Care Redesign

Physician Frustration and Fear of MACRA

Article · August 4, 2016

There are terms that conjure dread in certain groups: LDL for middle-aged people, Brexit for London bankers, and SGR among doctors. Is MACRA next?

SGR, the Sustainable Growth Rate, was the set of economic formulas to determine how much physicians were to be reimbursed by the Medicare program from year to year. Between the time the SGR debuted in 1997 and its demise last year, it was used exactly once; in 2002, the base payment rate was cut nearly 5%. The American Medical Association (AMA) and various other physician lobbies leaned hard on Congress to ensure SGR rode the pine for the next dozen-plus years, mostly obtaining small annual payment increases.

After years of negotiations, SGR was given an ignominious retirement last year when President Obama signed the Medicare Access and CHIP Reauthorization Act (MACRA) into law. Almost immediately, discussions of MACRA and its impact occupied health care industry press releases, conferences, and webinars. Although much of the physician community initially supported the law, as MACRA’s details have become clearer, many doctors have decried the likely impact on their time and money.

Unlike SGR, MACRA governs payments to physicians not through a group of abstract economic equations but in terms of how clinicians perform in delivering care and patient outcomes. Starting next year (if the current schedule holds), it would affect any physician who receives $10,000 or more a year in Medicare payments. That low bar means MACRA would apply to small physician practices as well as large groups. For small practices and solo physicians, the law could be the last straw.

Initial Physician Support

Passage of the MACRA legislation was supported by the AMA, as was the first draft of regulations released by the Centers for Medicare & Medicaid Services during the spring.

“When Congress overwhelmingly passed MACRA last year, lawmakers signaled that they wanted to transform Medicare by promoting flexibility and innovation in the delivery of care, changes that could lead to improved quality and better outcomes for patients. Our initial review suggests that CMS has been listening to physicians’ concerns,” AMA President Steven Stack, MD, said in April.

But Stack also cautioned that “the new incentive system needs to be relevant to the real-world practice of medicine and establish meaningful links between payments and the quality of patient care, while reducing red tape.”

MACRA takes two paths in pushing doctors toward higher quality care. One is the Merit-based Incentive Payment System, or MIPS, which melds together three prior programs: the Physician Quality Reporting System (PQRS), the Value Modifier (VM) program/resource use, and the Medicare Electronic Health Record (EHR) incentive program.

Under MIPS, doctors would be scored in four areas: cost of care; quality of care (providers would choose six measures on which to report to the Centers for Medicare and Medicaid Services, which vary by medical specialty); activities toward the improvement of clinical practice; and how they use their electronic health records in the exchange of clinical information.

MIPS is intended to be budget-neutral for the federal government. Thus, physician practices could qualify for incentive payments of no more than 4% greater than their current Medicare reimbursement, and no practice could be penalized more than 4%. But the incentives and penalties would increase over time, reaching 9% on both ends by 2022.

The other program within MACRA, advanced Alternative Payment Models, or APMs, is aimed toward larger and more technologically advanced practices. Participants would have to engage in a next-generation accountable care organization model, tracks 2 or 3 of the Medicare Shared Savings Program, or programs focusing on primary care, renal care, or oncology care. APM participants would qualify for a Medicare Part B incentive payment of up to 5% of their current reimbursement. CMS estimates that no more than 4% of physicians would qualify for the APM track.

Growing Concern

“I think MACRA is a step in the right direction in making care better,” says Amy Compton-Phillips, MD, who is Chief Clinical Officer for Providence Health & Services, a 34-hospital system with a significant presence on the West Coast, and NEJM Catalyst’s Lead Advisor for Care Redesign.

But she is quick to add that imposing the law as a one-size-fits-all solution may not be the way to go: “There’s going to have to be some flexibility.”

And as the rest of the physician community has had time to review the proposed regulations, concerns have begun to grow. One of the biggest worries for many is that MACRA’s quality initiatives will favor larger practices with vast resources but create a burden for smaller practices. For one thing, large practices will find it easier to participate in group reporting registries, which is required for many MACRA quality measures. Doctors working solo will at the very best be able to avoid some cuts, as opposed to reaping some financial benefits.

Geraldine McGinty, MD, a radiologist and Assistant Chief Contracting Officer and Professor of Clinical Radiology at Weill Cornell Medicine in New York City, explains why larger practices such as hers — with 1,200 physicians and more than 100 radiologists in total — are going to have an easier time navigating the new MACRA environment than smaller organizations: “Group reporting is much easier,” she says.

