. Key program partners included provider credentialing, payer enrollment and medical coding, payer relations, enterprise analytics and reporting, clinical practice, and members of the internal MinuteClinic Epic electronic health record team who were already working with Epic. External Epic partners included their technical solutions engineers and other personnel who specialize in supporting clients with developing quality measure reporting for programs such as MIPS.
CCC: How were you able to get MinuteClinic practitioners engaged in supporting the program and not just seeing it as more paperwork or data entry?
Anne Pohnert: We were able to leverage our existing and very robust internal clinical-quality dashboard, which is providerfacing and is an important tool for communicating performance of quality care and improvement over time. [Our clinicians are already] familiar with it, so linking it to the new project made sense. Our practice is becoming more primary-care enabled, and as our providers are delivering this expanded type of care, we’re engaging with them and supporting them so that they continue to be successful, not only with existing metrics but also with these new metrics that are more nationally and not just internally driven.
Tammy Todd: MinuteClinic offers an internal provider communication website which is leveraged to house all clinicalquality resources, including the MIPS-related work. Creating tip sheets, additional provider training, and provider access to an Epic-MIPS provider dashboard has been a focused strategy to enhance provider engagement. One of the most essential aspects of MIPS success is enhancing provider knowledge of what the measures mean, and describing proper documentation workflows to achieve success.
We also explained the patient benefit—that it’s not only CMS rewarding companies but also making a better outcome for the patient. That was already part of our strategic educational plan, because patient experience is a very important aspect of our work here in the Quality Department—if we can improve on that with the work we’re doing with MIPS, we certainly want to leverage that.
CCC: The CMS site mentions further improvements to come in 2023. Is there a learning curve every time the parameters change?
Tammy Todd: I would definitely say there’s a learning curve, but the approaches that CMS is trying to implement are thoughtful. They’re trying to reduce the burden of data submission. The process is so data-driven that if you don’t have the infrastructure to be able to submit that data, it’s going to be a barrier.
CCC: What did you learn in year one that you applied to year two?
Anne Pohnert: Submitting data each time gets you very familiar with the process, so it’s not as daunting as it was the first time around. Tammy Todd: In our first year, we were focused on learning the MIPS reporting process, identifying the quality measures to report, building the quality reporting framework in Epic, and mapping the clinical documentation behind the quality measures. Now, we’re looking for where we can expand success with metric outcomes and where we can build even greater success. We have some existing services for which we already deliver a lot of the components of the MIPS measures, but we need to optimize the documentation workflow to drive success with these metrics.
We’re also getting a better understanding of why companies get back the percentage that they do from CMS. A lot of people I work with at Epic who are really good in terms of MIPS say it’s a big question mark—you submit the MIPS data as directed, but there are so many variables to consider in terms of how the scores are calculated, that it is often hard to predict the outcome. For example, cost is assessed and adjusted for by CMS directly after submission. In 2021, MIPS distributed 20% of the score for cost, so this variable may have a strong impact on outcomes. In 2020, the cost measure was neutralized for all practices due to COVID-19, so it will be an important indicator for MC MIPS success in 2021.
Traditional MIPS
“Traditional MIPS” is the original framework available to eligible practices for collecting and reporting data. Performance is generally measured across four areas, some of which might be inapplicable or weighted based on the type of practice. For instance, NP- and PA-facing practices, such as MinuteClinic, are currently excluded from the “performing interoperability” reporting category, so the “quality” category takes on a greater weight for them.
There are four performance categories:
1. Quality. This category assesses the quality of the care a practice or organization delivers based on performance measures created by CMS as well as medical professional and stakeholder groups. Participants pick six quality metrics that best fit their practice.
2. Improvement Activities. This assesses how participating organizations improve their care processes, enhance patient engagement in care, and increase access to care. Participants choose activities appropriate to their practice.
3. Promoting Interoperability. This assesses how well a practice promotes patient engagement and the electronic exchange of health information using certified electronic health record technology.
4. Cost. This assesses the cost of the patient care provided by practices.
Participating organizations and practices submit the data collected on the first three categories during the performance year in an annual report. CMS collects and calculates cost metrics based on an organization’s Medicare claims to determine the cost of the care provided to qualifying patients. The four performance categories are assigned scores and added together to calculate the MIPS final score, which determines the payment adjustment applied to the organization’s Medicare Part B reimbursements.
