Thursday, May 19, 2016

Relax, it’s only MACRA

Over the past three weeks, I’ve had the chance to present the changes being brought by the Medicare Access and CHIP Reauthorization Act (MACRA) to audiences of hundreds of physicians—at ACP’s Leadership Day on Capitol Hill, ACP’s Board of Governors and Board of Regents meetings, several educational sessions and a news briefing at the College’s Internal Medicine 2016 Scientific Meeting, and on Saturday, to the California Medical Association’s Leadership Academy.  I’ve also had chats with dozens of physicians outside of these formal presentations.

Here’s what I have learned: most physicians look at the “value-based” payment reforms being brought by MACRA with a degree of trepidation: they aren’t sure how to proceed, what measures will be used, whether they will be unfairly penalized for things outside of their control, and worried it will result in more administrative “hassles.”  It is certainly true that MACRA will make significant changes in the way physicians are reimbursed by Medicare, and ACP is addressing such concerns, through our advocacy with CMS and Congress, by educating our members about MACRA and by helping them be prepared.  For instance, ACP has developed a two-page explanation  of the law, recommended 10 steps physicians can take right now, and developed implementation tools to help them.

Understandable anxiety and trepidation is one thing, but what worries me is that there is a growing undercurrent (just Google “MACRA will destroy private practice”) that implementation of the law will be a “sky-is-falling, end-of-medicine-as-we-know-it” type of disruption.

Frankly, this is nonsense, because MACRA offers physicians far more flexibility and choices than what that they currently have to put up with.   

Remember, MACRA didn’t create the idea of linking Medicare payments to measure of value, physicians have had to report on quality measures for years, with their payments being adjusted upward (and increasingly downward) if they don’t report successfully.  So the real question is, is MACRA better than what doctors currently have to put up with PQRS, Meaningful Use, and Value-Modifier programs?

  • Yes, by combining reporting of quality data into one program instead of the three separate ones, MACRA can substantially ease the burden of reporting. Already, CMS has proposed a reduction in the number of measures that have to be reported under the quality program that will replace PQRS and improvements in the Advancing Care Information program that will replace the Meaningful Use program to make them less burdensome.  In addition, MACRA adds a new category for reporting on Clinical Practice Improvement Activities, with approximately 90 flexible options for physicians to get credit for many of the improvements they already are making in their practices. Further, CMS has emphasized its commitment to ensuring that smaller practices get the flexibility and support they need.  Although CMS’s proposed improvements don’t go far enough, ACP intends to hold the agency to its commitment to “streamlining and strengthening value and quality-based payments for all physicians; rewarding participation in Advanced Alternative Payment Models (APMs) that create the strongest incentives for high-quality, coordinated, and efficient care; and giving doctors and other clinicians flexibility regarding how they participate in the new payment system.”

  • Yes, because MACRA’s maximum potential penalties for failing to successfully report quality and cost data for the next four years are less than under the current reporting programs.  Under the current PQRS, Meaningful Use and Value-modifier programs, physicians in 2017 could get a maximum downward adjustment of up to 8 percent:  -2% from PQRS, -2% from Meaningful Use,  -2% from the Value Modifier Program (for physicians in groups of 2-7) or -4% (for groups of 8 or more).  Under MACRA, the maximum downward adjustment a physician could get in 2019 (which CMS is proposing will be based on data submitted in 2017) is -4 percent, -5% in 2020, and -7% in 2021.  Only in 2022 and subsequent years would MACRA’s downward adjustment of -9% be greater than the current maximum downward adjustment of up to -8% under the current programs.

  • Yes, because MACRA allows physicians to earn positive payment adjustments while the current PQRS and Meaningful Use programs only allow physicians to avoid penalties (no positive adjustments allowed). Under MACRA, physicians can earn positive payment adjustments each year for quality reporting of up to +4% in 2019, +5% in 2020, +7% in 2021, and +9% in 2022 (although the actual maximum positive adjustments each year could be less than this, depending on how many physicians fall above or below the threshold required to avoid downward adjustments), and top performers can earn up to 10% more each year.  Under the current PQRS and Meaningful Use programs, there are no positive upward adjustments available, only avoidance of penalties for failing to report successfully.

  • Yes, because under the current PQRS and Meaningful Use programs, Medicare keeps the money from negative adjustments to some physicians while MACRA keeps it in the physician payment pool. Under MACRA, any negative adjustments to physicians who fall below the scoring threshold needed to get positive adjustments are redistributed to physicians who score high enough to receive positive adjustments.  While such “budget neutral” redistribution creates challenges, it’s clearly better for physicians that MACRA allows the money to stay in the physician payment pool rather than letting Medicare keep it as it now does.

  • Yes, because MACRA allows the thousands of  physicians in certified Patient-Centered Medical Homes (or who decide to get certified) to get favorable scoring, helping them qualify for positive payment adjustments.  No such opportunity exists under the current reporting programs.  CMS is proposing a number of flexible options for practices to get certified as PCMHs.

