MACRA 101: What You Need to Know
We are now 14 days from Election Day (assuming you did not participate in early voting). After more than 18 months of campaigning, the end is in sight. Soon, the nation will elect its 45th president, and our favorite television stations will return to a mix of auto insurance and pharmaceutical advertisements in place of the plethora of political ads that have aired for the past six months.
In my previous post, I outlined the two major party candidates' positions on health care issues. I urge each of you to vote on Nov. 8. Our democracy benefits from participation.
Fall also means rule-making, and the folks at CMS have been busy. On Oct. 14, CMS released the final rule implementing the Medicare Access and CHIP Reauthorization Act (MACRA). AAFP News has a good story on the rule and the AAFP's response. CMS finalized all provisions of the law, including eligibility, participation and evaluation requirements for the MACRA Quality Payment Programs (QPP). These criteria become effective Jan. 1.
The following is a high-level summary of the law. I will dig deeper into each of these sections during the next few months, but this post is designed to give you basic information.
First, I must state three things up front:
- This final regulation includes numerous policies that are the direct result of AAFP advocacy. Since submitting our comment letter on the proposed regulation, we have continued to advocate on your behalf to improve the regulation. I am especially proud of the Pick Your Pace program. This is a concept the AAFP provided CMS, and we are pleased that it was incorporated.
- All physicians participating in the Medicare program will receive a 0.5 percent update in payments for services provided in 2017.
- If you participate in the Merit-Based Incentive Payment System (MIPS) program, no matter for how long, you will not be penalized in 2019.
CMS has provided an excellent online resource on the QPP program. Let’s jump into the details.
The MACRA QPP creates two pathways for Medicare participating physicians:
- Advanced Alternative Payment Models (Advanced APM)
If you are one of the following, you are eligible to participate in either of the QPP pathways:
- physician assistant;
- nurse practitioner;
- clinical nurse specialist; and
- certified registered nurse anesthetist.
You are not required, as a condition of participating in the Medicare program, to participate in either of the QPP pathways. You may elect to provide care to Medicare patients and not participate in the QPP. However, if this is your decision, you will face maximum negative payment updates as outlined below.
Exemptions -- If your Medicare allowable charges are less than $30,000 a year or you do not provide care to more than 100 Medicare fee-for-service patients in a year, you are exempt from participation in the QPP. However, if your Medicare allowable charges exceed $30,000 a year and you provide care to more than 100 Medicare fee-for-service patients a year, you are part of MIPS. Additionally, if 2017 is your first year as a Medicare participating physician, then you are exempt from participation in the MIPS program. You may participate in an Advanced APM.
Performance period -- The performance period starts Jan. 1 and concludes on Dec. 31, 2017. Due to the flexibility provided by the Pick Your Pace provisions, physicians may initiate their 2017 performance period at any point between Jan. 1 and Oct. 2.
Data Submission -- Physicians participating in the MIPS pathway must submit quality, advancing care and clinical practice improvement activity data to CMS by March 31, 2018. Physicians participating in an Advanced APM also must submit data by March 31, 2018. If you do not submit 2017 data by the March 31, 2018 deadline, you will receive a negative 4 percent payment adjustment in 2019.
Report as an individual -- If you submit MIPS data as an individual, your payment adjustment will be based on your performance. An individual is defined as a single national provider identifier (NPI) tied to a single Tax Identification Number (TIN).
Report as a group -- If you submit MIPS data as a group, the group will get one payment adjustment based on the group's performance. A group is defined as a set of physicians and other clinicians, identified by their NPIs, sharing a common TIN.
Feedback -- Medicare will provide feedback to individual physicians and physician groups and notify you of your performance score and subsequent payment rate for 2019.
Payment -- Based on your performance in 2017, you will receive a neutral or positive payment update, up to 4 percent, in 2019. If you successfully participate in an Advanced APM, you will receive a 5 percent incentive payment in 2019.
MIPS Payment Adjustments
- 2019 = +/- 4 percent
- 2020 = +/- 5 percent
- 2021 = +/- 7 percent
- 2022 and beyond = +/- 9percent
Advanced Alternative Payment Model
- 2019 to 2024 = +5 percent
Performance Criteria & Weighting -- MIPS
Quality -- 60 percent of total score.
Report up to six quality measures, including an outcome measure, for a minimum of 90 days.
Clinical Practice Improvement Activities -- 15 percent of total score.