Each MIPS performance year begins on January 1 and ends on December 31. If an organization is eligible for MIPS, it must report the data it collected during the calendar year by March 31 of the following calendar year. Payment adjustments based on the submitted data for services provided are applied to Medicare Part B claims from January 1 to December 31 of the following performance year. CCC: What’s your advice for practices that want to attempt to participate in MIPS?
Tammy Todd: Planning is essential. Allow at least six months before the MIPS reporting cycle to lay all the groundwork. Build the project plan, build the team, build the knowledge, register on the QPP portal, and then you will be prepared to report the following year. Find your internal point person to serve as your quaterback. Connecting and collaborating with the various teams is essential to the success of the project. That’s especially valuable if there’s personnel turnover at your external partner’s organization, which we experienced late in the first year of the project. The more stability you can build within your internal project team, the better. If you don’t have a relationship with an outside team to support your work, a consultant is an option, but it’s costly, so you’d have to weigh that cost/benefit ratio.
Anne Pohnert: You have to understand your strengths as an organization and what types of measures make the most sense for you. Have a good understanding of how your reporting is set up so that you will have confidence that you’re reporting accurately. If you’re already measuring quality, tracking data, and using it in a productive way to support high quality in your practice, think of submitting to MIPS as taking it to another level.
Tammy Todd: If you select measures within MIPS that you’re already tracking and are successful with, you can build on that success right out of the gate. I also want to make the point that you have to go into a project as large as this with a long-term commitment. It can’t be something that you’re going to do for a year to see how it goes—the first year is just the first building block. You’re constantly learning and expanding knowledge that, in turn, should trickle down to your providers to have a greater impact on the quality of outcomes for the patient.
CCC: Can a smaller practice be as adept as a company as large as MinuteClinic at implementing MIPS participation?
Tammy Todd: A smaller practice can certainly do this well and, in some regards, it may be easier because their data volume would be lower. Also, CMS is in the process of creating the MIPS Value Pathways, a subset of measures and activities that can be used to meet MIPS reporting requirements beginning in the 2023 performance year. CMS is trying different approaches to reduce the burden of reporting on smaller practices. C
CARING
ON EMPTY
Beating burnout and compassion fatigue
In 2014, Kathryn Reed, MS, PA-C,
EMT-P, RYT, was a paramedic working in McKees Rocks, Pennsylvania, watching patients die one after another due to opioid overdose. After earning her physician assistant (PA) degree, she then began working on an acute inpatient behavioral health floor in a Veterans Affairs hospital, treating the physical ailments of young, mentally ill, often suicidal patients. While there, a colleague gave her advice that has stayed with her ever since: “You have five paid weeks off a year. Take them or else you’re going to get burned out.”
Burnout Symptoms
Several years later, the phenomenon Reed’s colleague was referencing has reached epidemic proportions among health-care providers. It has a constellation of symptoms:1,2 • emotional exhaustion • a reduced sense of competence • depersonalization (including emotions such as cynicism and apathy) • loss of perspective that one’s work is meaningful. Burnout syndrome affects more than half of all U.S. clinicians, per a 2019 study in The American Journal of Accountable Care. 3 That includes nurse practitioners (NPs) and PAs, both of whom experience the debilitating, sometimes career-ending syndrome in rates similar to that of physicians.1,4
Consequences of Burnout
Burnout carries significant consequences, and not just for clinicians, who experience elevated levels of stress, anxiety, and depression5; higher rates of alcohol and drug abuse, and suicide3; and lower job satisfaction. It also affects patients, who are more likely to fall victim to medical errors when treated by a burned-out provider.3
Besides potentially compromising patient safety, burnout also fuels significant financial loss when it drives health-care providers to leave their jobs. Employers, on average, spend approximately $250,000 to replace an NP or PA.6 Considering that half of the 3,680 providers who responded to the Center for Healthcare Leadership and Management 2018 PA and NP Workplace Experiences National Summary Report have quit their job at least once due to burnout, stress, or a toxic work environment, this phenomenon of career-related exhaustion is a real threat.7
Compassion Fatigue
Compassion fatigue (CF) is another modern-day scourge with similar consequences. Distinct from burnout (though the two may co-exist and share overlapping symptoms),8 CF happens “when you give and give until you ‘give out’ and become numb to caring,” explains Chelsia Harris, DNP, RN, FNP-BC, executive director
At a Glance
• Burnout can cause elevated levels of stress, anxiety, and depression; higher rates of medical errors, alcohol and drug abuse, and suicide; and lower job satisfaction.