Also, her group will avoid the tricky designation of “non–patient-facing” clinicians, which will entail different reporting thresholds for quality measures than those faced by other specialists. According to the CMS proposal, a radiology group would be considered non–patient-facing only if the entire group bills fewer than 25 from a list of yet to be determined patient-facing services during a calendar year. Since Weill Cornell will likely qualify as a patient-facing group, its radiologists will report quality measures using the same benchmarks as their colleagues.

McGinty is less sanguine as to how smaller practices will fare: “It’s likely going to be much tougher for [them],” she says. “It will be more likely that they will get a penalty than a bonus.”

McGinty is not alone in this concern. Thomas H. Lee, MD, a cardiologist, Chief Medical Officer for the Press Ganey patient experience consulting firm, and Founding Advisor for NEJM Catalyst, observes that physicians “who are practicing in big, well-organized organizations . . . we’re not worrying about MACRA, although there are people upstairs who are worrying about it.”

But Lee says that if he were in a small practice, “there would be no way I could deal with this . . . . It requires scale and leadership and management to respond.”

He notes that MACRA could wind up “driving more and more doctors away from the one- or two-physician practice into bigger organizations, so they can respond to the challenges without being completely overwhelmed.”

Distracting from Patient Care

In Columbia, Maryland, just a few hours’ drive down I-95 and a world away from the glass and stone high rises that house Weill Cornell, Andy Lazris, MD, practices geriatric and primary care in a modest two-story professional building.

Although his Personal Physician Care practice includes four nurse practitioners and four office staff and serves about 2,200 patients in all, Lazris is the only physician. For that reason, MACRA is a scary proposition to him.

“The problem with the whole MIPS program is that it is still either a win-or-lose proposition,” he says, referring to the zero-sum total of the bonuses and penalties. “You could do everything right, but some group that is a little more devoted to the process, that does a little better, they could get a bonus, while we would have the penalty.”

Compton-Phillips and others suggest that the requirements of MACRA will lead to a cottage industry of consultants assisting medical practices with compliance. But spending money on such contracts — and ensuring those expenditures are actually accompanied by concrete results — is not likely to bring cheer to many clinicians.

Consultants aside, the quality reporting initiatives would still take up an enormous amount of time for the office staffs of Lazris and other physicians. To comply with some programs, such as Meaningful Use, Lazris had to do most of the legwork himself. However, he only got his practice qualified for the first step. After an audit that consumed at least 40 hours of his time, he gave up.

“I decided to not even try anymore,” he says, reasoning the 1% penalty taken from his Medicare payments was not worth the amount of work required to pass future phases.

By contrast, Michael Koriwchak, MD, could probably attain Meaningful Use in his sleep. An otolaryngologist in the 15-doctor practice Ear, Nose, and Throat (ENT) of Georgia in Atlanta, he’s been writing computer code since the 1970s, when he was devising his own program to assist in laboratory research while attending Duke University School of Medicine.

Koriwchak wrote most of the code for ENT of Georgia’s electronic medical record system, which took about eight months before it went live. He later updated the system for ICD-10 compliance. He also manages to co-host a weekly web-based radio show on health care delivery.

But Koriwchak is not relishing the prospect of having to update the practice’s system for MACRA reporting. For ENT specialists, that would include incorporating a variety of measures, such as whether a risk assessment was performed prior to performing sinus surgery or whether excessive CT scans were ordered for sinusitis patients.

“It would be onerous for me to write all that code because I’d have to pull all the orders on CT prophylaxis” and input them into the program, he says.

“The main objection is this is a distraction from patient care,” he adds. “Every hour I am writing code and doing attestations is an hour taken away from seeing patients.”

Critical Comments

That view relates to another of Koriwchak’s gigs, as Vice President of the Docs 4 Patient Care Foundation. Among its primary tenets is less government regulation of health care delivery.

The lobbying doesn’t seem to be making a difference, Koriwchak says.

“We’re talking into a telephone and no one else is listening,” he says, adding that the federal government already spends more than $15 billion a year on quality reporting.