Attest that you completed up to four improvement activities for a minimum of 90 days. For solo and small group physicians, or if you practice in a rural or health professions shortage area, attest that you completed up to two activities for a minimum of 90 days. If you are a certified patient-centered medical home or an APM designated as a medical home model, you automatically receive full credit for this category.
Advancing Care Information -- 25 percent of total score.
Fulfill the five required functions which are: security risk analysis, e-prescribing, patient access, summary of care, request/accept summary of care. You may earn additional credit if you submit up to nine measures for a minimum of 90 days. Additionally, you can earn bonus credit for reporting public health and using clinical data registry reporting measures and/or use a certified EHR to complete clinical improvement activities in the performance category.
Cost -- 0 percent of total score.
This category is delayed until 2018 and will not impact payments in 2019. Compliance with the measure does not require data submission on the part of the physician. It is measured using claims data submissions.
Performance Criteria -Advanced APM
APM Model -- You must participate in a selected APM, which includes the following:
- Comprehensive Primary Care Plus (CPC+)
- Next Generation ACO
- Shared Savings Program Track 2 and Track 3.
Risk -- The APM must take on more than nominal risk or be a recognized medical home model as determined by the Center for Medicare and Medicaid Innovation (CMMI) a recognized Medicaid Medical Home Model.
Beneficiary Threshold -- Twenty-five percent of your Medicare Part B payments must be received through the Advanced APM or 20 percent of your Medicare patients are assigned to your Advanced APM.
Data Submission -- Advanced APMs are required to submit data on identified quality measures using a certified EHR.
Pick Your Pace Program
Test -- If you submit a minimum amount of 2017 data to Medicare, you can avoid a downward payment adjustment in 2019. Minimum amount of data can be as de minimis as one quality measure, one improvement activity, or only four advancing care information measures.
Partial Participation -- If you submit 90 days of 2017 data for all three categories (quality, advancing care information and clinical practice improvement activity) to Medicare, you may earn a neutral or small positive payment adjustment in 2019.
Full Participation -- If you submit a full year of 2017 data, in all categories, to Medicare, you may earn moderate positive payment updates in 2019.
Advanced APM -- If you receive 20 percent of Medicare payments or see 20 percent of your Medicare patients through an Advanced APM in 2017, then you earn a 5 percent incentive payment in 2019.
For additional information, check out the following resources:
- AAFP MACRA Ready resources
- AAFP advocacy on MACRA final rule
- AAFP News
- CMS assistance is available by email or by calling 1.866.288.8292.
- Finally, here is my MACRA presentation at the Family Medicine Experience.
Academy Offering Tools for Chronic Care Management
Most of you are aware that there is a large-scale and coordinated effort underway to change how care is provided and, just as importantly, how care is reimbursed. This effort was set in motion more than a decade ago through policy changes such as the establishment of the physician quality reporting initiative -- which is now known as the physician quality reporting system -- the push for electronic health records, and the failure of commercial disease management programs; among others.
The AAFP, through sound leadership, read the tea leaves appropriately and began to promote delivery and payment models that would place a greater emphasis on the critical role primary care plays in our health care system. Through the Future of Family Medicine project, the AAFP and six other national family medicine organizations promoted a vision for a health care system in which each patient would have an ongoing relationship with a primary care physician. In return, primary care physicians would provide care that was built on five Cs -- first contact, comprehensive, continuous, coordinated and connected. These fundamental elements of primary care were promoted by Barbara Starfield, M.D., but they also were the cornerstone of high-functioning health care systems around the world that exceeded the United States' performance on quality and costs.
To accomplish this goal, the AAFP began identifying, developing and promoting new delivery models, such as the patient centered medical home (PCMH), advanced functions such as electronic health records, and, most importantly, we began to promote the need for primary care physicians to be paid differently and better.
A key aspect of the AAFP's payment policy was the implementation of a blended payment model whereby family physicians would be paid for direct patient care, but also for those services that are provided outside of the traditional face-to-face office visit. This payment would ultimately become known as the care management fee.
Although the Patient Protection and Affordable Care Act contributed to the so-called value-over-volume movement, it was really two events that happened in the first quarter of 2015 that accelerated the pursuit of value-based payments. The first was an announcement by the Obama Administration that it would push to tie 30 percent of traditional fee-for-service Medicare payments to value-based payments by 2016 and 50 percent by 2018. The administration challenged commercial insurers and Medicaid programs to do the same. The second event was the enactment of the Medicare Access and CHIP Reauthorization Act (MACRA), which codified value-based payment designs and put in motion a concerted effort to move away from the traditional fee-for-service construct as a means of compensating physicians for the care they provide. A central part of the MACRA reforms was placing a greater emphasis on the coordination of care across the health care spectrum.