• Compassion fatigue (CF) is distinct from burnout, but the two may co-exist and share overlapping symptoms. CF occurs when health-care providers “give out and become numb to caring.”
• Therapy, social support, exercise, and laughter can all lower stress and help some of the symptoms of burnout, but they’re not enough on their own.
• Health-care leaders must address the systemic issues that are causing high rates of burnout and CF.
of Lipscomb University’s School of Nursing in Nashville, Tennessee, and an expert in compassion fatigue. This is an unconscious self-preservation technique that strikes clinicians who are “continuously exposed to trauma and seeing an exponential amount of loss,” like they have during the COVID-19 pandemic. It renders one “unable to love, nurture, care for, or empathize with another’s suffering.”
Causes of Burnout and Compassion Fatigue
The National Academies Press’ (NAP) “The Future of Nursing 2020-2030:Charting a Path to Achieve Health Equity” cites factors such as excessive workloads, staff shortages, and extended shifts as contributors to nurse burnout, while “chronic and intense patient contact, prolonged stress, a lack of support, high workload” and other pressures can trigger CF.1 But that’s not all:
Pandemic effects. Serving on the front lines of the pandemic has driven up burnout rates,9 with sources of burnout-producing stress stemming from witnessing numerous deaths, the uncertainty of how to care for patients, social isolation, fear of spreading the virus to loved ones, severe staff shortages, and more.1,10
Nurses working at retail clinics and in inpatient hospital care have been hit especially hard, with 59% and 76% of them, respectively, having treated COVID patients.10 Dr. Harris says colleagues working in retail health and urgent care have reported CF after months of attempting to educate thousands of patients on proper masking protocols and vaccination, only to be ignored and asked for experimental treatments recommended by friends and family.
Documentation burden. Electronic medical records, excessive documentation demands, and the pressure to bill in high volumes all contribute as well, says Tim Cunningham, RN, DrPH, FAAN, vice president of practice & innovation at Emory Healthcare in Atlanta and co-author of “Self-Care for New and Student Nurses.”
Scope of practice. “A lot of state and federal laws had to shift to allow us to operate at the top of our scope, and some of those regulations have stayed, which has been a silver lining. But that also means many of us were … working more hours, interfacing with more patients, and being utilized at the tiptop of our practice in settings that didn’t have enough providers,” Reed adds.
Racism at Work
Systemic racism fuels burnout and CF as well. Reed, a biracial woman and founder of the National Society of Black Physician Assistants (NSBPA), says that being a provider of color in a mostly white field can take a toll on one’s mental health and career satisfaction. During the George Floyd protests of 2021, she says, she was followed into work by a police officer on Blackout Tuesday, even though she was
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Leadership Needs to Change the Culture
Health-care leadership needs to walk the walk when it comes to prioritizing clinician wellbeing. Here are a few strategies that can help.
Adaptive staffing. During a recent American Medical Association webinar titled, “COVID-19 and Rethinking Wellness,” the chief wellness officer of Chicago’s Rush University Medical Center, Bryant Adibe, MD, recalled receiving a consult from a team leader who reported their team was experiencing excessive stress and a 30% increase in workload volume likely related to COVID-19.
“What the team needed was not wellness tips and tricks,” Dr. Adibe said. “[It needed] an adaptive staffing plan— one that would allow for a flexible, temporary increase in staffing to meet that 30% increased demand so that their load would be more manageable.”1
Stick with essentials. Pruning away tasks that don’t improve patient care, reducing charting burdens, and improving the user-friendliness of health information technology are three other examples of carving out room for clinicians to better attend to patient needs while also taking care of their own.2
Create safe spaces at work for staff to retreat to when stressed. Leaders need to trade “draconian policies around rest and relaxation” for “resilience rooms or wellness zones so staff can take a few minutes to breathe, stretch, read, cry, hydrate, or nap,” says Dr. Cunningham. Wellness rooms
can be existing areas, such as a dining or meeting room, that are repurposed and outfitted for self-care endeavors. Outdoor spaces work as well. Robust literature shows that time spent in nature is mentally and emotionally healing.
