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?


Michael Banks said...

MACRA is more of the same numerators, denominators, attesting, etc. even adds a Clinical Practice improvement section.
Read John Halamka's posts on it. Its just more of the same meaningless counting of measures. So how has MU done with its goals of interop and reducing costs, improving safety, making things more efficient and usable, and worse yet, security of PHI?
MACRA uses pandering language of "simpler and flexible' but its MARKEDLY more complex and you would need a team of lawyers, accountants, policy advisors and bankers to do a AAPM. So DON'T tell me to relax, the blowback is coming and coming hard. We are NOT going to take this abuse anymore. Read the rule's comments. They are 100% negative. Read the HealthCareBlog's Kip Sullivan's
You ARE destroying and irreversibly damaging the practicing frontline physicians. So LISTEN UP. We are NOT going to do this.

Victor G Ettinger said...

If Physicians are to regain the ability to practice Medicine we will have to learn TO JUST SAY NO to CMS & stop seeing ALL Medicare patients. MACRA is just the middle of the downfall of our beloved system. And ACP has to STOP being an apologist for our f@@$)&$ up government.

PCP said...

How can ACP stop being an apologist for the gov't when they were there from the start actively pushing things in the direction and trying to 'sell it' to their membership?
Wake up folks, ACP is a part of the problem, not a part of the solution. They sure don't represent me. They haven't for a long time, it just t
took me a while to realise that through all the smoke and mirrors and spin that DC represents. Just remember folks, the ACP has
been at the table every step of the way, and if you don't appreciate the direction things have gone with your profession over the
past 2-3 decades, then ACP deserves some of the blame directly.

Jay Larson MD said...

MACRA is still built on top of fee for service. FFS's RVU system is flawed if you do primarily E and M coding. It just adds one more burden to an overwhelmed primary care internist. Even is you do everything right, the end result will still be substandard reimbursement for what an internist does. I stopped seeing Medicare patients 3 years ago so that I could keep my doors open. Medicare does not reimburse enough to cover overhead. MACRA will have no effect on me. Don't have to worry about RAC audits, PQRS, or meaningful use. So long as physicians are willing to take the abuse, the system will not change for the better.

Harrison Robinson said...

I am re-reading the book Reading Lolita in Tehran, and I guess I'm struck by a parallel. The women working as professors at the Univ of Tehran in '79 and '80 were reluctant to start wearing 'the veil.' Their problem with it was the mandate. The men who were idealists for the revolution tried to reason with them that this was just a small piece of cloth and couldn't they see that their solidarity with Islamic Principles would go a long way and be worth more than the inconvenience.

Of course the parallels end there and I don't wish to draw it any further. The Islamic Revolution has as one of its core principles a fear of educated women.....
That doesn't translate into the MACRA argument.

But Bob comes across as a bit of an apologist for the 'revolution' in physician payments. It just isn't okay to allow the freedom to choose whether to practice as before with a degree of autonomy in a fee for service model. Can't we primary care providers just accept a bit of sacrifice in service of the cause of improved population health and quality and hopefully cost reduction?

I'm sympathetic to the arguments against MACRA.
I'm also sympathetic to Bob's argument.
Physician payment reform is not the Islamic revolution and MACRA is not 'the veil'.

I see Bob's point that MACRA is better than what we have and it is the next step in a process.
And I can see a future where patients will find their doctors practicing in models resembling Patient Centered Medical Homes, with NP's as colleagues, and MA's and LVN's and RN's working as members of a team.

But we are painfully far from it.


DrJHO7 said...

I appreciate Bob's effort to shed light on MACRA and help physicians to understand it. It really is complicated/difficult to understand at 1st, even second consideration. I disagree with those who propose that ACP is part of the problem. As a professional membership organization, ACP is supporting its membership by providing clarity on the content of the regulations put forth by CMS.
Unfortunately, many physicians have had their limit for tolerance of "regulopathy" exceeded by MACRA/MIPS/APM/ACI/PQRS/VBPM/MU/ETC and HIPPANOIA. In my small community, over the past year, 7 physicians have changed to retainer/concierge practices, downsizing their practices by 66-75%, 4 physicians have closed their practices, and 1 large family med practice closed one of its 2 offices due to loss of staff and overhead issues. This is PRIOR to implementation of MACRA, ETC. It's not just CMS payment policy that is affecting the choices of private practice physicians. The indifference (complete lack of concern) of the commercial insurers for small medical practices also significantly impacts on decisions of these practices regarding their future. Flat reimbursement for 8-9 years just doesn't help sustain practices. So, there will be contraction of the physician community. Significant, palpable contraction, and problems with access to care. Change and innovation within the delivery system will bubble up from such pressures. We'll see where it goes...

Yasir Anzar said...

Perhaps, ACP needs to take stronger stance in this issue.