The ability to manage the care of individual patients and populations of patients, especially those with one or more chronic health condition, has been identified as one of the most promising aspects of advanced primary care delivery models such as medical homes. Furthermore, effective care management by family physicians has proven to improve the quality of care for patients and reduce the per capita cost of health care. This has been proven in both public and private health care systems, as noted in the Patient Centered Primary Care Collaborative’s annual evidence report.
About five years ago, the AAFP started studying the concept of care management. What was it? What should it be? How much does it cost to provide care management services? How much should family physicians be paid for care management? How should these payments be risk-adjusted?
We initially asked the Robert Graham Center to study care management programs and fees. Its report -- Blended Payment Models and Associated Care Management Fees -- identified some common care management functions across public and private health care systems and provided a solid foundation for our next project, a partnership with Discern Health which aimed to further examine care management and identify three key findings:
- What is care management?
- What are the benefits of care management?
- What is the value of care management to patients, physicians, and payers?
Discern Health recently provided the AAFP its findings in an issue brief titled Valuation of Care Management Performed by Primary Care Physicians. Here is what Discern Health found with respect to the three questions above:
- Numerous studies have identified reductions in total cost of care associated with patients who have received care management services organized by primary care physicians in a PCMH model. Research has found reductions, ranging from 4.4 percent to 11.2 percent for a particularly high-cost, frail, and elderly population.
- When people receive high-quality care from primary care physicians, particularly for chronic conditions, they are less likely to experience rapid declines in their health that require costly treatment in a hospital.
- A benefit of care management is an increase in the proportion of patients receiving high-quality, appropriate care.
- Care management demonstrated a benefit for patient and staff experience of care, and staff reported lower emotional exhaustion scores on the Maslach Burnout Inventory Scale.
A final finding about per member per month (PMPM) fees is key, so I have included the full paragraph. It reads: "Studies have shown primary care physicians who invest in care management are creating significant value for the health care system through higher quality care at a lower total cost. On the whole, care management payments do not fully compensate physicians for the value they create. One of the best studies of the reduction in total costs of care (a benefit to health insurers) created by effective care management in a commercial population found a $16.73 PPPM reduction. This is considerably more than what insurers are paying for care management, which is $4.90 PPPM."
The AAFP sees care management as an important function of advanced primary care practices, so the Academy has developed an extensive set of resources to help you implement care management in your practices. We have prioritized the resources into the following categories:
- care management;
- risk-stratified care management; and
- population health management.
In addition to these resources, the AAFP, as part of our collaboration with Discern Health, created a care management calculator (member log in required). This tool is designed to assess various factors that might influence care management costs and to provide an estimate of care management costs and savings based on: staffing hours, overhead, the chronic disease burden of the patient panel, the state where the practice is located, and revenue from care management billing or program funds. The calculator is Excel-based and organized in a stepwise process.
You can read more about the brief and the cost calculator in AAFP News.
Family Practice Management also has a number of good resources on care management, specifically the Medicare chronic care code.
AAFP Welcomes New Director of Government Relations
On Sept. 12, Robert Hall, J.D., will join the AAFP as director of government relations. Hall, who most recently worked for the American Academy of Pediatrics, brings more than 20 years of experience to the AAFP. He will oversee the AAFP's vast government relations, advocacy, and political operations. In addition, he will work closely with the AAFP's Commission on Governmental Advocacy and will advise senior management and the Board of Directors on legislative and regulatory matters.
CPC+ Holds Plenty of Potential for FPs
“Even after expenses, this will mean a six-figure boost in income for each of us and the delivery of care will be significantly better.”
This is a portion of an email we received from a family physician in Michigan who wanted to share the impact that the Comprehensive Primary Care Plus (CPC+) program would have on the writer's six-physician practice. This physician estimates that not only will the program allow everyone in the practice to better serve their patients, especially those with complex health conditions, but it will generate significant revenue for each of them, as well as for the practice.
The AAFP shares this excitement about CPC+, but we recognize that to realize the full potential of the program we need to ensure that a high number of family physicians apply and participate in it.
On Aug. 1, CMS announced the 14 states and regions that will participate in CPC+ and opened the application process. Interested and eligible physicians who practice in one of the selected states/regions may apply by Sept. 15.
CPC+ is a five-year primary care medical home program that will begin in 2017 and conclude in 2021. It is a multi-payer model, which means that Medicare, Medicaid and commercial insurance programs will all be participating in the selected states/regions. The multi-payer approach is essential to creating alignment across a practice. Fifty-seven payers have signed up to participate in the program.