Peer-to-peer support. Dr. Kaushik endorses peer-to-peer coaching sessions to give clinicians the chance to feel heard, swap tips, and commiserate.
• Minute Clinic provides colleague interest groups that provide outlets for special interests and focus on individualized professional practice, says Kristene Diggins,DNP, FAANP,
MBA, CNE, NEA-BC, from CVS MinuteClinic. “These groups help prioritize personal life and allow providers to develop goals professionally that can support a group vision and strategy in times of stressful work.”
• Kroger Health has initiated conversations with team members to address the multiple issues and concerns that they are facing, says Meggen Brown MSN, FNP-BC, and developed a strategy to provide peer support on “mind, movement, and nutrition.”
• At the University of North Carolina at Chapel Hill, the
Peer Support Program connects providers with trained volunteers for support following adverse patient events, patient losses, or verbal or physical assaults from patients or visitors.3,4
• Johns Hopkins Medicine’s confidential peer-support program,
RISE (Resilience in Stressful Events), provides similar “inperson psychological first aid and emotional support” to health-care professionals and has been replicated in more than 30 U.S. hospitals in the past six years.5-6
Address racism. In terms of addressing burnout stemming from systemic racism, Reed would like to see clinic and hospital leadership institute zero-tolerance policies and procedures for discrimination, harassment, and microaggressions, including an easy reporting system that allows for anonymity.
“Taking the concerns of their teams seriously can build rapport and create an environment that brings folks from diverse backgrounds together,” she says.
Dr. Cunningham would like to see an end to the still commonplace practice of allowing patients to make requests regarding their health-care providers’ race. Mayo Clinic, he notes, has adopted a progressive policy, now stating: “We won’t grant requests for care team members based on race, religion, ethnicity, gender, sexual orientation, gender identity, language, disability status, age or any other personal attribute.”7
Provide mental health services. To support clinicians through the pandemic, the American Nurses Foundation launched a national wellbeing initiative to provide nurses access to a menu of mental health and wellness-related resources designed to help manage trauma and mitigate burnout, including peer-support video chats, a narrative expressive writing program, and a smartphone app that connects nurses one-on-one to a trained support giver 24/7.8 Kroger Health partnered with Magellan Health to provide free mental health services to its employees, Dr. Brown says.
The very existence of such endeavors sends the message to staff that they matter, Dr. Cunningham says, noting that, “When people feel heard, and their needs are being met, they’re less likely to feel burnout.”
REFERENCES
1. American Medical Association. How the last year has forced rethinking on physician burnout. Accessed December 9, 2021. 2. American Medical Association., Bryant Adibe, MD, discusses rethinking wellness during COVID-19. Accessed December 9, 2021. https://www.ama-assn.org/practice-management/physician-health/ bryant-adibe-md-discusses-rethinking-wellness-during-covid-19 3. Rush University Center for Clinical Wellness. Accessed December 9, 2021. https://www.rushu.rush.edu/rush-experience/student-services/ center-clinical-wellness 4. University of North Carolina. Integrated Emotional Support Program. Accessed December 9, 2021. https://www.med.unc.edu/ psych/wellness-initiatives/integrated-emotional-support-program/ 5. University of North Carolina. Peer Support Program. Accessed December 9, 2021. https://www.med.unc.edu/psych/ wellness-initiatives/peer-support-program 6. Johns Hopkins University. Caring for the caregiver. Accessed December 9, 2021. https://www.hopkinsmedicine. org/armstrong_institute/training_services/workshops/ Caring_for_the_Caregiver/ 7. Wu AW, Connors C, Everly, GS, Jr. COVID-19: Peer support and crisis communication strategies to promote institutional resilience. Ann Intern Med. June 16, 2021. Accessed December 9, 2021. https://www.acpjournals.org/doi/10.7326/M20-1236 8. Warsame RM, Hayes SN. Mayo Clinic’s 5-step policy for responding to bias incidents. AMA Journal of Ethics. June 2019. Accessed December 9, 2021. https://journalofethics.ama-assn.org/article/ mayo-clinics-5-step-policy-responding-bias-incidents/2019-06
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wearing scrubs and had her hospital ID around her neck.