These frustrations are echoed among the many comments CMS has received on the proposed rules, which will likely be finalized later this year after the agency sifts through and responds to the comments. Among them:

  • “This proposal is doomed to self-destruct because it will increase costs, pile on more secretarial work on us providers . . . . I realize we will not be able to stop the miserable legislation, but I see this as another reason to stop doing surgery.” – A general surgeon in North Carolina
  • “MIPS and APM are very bad for the solo practitioner. They likely signify the destruction and death of the one- and two-doctor practices, particularly primary care physicians.” – A family practitioner in Georgia
  • “Once again we have a regulation that feeds the regulatory compliance industry and distracts the provider energy and focus away from patients. And, once again, the punitive consequences, which, given the budget-neutral component will far exceed the positive consequences, are to be imposed only on the caregivers.” – A rheumatic practice manager in New Jersey
  • “The burden of work just for documenting these silly ‘quality measures’ just takes away not only from the time we get to spend with our patients, but significantly reduces our enjoyment of what we were trained to do — look after patients — not create a data trail for big government. When I started practice, the costs of my medical record keeping was almost nothing. Now with an EHR it is costing me around $10k per month!!! LUDICROUS!!!! And for WHAT!!!!” – An anonymous commenter from Washington State

In Lazris’ own comments to CMS, he suggested that the agency appoint liaisons who would work with smaller medical practices. That idea was praised by McGinty as “terrific,” but she adds that she has never heard of CMS doing something like that.

Compton-Phillips also believes that such a liaison would be “sensible and workable,” but suggests that a private organization assisting small practices, such as the National Committee on Quality Assurance (NCQA), might be the better way to go.

A Texas-Sized Push for Change

A common refrain among many of the other commenters begins this way: “I am a Texas physician who is extremely disappointed and disillusioned with the Centers for Medicare & Medicaid Services’ draft rule to implement the Medicare Access and CHIP Reauthorization Act.”

These submissions, more than 650 of the nearly 4,000 submitted, were orchestrated by the Texas Medical Association (TMA), one of the most influential of the state medical lobbies.

Don R. Read, MD, a Dallas colorectal surgeon with a wry sense of humor who became the TMA’s president last April, concedes that MACRA is an improvement over the SGR. But “MACRA is the ‘be careful what you ask for because you might get it’ law,” he says. “The little guys will get punished.”

One of the biggest changes Read and the TMA are advocating for is to bump up the minimum Medicare revenue for MACRA reporting from $10,000 to $250,000. Read believes that at that level, the possibility of earning a 4% bonus would at least cover the $10,000 in estimated costs to compile and report data.

There are other issues for which the TMA has pushed for changes. Read and the TMA are concerned there is no streamlined way to extract data from EMR systems and report it to the feds, likely leading to hours and hours of prep work. They are exercised about MACRA’s timeline; if CMS finalizes the rules this fall and makes reporting mandatory, there will not be enough time to prepare. Such concerns are echoed by the AMA, which asked for reporting exemptions for smaller and rural practices, particularly for resource use and clinical information exchange, and the Medical Group Management Association, which wants the start of the reporting period pushed back to 2018.

Read has given CMS credit for being open-minded and sending officials to meet with the TMA.

Meanwhile, the grumbling among physicians and their lobbying groups about government mandates is not an uncommon phenomenon; it’s among the reasons SGR was rarely deployed and eventually repealed. To what extent CMS will change MACRA rules to accommodate the demands of doctors remains to be seen.

One of the most likely changes to occur between the proposed and final regulations is a delay in the initial data-gathering and reporting components, which are currently set to begin in 2017 and 2018, respectively. More time to begin MACRA has been the predominant request of many commenters.

“A delay would be very good,” says Compton-Phillips, who believes at least an additional year is reasonable. “I don’t think CMS is ready yet, and the infrastructure isn’t quite there. Taking the time to get it right is a good idea.”

CMS often relents when such requests are made en masse; the most recent example of kicking the timetable down the road came just earlier this summer when CMS issued the final rules for implementation of the Protecting Access to Medicare Act, which impacts payments to clinical laboratories. That sector, which is vastly smaller than that of medical practices, won a one-year delay in implementation.

But given the push for quality reporting and initiatives in many other facets of health care delivery, it is likely that MACRA, delayed or not, is going to be around for a while.

Koriwchak, the politically active otolaryngologist who is deeply skeptical of government, all but acknowledged as much.

“Whatever the law is on January 1, 2017 — that’s what we’ll do,” he says.

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