CMS plans to select 5,000 practices for participation in the CPC+ program from the selected states and regions. The participating states are Arkansas, Colorado, Hawaii, Michigan, Montana, New Jersey, Ohio (including northern Kentucky), Oklahoma, Oregon, Rhode Island and Tennessee. In addition to the 11 states, three regions were selected: Kansas City metro (Kansas and Missouri), Philadelphia metro and New York Hudson Valley. Many of the selected states/regions also participated in the Comprehensive Primary Care Initiative (CPCI), which concludes at the end of this year.
The CPC+ program aims to build on the experiences gained from CPCI or, as it is now known, the CPC Classic program.
CPC+ will have two tracks. Track 1 aims to support practices in building key comprehensive primary care capabilities. Track 2 targets practices that have more experience delivering advanced primary care and aims to support delivery of enhanced care through IT, targeting patients with complex needs and helping to meet patients' psychosocial needs. Participating practices in both tracks must develop, implement and execute against five key primary care functions. Those five functions are:
- access and continuity;
- care management;
- comprehensiveness and coordination;
- patient and caregiver engagement; and
- planned care and population health.
In addition, participating practices must prove that they have support from multiple payers, use a certified electronic health record technology and report electronic clinical quality measures at the practice level. Practices participating in Track 2 must also demonstrate a commitment to using enhanced health IT functions in their practice and a commitment to caring for complex patients. Track 2 practices are required to have a letter of support from their IT vendor(s) when applying. All IT vendors for Track 2 practices will be required to enter into a memorandum of understanding with CMS.
Participating practices will receive prospective payments in three forms: comprehensive primary care payments, care management fees and performance-based incentive payments. Unlike other pay-for-performance programs, payments under the CPC+ Performance-based Incentive Payment (PBIP) system will be made to practices at the beginning -- not the conclusion -- of the performance year. Practices will be retroactively evaluated on their performance on patient experience, clinical quality and utilization. Practices that fail to meet quality and utilization thresholds must repay some of PBIP.
Track 1 practices will continue to receive Medicare fee-for-service (FFS) payments along with a prospective per-beneficiary-per-month care management fee. The practices also will receive prospective PBIP payments of $2.50 per beneficiary per month.
Track 2 practices will receive a blended payment made up of Medicare FFS and a prospective percentage of expected Medicare reimbursement for evaluation and management claims, along with a prospective per-beneficiary-per-month care management fee. The practices also will receive prospective PBIP payments of $4 per beneficiary per month.
Care Management Fee
Participating practices in both tracks will receive prospective monthly care management fees (CMF) on a per-beneficiary basis. The amount of the monthly payment will be based on the health care condition (HCC) of the beneficiary. CMS estimates that the average CMF will be $15 per beneficiary for Track 1 practices and $28 per beneficiary for Track 2 practices. Additionally, Track 2 practices will receive a CMF of $100 per beneficiary for their most complex patients. The CMF structure is as follows:
|Risk Tier||Attribution Criteria||Track 1||Track 2|
|Tier 1||First quartile HCC||$6||$9|
|Tier 2||Second quartile HCC||$8||$11|
|Tier 3||Third quartile HCC||$16||$19|
|Tier 4|| Fourth quartile HCC for Track 1
75% to 89% for Track 2
|Tier 5||Top 10% HCC||Not available||$100|
Family physicians who meet the eligibility criteria and practice in one of the selected 14 states/regions may apply to participate in the CPC+ program by Sept. 15. Practices applying to Track 2 will need to submit a letter of support from their health IT vendor(s) that outlines the vendors' commitment to supporting the practice with advanced health IT capabilities.
The AAFP has numerous resources that can assist you in evaluating your eligibility and completing the application process. We also have partnered with Caravan Health to provide assistance in the practice evaluation and application process. If you are interested in partnering with the AAFP and using the resources available from Caravan Health, please email firstname.lastname@example.org.
- CMS CPC+ Fact Sheet
- CMS CPC+ Practice Open Door Forum schedule
- CPC+ Application Checklist
- CPC+ Frequently Asked Questions
- CPC+ Request for Application
Making MACRA Manageable
On June 24, the AAFP submitted formal comments in response to the "Medicare Program: Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models" proposed rule, which was published by HHS on May 9.
The AAFP’s 107-page response lays out a vision and series of recommendations on how CMS can improve the regulation to better align with the Congressional intent of the Medicare Access and CHIP Reauthorization Act (MACRA) and establish a framework that will allow family physicians to deliver high quality, efficient health care to their patients -- regardless of practice size and location.