“That same day, a patient came in saying, ‘We need to kill all the [racial slur] protesters.’ It’s exhausting having a lack of support, lack of mentorship, lack of seeing myself represented in my colleagues, lack of a sounding board.”
Asian providers have reported verbal and physical abuse in the wake of COVID, too. Internationally educated nurses contend with racism and discrimination as well, according to the NAP.1 Add to that the fact that many Black and Latin clinicians feel the pressure of the “Minority Tax,” the unspoken burden placed on employees of color to do the heavy lifting when it comes to creating awareness of workplace diversity.11
“We’re doing all we can for patients, and you’re also asking us to create cultural and systemic changes within the institution,” Reed notes, adding that she knows of one Black PA who quit medicine to work at Trader Joe’s because “she felt unappreciated in a system that doesn’t seem to prioritize the lived experiences and mental health state of any providers, and specifically minority providers. It’s all cumulative and over time, it can create burnout.”
Finding Fixes
Dharam Kaushik, MD, an associate professor of urology and a urologic oncologist at the University of Texas Health San Antonio, says the first step towards finding solutions is recognizing that burnout and CF exist. Whether you’re a student, doctor, NP, or PA, the message ingrained early on is: “There is no room for complaining, and you’re expected to have empathy for everyone else but not yourself. You can take vacation days, but there are no wellness days off.” This mindset, he says, is damaging and can breed burnout and CF.
Clinician Self-Help
Personal stress management strategies—while not enough to address the issue of clinician burnout on their own—can provide meaningful relief from feelings of burnout and CF.12
Therapy
Working with a therapist gives you the opportunity to vent, judgment-free, and can also teach you to challenge and reframe unhealthy or unproductive thoughts. (“I’ve lost my touch” becomes “I’m doing the best I can under difficult circumstances.”)
Cognitive behavioral therapy and acceptance and commitment therapy are two proven methods to help address anxiety, depression, and burnout.13,14,15 Pandemic-related changes in telehealth mean that you can now teleconference with your therapist from your living room couch, eliminating some of the traditional barriers. Don’t let outdated stigma surrounding therapy deter you: One out of every six Americans tried therapy for the first time in 2020, joining the one-third of Americans who either continued or returned to it.16
Dr. Harris notes that non-traditional types of therapy, like art therapy and pet therapy, offer similar benefits, too. (She recently took up painting for just this reason.)
Find your Village
Reed recommends finding a support system, whether that’s friends and family who can lend an ear, or by joining a specific caucus of your health-care professional organization.
“Finding your community helps you see past the misery of that day and look more broadly at the impact you are making,” Reed says. “You can interact with like-minded individuals who give you the energy and strength to keep pushing on as well as remind you to take breaks.” It can also help you find a mentor and networking opportunities.
Exercise
Jogging, dancing, basketball, Spinning, tennis, yoga: Exercise has the ability to reduce stress, improve sleep, and trigger the release of feel-good endorphins.17 Research suggests that working out may also help ease burnout by offering a distraction from stress, reducing a person’s physiological sensitivity to chronic stress, and boosting resilience,18 which has been shown to serve as a sort of antidote to burnout while improving compassion satisfaction.19 Dr. Harris calls compassion satisfaction the joy and satisfaction one feels from working as a professional caregiver, “the opposite of compassion fatigue.”
Laughter
Laughter is wonderful, stress-relieving medicine. It promotes relaxation, improves self-esteem and energy levels, and cuts through anxiety.20 As a board member of Clowns Without Borders who has performed in Sierra Leone, Turkey, Haiti, and more, Dr. Cunningham has witnessed this first-hand. Whatever you find funny—live comedy, spending time with your most amusing friend, tuning into a humorous podcast—seek it out.
Still, running along the lake and binge-watching The Office reruns, enjoyable as they may be, aren’t enough to cure burnout. “Personal resilience is only one small piece of the puzzle,” Dr. Cunningham recently wrote in the American Journal of Nursing. “If we, as leaders, push nurses to practice resilience but do nothing to address systemic problems such as staffing, the electronic health record, and incivility in the workplace, then we are missing the boat.”21
He notes that leaders say, “To fix your burnout, you just have to meditate more,” but health-care providers don’t have time to meditate. The organizational culture needs to shift, he says, so that self-care is not just a possibility, but a priority. See the sidebar for more information on how leaders can address burnout. C
