MACRA 911: Will MACRA Destroy the Small Physician Practice?

The Centers for Medicare and Medicaid Services may be serving MACRA up as “part of a broader push toward value and quality,” but most small physician practices feel the federal regulation will more likely push them out of business, according to a new survey.

In a May survey by Black Book Market Research of 1,300 physician groups with five or less clinicians showed 67 percent of high Medicare-volume physicians said MACRA means “the end of their independence.” These practices believe they “will not have the technology, capital or staffing to sustain under the conditions of the Merit-based Incentive Payment System (MIPS).”

The survey also shows that a strong majority of smaller practices are struggling with reporting requirements, revenue collection, and competition from larger practices and physician networks:

• 89 percent of respondents said they “expect to minimize Medicare volumes” to avoid having to submit reports for quality improvement activities or cost performance
• 77 percent said they currently are financially struggling “due to physician staffing losses to larger group practices and hospital integrated delivery networks”
• 72 percent said they “blame their under-performing billing technology and compounding payment issues” for their financial woes

“Physician payment based on 2017 performance isn’t scheduled to kick in until 2019,” Doug Brown, managing partner of Black Book, said in a statement. “That’s far too long to maintain operations for the most stressed practices to hold on with outmoded technology and scarce billing support.”

Most small physician practices appear to agree. Nearly four-fifths of survey respondents (78 percent) said they anticipate joining a larger practice or network “to gain needed reporting, revenue cycle tools and support before 2019,” Black Book said.

However, the survey revealed that 63 percent of practices with fewer than 10 practitioners, as well as solo practice physicians, have still not settled on a technology suite or set of products that delivers to their expectations on Meaningful Use, clinician usability, interoperability and coordinated billing and claims. But over a third of those slower adopters expect to make product decisions before the end of this calendar year.

American Medical Association President Dr. Andrew Gurman is a solo-practice orthopedic hand surgeon who doesn’t use an EHR, according to MD Magazine.

“I don’t have an EHR,” Dr. Gurman told MD Magazine. “I just take the penalties.”

MACRA’s payment adjustments are scheduled to begin in January, and CMS has already made moves to help small practice physicians. HHS recently announced it will award $100 million over the next five years to organizations that provide support and training to Medicare physicians in group practices with 15 or fewer clinicians to comply with MACRA.

The Medical Association is studying the proposed rule and may provide comments particularly on those provisions of the rule of most significance to smaller practices. The timeline of the implementation of MACRA is of the utmost importance in that physicians will begin reporting Jan. 1, 2017, which will affect Medicare payments in 2019. The Association will provide more information as it becomes available.

MACRA 911: Physicians Urge MACRA Delay

The Medical Association joined the American Medical Association and numerous physician groups to urge the Centers for Medicare & Medicaid Services delay implementation of the Medicare Access & CHIP Reauthorization Act of 2015, which replaced the Medicare Sustainable Growth Rate, and ensure new federal reimbursement programs “reward physicians for the improvements they make to their practice and the quality of care they provide to their patients.”

MACRA has been sharply criticized by physicians because of its framework establishing payment incentives for physicians and other clinicians based on quality of care rather than quantity, or fee for service. This framework for determining care standards, or Quality Measure Development Plan, includes measures in six quality “domains” such as clinical care, safety, care coordination, patient and caregiver experience, population health and prevention, and affordable care. Physicians would be paid based on their quality and cost metrics.

CMS plans to base reimbursements in 2019 on physician performance beginning Jan. 1, 2017. The proposed start date is too early and will create significant problems for the launch of the MACRA programs, and physician groups are calling for a six-month delay.

Other recommendations include:

• Provide more flexibility for solo physicians and small group practices, including raising the low-volume threshold
• Provide physicians with more timely and actionable feedback in a more usable and clear format
• Align the different components of MIPS (Merit-Based Incentive Payment System) into a unified program rather than four separate parts
• Simplify reporting burdens and improve odds of success by creating more opportunities for partial credit and fewer required measures within MIPS
• Reduce reporting thresholds for quality measures

According to a new Medscape Medical News survey, almost four in 10 physicians in solo and small group practices predict an exodus from Medicare within their ranks on account of the program’s new payment plan and its punishing penalties. Fifty-nine percent of physicians in practices with fewer than 25 clinicians also said they expect to receive a performance penalty as high as 4 percent under proposed regulations that implement MACRA. Only 9 percent of physicians in under-25 groups expect a bonus, with another 12 percent counting on no change in compensation. Roughly one-third of physicians in small practices said merger into larger groups promises to be the most likely fallout from MACRA.

If you would like to take part in the poll, click here.

Could MACRA Be Delayed?

During a recent Senate Finance Committee hearing, CMS Acting Administrator Andy Slavitt hinted at the possibility the agency might delay the start date of the Medicare Access and CHIP Reauthorization Act, or MACRA. Under MACRA, CMS would begin measuring performance in 2017 for payments that begin in 2019 – a timeline that has been a huge concern for physicians that are still awaiting a final rule.

“Every physician in the country needs to feel like they are set up for success,” and to do that the agency “remain[s] open to alternative approaches,” which include later start dates, shorter reporting periods and additional methods to ease physicians into the program,” Slavitt said during the hearing.