A majority of our key recommendations are included in an executive summary and outlined in an excellent AAFP News story.
I am not going to attempt to provide you a complete summary in this posting. Instead, I am going to focus on three areas of our comment letter. I will continue to write on MACRA during the summer and fall, and future posts will focus on other key areas of the proposed regulation.
The AAFP noted in our response that the proposed rule and the general framework for both the MIPS and APM program was complex. In fact, really complex. The AAFP is concerned that family physicians will be challenged to understand the various layers of eligibility standards, reporting requirements, thresholds, weighting, risk-adjustment and evaluation/scoring criteria created by this rule. In fact, we are concerned that anyone outside of CMS will be challenged to understand. The MACRA law was far simpler in construct, and we strongly encouraged CMS to pull the throttle back and make this regulation far less complex.
We also called on CMS to issue an interim final rule with a comment period versus a final rule so that the AAFP and others would have an additional opportunity to provide comments on the various provisions implementing MACRA.
A key passage in our letter says, "While our support for MACRA remains strong, we must state that we see a strong and definite need and opportunity for CMS to step back and reconsider the approach to this proposed rule which we view as overly complex and burdensome to our members and indeed for all physicians. Given the significant complexity of the rule, we strongly encourage CMS to issue an interim final rule with comment period rather than to issue a final rule."
MACRA requires that physicians participate in a "performance period" that will determine their payment rate for a future year. Under the proposed rule, CMS establishes the initial performance year as Jan. 1, 2017 to Dec. 31, 2017 and uses a two-year cycle, meaning that physicians' performance in 2017 would determine their payments in 2019. The AAFP is concerned that a Jan. 1, 2017 initiation of the performance period is ambitious both for physicians and CMS.
Furthermore, we strongly disagree with the two-year data cycle that CMS is proposing. We believe that physicians should receive data and performance reports closer to the time care was provided in order to learn and adjust. If CMS officials think that quality and performance data will inform and influence care delivery, then they should place a priority on ensuring that the delta between the performance and payment years is no longer than six months.
Another key passage in our letter says, "the AAFP urgently and strongly recommends that the initial performance period should start no sooner than July 1, 2017."
Solo and Small Practices
The AAFP reserved its most aggressive and constructive comments for those provisions impacting solo and small practices. We see and promote the tremendous value that solo and small practices bring to the health care system. The quality of care provided by small practices has been well documented in literature, and there is broad agreement that preserving this practice model is essential to the success of MACRA and our health care system more broadly.
The AAFP worked aggressively to ensure that MACRA included protections and opportunities for solo and small practices. Some of these were captured in the proposed rule, but many were not. Due to our dissatisfaction with how the proposed rule promoted and protected this practice model, we proposed that CMS create a "safe harbor" for solo and small group practices until such time that policies specifically aimed at helping these practices, such as "virtual groups," are implemented. The lack of virtual groups may result in a "methodology bias" between solo and small practices and larger practices -- something that is unacceptable.
A key passage in our letter says, "Given the fact that a provision, mandated by law, to ensure the viability of solo and small physician practices in the MIPS program will not be available for such physicians and their practices in the initial performance period, we are strongly urging CMS to include an interim pathway to virtual groups, as outlined below, in the final regulation. Physician practices with five or fewer physicians, billing under a single tax identification number who participate in the MIPS program through the submission of quality data, use of a CEHRT electronic medical record, and participation in clinical practice improvement activities should be exempt from any negative payment updates resulting from the MIPS program until such time that virtual groups -- as outlined and mandated by MACRA -- are readily available. These physician practices are, however, eligible for any positive payment updates that they may warrant based upon their performance in any given performance period."
As a frequent reader of other news sources and blogs, I am well aware that many physicians are throwing shade on MACRA and the reforms that it advances. Some have gone so far as to suggest that the SGR was better. I fundamentally disagree that the flawed sustainable growth rate and current penalty performance programs (PQRS, MU, VBM) were better. Under the SGR methodology, the best you could hope for was level funding from year-to-year. There was never a plausible chance to secure positive payment updates. Furthermore, the penalties associated with PQRS, meaningful use, and the value-based modifier -- all currently in place -- are greater than those associated with the MACRA MIPS pathway. Putting a finer point on this, under the previous payment formula the best you could do was prevent reductions in payment, you were never able to pursue increased payments. MACRA creates opportunities to actually increase payments, something that hasn't existed for physicians participating in the Medicare program for more than a decade.