  • Yes, because under MACRA, physicians in Advanced Alternative Payment Models can to earn 5% Medicare FFS bonus payments each year from 2019-24 (and more favorable updates afterwards), plus whatever payment incentives and additional revenue opportunities apply to their advanced APM. To illustrate, CMS has proposed that physicians participating in the new Comprehensive Primary Care Plus program, which I blogged  about last month, could qualify as Advanced APMs, meaning that they would get risk adjusted prospective payments averaging $15-27 each month per beneficiary, plus at risk incentive based monthly payments of $2.50-$4.00 per beneficiary per month (this portion would have to be paid back if savings weren’t achieved), plus their FFS billings, plus the 5% bonus on Medicare FFS payments available only to advanced APMs.

So yes, MACRA is a big deal, but not in the way many physicians think it is. Compared to what physicians are currently dealing with under the current Medicare reporting programs, MACRA offers more opportunities for physicians to earn positive adjustments, exposes physicians to less risk from negative adjustments through 2021, creates positive rewards for the thousands of physicians who are practicing in certified PCMHs or who choose to get such certification, keeps all of the money from downward adjustments in the physician payment pool rather than letting Medicare keep it, and creates very substantial payment rewards for physicians in advanced Alternative Payment Models.  These changes are all good for physicians, especially those in smaller practices.

And, don’t forget, because of MACRA, we no longer have to deal with the annual SGR cut and all of its associated baggage.   

Sure, MACRA remains a work-in-progress; more can and must be done to simplify reporting and create additional options and flexibility for physicians in all types and sizes of practice, and physicians will need help in making the necessary changes in their practices.  But even as it stands right now, MACRA clearly is a change for the better compared to what physicians currently have to deal with.

Today’s question: what do you think the impact of MACRA will be on your practice?

Thursday, April 14, 2016

Will Medicare’s new Comprehensive Primary Care+ program truly be a Plus for primary care?

On Monday, the Center for Medicare and Medicaid Services (CMS) announced what it describes as the “largest-ever initiative to transform and improve how primary care is delivered and paid for in America."  Called the Comprehensive Primary Care Plus (CPC+) program, the initiative is modeled after the existing Comprehensive Primary Care Initiative (CPCI), a 4-year pilot of advanced primary care medical homes (PCMHs) that has been rolled out in 500 practices in 7 regions around the country.  CPCi is scheduled to wrap up in October of this year; its participating practices will have an opportunity to transition into the new Comprehensive Primary Care Plus program, and many more practices will be invited and eligible to join.

So how is the new program going to be a Plus for physicians and their patients compared to the current CPCi pilot and traditional fee-for-service Medicare?

For one thing, it’s Plus-sized: CMS envisions that the program will be available “in up to 20 regions and can accommodate up to 5,000 practices, which would encompass more than 20,000 doctors and clinicians and the 25 million people they serve”—a 10-fold increase in the number of participating practices, and a nearly three-fold increase in the number of regions where the program will be offered.

CPC+ could also be a Plus for practices because it will offer more options.  Physicians and their practices can choose from two different participation tracks, with different care delivery requirements and payment methodologies that reflect how advanced they are in incorporating PCMH principles into their care delivery. Track 1 is for those that are less advanced in fully implementing the attributes of advanced Primary Care Medical Homes; track 2 is for more advanced practices.

CPC+ could be a Plus for practices, especially compared to traditional FFS Medicare, because it gives them more Medicare dollars upfront, which will be in addition to the amounts they get reimbursed for individual patient encounter (evaluation and management service) codes:
  • Track 1 practices will receive an average risk-adjusted payment of $15 per beneficiary per month; they can earn another $2.50 PBPM if they do well on metrics of quality and utilization. 
  • Track 2 practices would receive an average risk-adjusted PBPM payment of $27 and up to $100 PBPM for the highest risk patients); they can earn an additional $4 PBPM based on performance.

However, CPC+ also adds financial risk to the equation. If track 1 practices do not meet their performance metrics, they will have to repay Medicare for the $2.50 PBPM incentive payment.  If track 2 practices don’t meet their metrics, they would repay Medicare for the $4.00 PBPM incentive payment. 

My back-of-the envelope calculation shows how much more in upfront Medicare money this could mean for participating practices.  A track 1 practice with 1000 Medicare beneficiaries would on average receive $15,000 in monthly (PBPM) payments, or $180,000 over 12 months.  If they are able to keep the $2.50 PBPM incentive payment, it would be $17,500 per month, or $210,000 for the year. Track 2 practices with 1000 Medicare patients would on average get $27,000 per month in PBPM advance payments, or $324,000 for a year; with the additional $4 PBPM incentive payment, it would be $31,000 per month, or $372,000 for the year. 

For track 1 practices, these upfront PBPM payments would be in addition to getting 100% of their usual Medicare FFS payments for office visits and procedures billed a la carte.