With no official start date confirmed for MACRA, and a final rule expected to be published Nov. 1, physicians are on edge about the timing of this new program, which is set to replace the sustainable growth rate formula for physician payment adjustments under Medicare. The Medical Association joined the American Medical Association and numerous physician groups to urge CMS delay implementation of MACRA, and ensure new federal reimbursement programs “reward physicians for the improvements they make to their practice and the quality of care they provide to their patients.”

In his testimony, Slavitt conceded that small, rural and independent practices will struggle with the new rules, and a central theme emerging from the public comment period was the need to design a program with special consideration for these groups.

“They do not have the resources of larger groups and each new administrative requirement takes time away from patient care,” Slavitt said.

He said another central theme from the 4,000 formal comments CMS received asked that CMS look for flexibility to allow physicians, other clinicians and their communities time to learn about and prepare for the sweeping changes.

“While the quality payment program builds on programs that should be familiar to clinicians, we understand new rules require adjustment and preparation,” Slavitt said.

Slavitt said CMS would consider numerous approaches to help delay and soften the blow of MACRA going live, including alternative start dates and shortened reporting periods. CMS is also looking into ways to reduce reporting burdens and eliminate reporting where physicians have consistently performed well.

MACRA 911: What Questions Should You Be Asking Right Now?

While there is still no official start date confirmed for MACRA, and a final rule expected to be published Nov. 1, physicians continue to be on edge about the timing of this new program, which is set to replace the sustainable growth rate formula for payment adjustments under Medicare. With November just around the corner, what questions should you be asking right now?

Unfortunately, nearly half of U.S. physicians are unfamiliar with the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA, according to a new survey of 600 doctors by research and consulting giant Deloitte. Under MACRA, CMS would begin measuring performance in 2017 for payments that begin in 2019 – a timeline that has been a huge concern for physicians that are still awaiting a final rule.

The Medical Association joined the American Medical Association and numerous physician groups to urge CMS delay implementation of MACRA, and ensure new federal reimbursement programs “reward physicians for the improvements they make to their practice and the quality of care they provide to their patients.”

According to HealthcareFinanceNews online, there are some questions physicians should be asking about MACRA right now:

Who are your eligible clinicians and how are they structured?

MACRA isn’t just about physicians. The answer to this question is important to allow you to formulate a solid plan of action to determine whether you will use MIPS (be measured and paid based on quality, resource use, clinical practice improvement and Meaningful Use), or APM (a payment method with a time limit of six years).

How do you optimize MIPS reporting and performance?

Most physicians will start under the MIPS system until you decide what reporting system suits your practice best: what measures you would perform best on, whether you feel confident in your ability to perform well under these measures, and ultimately if you want to stay under just MIPS.

Should I participate in an APM, and do I want to do a MIPS APM or Advanced APM?

Look at what models are available in your area, as some are geographically based, and also what is available for application. There are application periods that need to be taken into account. One thing to remember if you go with a MIPS APM, a one-sided model that carries no direct risk, you still have to be building your capacity to take on risk even while maximizing your time as a MIPS APM.

How are you communicating your strategy to your organization, the clinicians you work with and to your community partners?

Everyone needs to be on the same page. The official, finalized rules will be published for implementation in November, at which point providers will be expected to quickly prepare for reporting in 2017. Those reports will determine reimbursement, and penalties and bonuses where applicable, in 2019.

MACRA 911: Physicians Will Have More Flexibility

MACRA will begin on Jan. 1, 2017, and according to CMS Acting Administrator Andy Slavitt physicians will have more options to comply and avoid a negative payment adjustment in 2019.

The announcement comes after intense pressure from industry stakeholders and policymakers to ease implementation of the Medicare Access and CHIP Reauthorization Act, which is set to start Jan. 1, 2017. Just two months ago, CMS announced the agency was considering delaying the start date.

Now, CMS seems to be conceding a bit of ground by adding more flexibility to the MACRA program with four options for participation:

Option One: The first option is designed to ensure more physicians are prepared to participate in 2018 and 2019 and will enable clinicians to submit data to the Quality Payment Program, including data after Jan. 1, 2017, and still avoid a negative payment adjustment.

Option Two: The second option will allow participation for part of the calendar year. Physicians may choose to submit Quality Payment Program information for a reduced number of days. The first performance period could begin later than Jan. 1, 2017, and the practice could still qualify for a small positive payment adjustment. This option can include the submission of information on how the practice uses technology and what improvement activities are being used. Physicians will choose from a list of quality measures and improvement activities under the Quality Payment Program in this category.

Option Three: The third option will allow physician groups to submit information for the entire 2017 year on quality measures and could qualify for a modest positive adjustment.

Option Four: The fourth option is for physicians participating in an Advanced Alternative Payment Model in 2017. Instead of reporting quality data and other information, the law allows participation in an Advanced APM, such as Medicare Shared Savings Track 2 or 3 in 2017. Physicians that receive enough of their Medicare payments or see enough of their Medicare patients through an Advanced APM in 2017 would qualify for a 5 percent incentive payment in 2019.

These changes come in response to feedback on CMS’s April proposal for implementing the Quality Payment Program on how excessive reporting can distract from patient care; how to encourage new programs, such as medical homes; and the unique issues facing small and rural non-hospital-based physicians, Slavitt wrote in a blog post.

More details on these options will become available when CMS releases its final rule for implementing the Quality Payment Program, sometime before Nov. 1.