However, I do recognize that MACRA is not easily understood and it has inherent risks for all physicians in all practice models. It is our job to ensure that you have the appropriate information and resources to be successful in your practice. I encourage you to do three things this week.
- Visit our MACRA Ready resource page. This page has numerous resources and tools that will help you better understand the new payment pathways and begin developing a strategy for your practice.
- Prepare for the CPC+ program by emailing email@example.com. We have a new partnership that will provide you direct assistance in preparing an application for participation in this important payment model should your state or region be selected. This service costs you nothing. It's a member benefit. Please use it.
- Connect with a Practice Transformation Network (PTN). The PTN's have resources and tools that are free to physicians, and we encourage you to take advantage of them. To find a PTN in your area, email firstname.lastname@example.org.
The AAFP is committed to ensuring that you are MACRA Ready and we are equally committed to ensuring that this law is implemented in a manner that reflects Congressional intent and allows each of you to provide quality care to your patients, regardless of where and how you practice.
AAFP Offering Resources, Support for Small Practices
"There is nothing wrong with staying small. You can do big things with a small team."
-- Jason Fried, software entrepreneur
For decades, medicine -- especially primary care -- was delivered by a cohort of independent physicians who dedicated themselves to their patients and their communities. These physicians delivered their services and compassion through a network of solo and small group practices that were largely isolated from each other and other physicians. There was connectivity to the local hospital because family physicians, not hospitalists, took care of their patients who were admitted. They also worked the emergency room, delivered a few babies along the way, performed school physicals, and made weekly trips to the nursing home. This scenario was the prototypical family medicine practice in countless communities across the nation, large and small.
I know this model well because I grew up with one of these family physicians, and I witnessed first-hand the relationship that he had with his patients and our rural Oklahoma community.
One thing that has long been a concern for the AAFP is ensuring that solo and small group practices are able to sustain their business model and continue providing care to their patients. Yes, many physicians have chosen to pursue other practice settings and financial arrangements. We support these practice choices fully in our education and advocacy activities, but we have added emphasis to the future of the solo and small group independent practice. We are not alone in this work, and several people have begun to invest thought and energy into the importance of maintaining diversity in physician practice types and arrangements. In a May 26 blog posting, David Blumenthal, M.D., and David Squires from the Commonwealth Fund posed an interesting question: "Do Small Practices Have a Future?"
This question has taken on renewed interest and importance as we approach the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) and became highly emotional thanks to the now infamous "Table 64," which CMS published as part of proposed MACRA regulations that inaccurately predicted that more than 80 percent of solo and small practices would take a penalty under the MACRA payment pathways. CMS published a follow up fact sheet explaining how solo and small practices can achieve success under the new payment programs.
The Commonwealth Fund article noted some interesting facts:
- Between 1983 and 2014 the percentage of physicians practicing alone fell from 41 percent to 17 percent.
- During the same time, the percentage of physicians in practices with 25 or more doctors grew from 5 percent to 20 percent.
- Younger doctors are 2.5 times less likely than older doctors to be in a solo practice.
It likely is no surprise to any of you that the solo, independent practice model has been in decline for several decades. There are multiple reasons (population shifts, economics, costs of education) why this shift has occurred, and I am quite confident that the comments associated with this article will provide some colorful clarity on this subject. However, before you throw in the proverbial towel, let me remind you of a few additional facts about the strengths of solo and small practices:
- Four of 10 physicians are in practices with fewer than five physicians. This is especially true in non-urban and rural communities. So, despite all the public commentary about the elimination of the solo and small group practice, they actually still exist and are an essential part of our health care delivery system.
- Solo and small practices often outperform larger practices in many evaluations. In fact, a recent Commonwealth Fund study found that patients of physicians practicing in solo and small practices have lower rates of preventable hospital readmissions. The Robert Graham Center recently published a study that found that "more comprehensive care among family physicians is associated with lower costs and fewer hospitalizations."
These studies and many others demonstrate that there are significant public policy justifications for why the preservation of solo and small practices should be a priority. Setting aside the simple fact that consolidation in health care escalates costs for patients and decreases payments for physicians professional services, the fundamental reason that community-based primary care should be preserved is that it actually benefits patients.