It’s more complicated, though, for track 2 practices, because their upfront PBPM payments will be offset by reduced payments for separately-billed office visits and other evaluation and management services.  In an editorial published in the Journal of the American Medical Association, CMS officials explain how this will work:
“Track 2 practices will receive an up-front payment of a portion of their expected evaluation and management claims on a per capita basis, independent of claims.  Subsequent claims for evaluation and management services will be paid at a commensurately reduced rate. As the ratio of the hybrid payment is titrated up during the model, the reduced payment for billed evaluation and management services will pay practices for the marginal cost of an office visit, making practices ‘incentive neutral’ to the mode of care delivery and allowing them the flexibility to deliver care in the manner that best meets patients’ needs—without being tethered to the 20-minute office visit. Practices might offer non–face-to-face visits (e.g., electronic or telephone), offer visits in alternate locations, or simply provide longer office visits for patients with complex needs. CMS will monitor practices to ensure delivery of quality health care.” 
Their non-evaluation and management services would continue to be paid 100% of the usual rates.

So for Track 2 practices especially, it comes down to them deciding whether having a big pot of “bird-in-the-hand” upfront PBPM payments, and the financial support and flexibility it provides to manage things without being “tethered” to visits, is worth being paid commensurately less when they have to bill separately for a visit. 

Or, to put it another way, do they prefer getting more of their revenue upfront from risk-adjusted capitation and less downstream from FFS billings?

The Comprehensive Primary Care Plus program could also be a Plus for practices by giving them access to extra support and revenue from payers other than Medicare: CMS will be seeking formal commitments from non-Medicare payers to support participating practices, and will only launch the program in localities where there is such a commitment from enough payers.

The CPC+ program could also be a Plus for participating physicians and their practices because it should give them a big leg-up in qualifying for higher payments under the new MACRA law, either as an Alternative Payment Model (APM) or under the Merit-based Incentive Payment System (MIPS) created by the legislation.

Finally, the Comprehensive Primary Care Plus program would also be a Plus for patients, if it truly achieves its goals of providing practices with the “financial resources [needed] to implement the processes and hire the staff needed to deliver the 5 primary care functions: (1) access and continuity, (2) risk-stratified care management, (3) planned care for chronic conditions and preventive care, (4) patient and caregiver engagement, and (5) comprehensiveness and coordination of care.”

ACP, in a supportive statement, noted several features of the program that will be critically important for it to be successful in meeting the goals of supporting and strengthening primary care:

·       We strongly support the goal of ensuring that practices in each track will be able to build capabilities and care processes to deliver better care, which will result in a healthier patient population.
·       We agree with the need for payment redesign that offers the ability for greater cash flow and flexibility for primary care practices to deliver high quality, whole-person, patient-centered care and lower the use of unnecessary services that drive total costs of care.
·        We support the critical importance of obtaining commitments from other (non-Medicare) payers to join with Medicare to support CPC+ practices.
·       We are encouraged that CPC+ will provide practices with a robust learning system, as well as actionable patient-level cost and utilization data, to guide their decision making.

Yet ACP’s statement concluded with a cautionary note:  “The success of the Comprehensive Primary Care Plus program will depend on Medicare and other payers providing physicians and their practices with the sustained financial support needed for them to meet the goal of providing comprehensive, high value, accessible, and patient-centered care, with realistic and achievable ways to assess each practices’ impact on patient care.  The College is committed to working with CMS on the details of implementation to ensure that the program is truly able to meet such requirements of success.”

While the verdict is still out, the Comprehensive Primary Care Plus initiative truly is a big deal for primary care, potentially offering a way for practices that embrace the PCMH model—as long championed by ACP—to get more upfront payments from Medicare and other payers to help them make their practices more accessible and responsive to the needs of their patients, while accepting a degree of financial risk for achieving the desired results.

Today’s questions:  Do you think that the Comprehensive Primary Care Plus program will truly be a Plus for primary care physicians, their practices, and their patients?  Would you consider having your practice participate?

Thursday, March 17, 2016

A Limerick for Saint Paddy’s Day

Readers of this blog know that I am first-generation American of Irish descent. My beloved father, Jack Doherty, came over to this country at the age of 10.  My dad was born in a thatched cottage (with no plumbing and electricity) in Drumshambo, County Leitrim, Ireland.  After emigrating to the United States with his mother, Elsie, at the age of 10, they were reunited with his father, who they hadn’t seen for eight years.  Later, my Dad took over (and tended bar) at Doherty’s Bar in Woodside, Queens, NYC, after my grandfather passed away.  Jack Doherty later went on to get a bachelor’s degree and master’s degree at night while tending bar 6 days and one night a week, sold the bar, and became a public high school teacher for inner city kids in Brooklyn, New York.  The complete amazing immigration experience, in a nutshell.

 My Dad passed away almost eight years ago, but I remember him almost every day, especially on Saint Patrick’s Day.

In tribute to my Irish heritage, here is my annual Saint Patrick’s Day limerick (named after the city in Ireland), on a topic near and dear to physicians:
Oh, how MACRA has taken over our days
Each deadline, and rule, a cause for dismay.
We do our best, oh we try
But sometimes we ask, why?
Wouldn’t it have been simpler to let the SGR stay?
Today’s questions: How are you celebrating Saint Patrick’s Day?  Care to write a limerick for readers of this blog?