The AAFP is dedicated to ensuring that family physicians, regardless of practice type or location, have the tools and resources needed to be successful. We strive to ensure that each of you can find and maintain a practice that enables you to provide high quality care to your patients and allows you to realize your professional and personal goals. We recognize that many solo and small group practices feel that the current trends in health policy are moving away from them, or as some put it, destroying them. We understand why this anxiety exists and we prioritize the development and distribution of resources that can assist our members in these practice settings. The following is a sampling of the tools and services the AAFP has created for members:
- Solo and small practice resources;
- Independent solo and small group practice member interest group;
- Chronic care management toolkit;
- Family Practice Management's "Four Coding and Payment Opportunities You Might Be Missing."
In addition, the AAFP is working closely with CMS to prepare physicians for value-based payment models through two programs, the Transforming Clinical Practices Initiative (TCPI) and the recently announced Comprehensive Primary Care Plus program.
You can learn more about the practice transformation opportunities available through the TCPI program on our resource page. I also encourage you to join our TCPI member interest group.
The AAFP also is actively engaged in identifying and recruiting physicians to participate in the CPC+ program, which will be launched later this summer. While the exact regions are not yet known, we are seeking to identify family physicians who have an interest in participating in this program in advance of the enrollment period, which opens July 15. We are especially interested in identifying solo and small group practices so that we can begin assisting you prior to the open enrollment period. If you are interested in participating in the CPC+ program, please email us at CPCPLUS@aafp.org.
As noted in this posting, the AAFP continues to place an emphasis on solo and small group practices. We see these practice settings as contributory to the betterment of our health care system. However, we fully recognize that much has changed during the past 30 years. We feel it is important to hear directly from our members on how these changes in care delivery and physician payment may impact your practices.
If you practice in a solo or small independent practice and you are interested in learning more about MACRA and its opportunities for solo and small practices, we will be hosting a webinar on Thursday, June 16 at 7:30 pm Eastern. We will be posting registration information on the Solo and Small Group Member Interest Group listserve and directly emailing to our CPC Plus community. To ensure you receive the registration information, please email us at CPCPLUS@aafp.org or join the solo and small practice group member interest group.
Why You Should Apply for CPC+ Program
On April 11, CMS announced the establishment of the Comprehensive Primary Care Plus (CPC+) program. CPC+ is an advanced primary care medical home delivery and payment model that builds on the Comprehensive Primary Care Initiative (CPCi) program, which was launched in 2012 and concludes at the end of this year.
In its announcement, CMS referred to CPC+ as "largest-ever multi-payer initiative to improve primary care in America." The AAFP welcomed the announcement of the new program. Fundamentally restructuring how we pay for primary care is an important step towards our goal of reforming the health care system to one that is foundational in primary care. The underlying policies of the CPC+ program are consistent with the AAFP policies on primary care delivery system and payment reform.
The program, which is a regionally-based and multi-payer, will launch formally in January 2017 and run for five years. CMS plans to identify and enroll 5,000 practices -- up to 20,000 total participants -- practicing in 20 yet-to-be-identified regions to participate in the program. Up to 2,500 practices will be selected to participate in one of two tracks (5,000 total participants).
Additionally, and probably most importantly, the CPC+ has been identified as an advanced alternative payment model (Advanced APM) under the Medicare Access and CHIP Reauthorization Act, meaning that practices participating in the CPC+ program will be eligible to receive a 5 percent bonus payment on their Medicare allowable charges starting in 2019.
CPC+ is designed to reward primary care physicians for the comprehensive, coordinated, and continuous care they provide their patients. By incorporating a multi-payer approach, the CPC+ program promotes alignment in delivery and payment policies across all payers in a physician’s practice. This means that all patients cared for by that primary care physician practice will be participating in the program versus just a physician's Medicare patients.
Participating practices will be asked to transform their practices to focus on the five core principles of advanced primary care, also known as the Comprehensive Primary Care Functions, which were established as part of the original CPCi program. These five functions, when accompanied by the Joint Principles of the Patient-Centered Medical Home, are consistent with the AAFP’s definition of an advanced primary care practice. The five functions are:
- access and continuity;
- care management;
- comprehensiveness and coordination;
- patient and caregiver engagement; and
- planned care and population health
Clearly, practice transformation consistent with these five functions necessitates payment policies that support such activities. The CPC+ program adheres to the AAFP's long-standing policy that advanced primary care practices should receive advanced payments on a per capita basis for both care delivery and care management. In an April 11 JAMA article, Laura Sessums, J.D., M.D., director of the Division of Advanced Primary Care at the Center for Medicare and Medicaid Innovation, expressed similar sentiments.
"To support fundamental change in care delivery, practices require a fundamental change in payment structure," she wrote.
The CPC+ program is designed to accomplish this goal in three ways.
- Care management -- All practices participating in the program will receive, from Medicare, an advanced care management fee for each attributed beneficiary. They also will receive an advanced care management fee from participating private insurers. The care management fee for CPC+ Track 1 will be determined in four risk tiers, but it is expected to average $15 per beneficiary per month or $180 per year. Track 2 payments will be determined in five risk tiers, but are expected to average $27 per beneficiary per month or $324 per year.
- Performance-based incentive payments -- All practices participating in the program will receive an advanced, performance-based incentive payment for each attributed beneficiary. The per beneficiary incentive payment for practices participating in Track 1 will be $2.50 and $4 for those in Track 2. These payments are designed to both facilitate and reward performance on patient experience, clinical quality, and utilization measures. The payments will be made at the beginning of each year, but will be subject to recoupment if the practice fails to meet its thresholds for the quality and utilization performance.
- Payment reform -- Practices participating in Track 1 will continue to receive fee-for-service payments for services provided to Medicare beneficiaries. However, practices participating in Track 2 will receive a blended payment of a global payment for evaluation and management services and fee-for-service. The advanced E&M payment, referred to as the "comprehensive primary care payment," is designed to pay the practice for the costs of a typical office visit, thus creating flexibility in how the physician delivers care to their patients. More explicitly, the comprehensive primary care payment is designed to create parity in delivery modalities -- face-to-face, telemedicine, phone, etc.
The AAFP sees the CPC+ program as a positive step towards creating and implementing a payment model that aligns with the core functions of an advanced primary care practice. Yes, there are likely things that will need to be tweaked or improved, but we should not allow the perfect to become the enemy of the good. It is important that we have robust participation among family physicians in the CPC+ program -- especially those in solo and small practices. To this end, we are urging family physicians to pursue this opportunity. Enrollment for physicians opens July 15 and concludes Sept. 1.
Additional information and a complete timeline are available on our CPC+ resource page.
If you are interested in learning more about how you can participate in this program please send an email to CPCPLUS@aafp.org. We will follow up regarding how the AAFP can help prepare for your practice for the open enrollment period.
MACRA is Coming, the AAFP Has Resources to Help
A little more than a year ago, Congress approved the Medicare Access and CHIP Reauthorization Act (MACRA) by substantial bipartisan votes of 392-37 in the House and 92-8 in the Senate.
To put these votes in context, 91 percent of Congress voted to repeal the flawed sustainable growth rate (SGR) formula and put our nation’s health care system on a new trajectory. On April 16, 2015, President Obama enacted this historic legislation into law. With a single stroke of the pen, the entire construct of how physicians are paid for their services, changed.
During the past 11 months, the AAFP has been diligently reviewing and analyzing MACRA in an effort to better understand the law so that we can prepare and position you for success. In addition, we initiated programs aimed at educating family physicians about the changes that are coming with respect to delivery system and payment reforms.
We launched a resource center and published content designed to assist you in understanding the scope and implications of the law. My colleague Amy Mullins, M.D., wrote a great primer for Family Practice Management entitled "Making Sense of MACRA."
I addressed the two payment pathways established by MACRA -- the Merit Based Incentive Payment System (MIPS) and the Alternative Payment Models (APMS) in previous posts on this blog. These resources were appropriate and adequate for the early stages of our member education campaign, but we promised you we would do more for you, our members.
Last Friday, we took the first step towards fulfilling that promise by ramping up our efforts in a big, big way through the announcement of MACRA Ready, which is a multi-faceted, multi-year campaign aimed at preparing our members for the new delivery reforms and payment pathways created by the law. The campaign features educational content on how the law is structured and functions, timelines for implementation, and tools aimed at helping you and your practice understand and prepare for one of the two payment pathways.
The most common question I am asked these days goes like this, "What should I be doing to prepare myself and my practice for MACRA?" I encourage you to visit the AAFP’s MACRA resources page. Here you will find information, tools and resources that are designed to help you better understand the new law. I have selected a few resources that will provide a good starting point:
- MACRA overview video;
- frequently asked questions;
- implementation timeline;
- MACRA acronyms;
- practice readiness assessment;
- AAFP News resources; and
- Making Sense of MACRA infographic.
The AAFP has also produced a series of MACRA webinars. This four-part series provides you with:
- an overview of MACRA;
- an introduction to MIPS;
- an introduction to APMs; and
- information about your current payment track.
I encourage you to sign up to receive MACRA email updates from the AAFP. These periodic emails will provide you the latest details on the new payment law and access to the latest tools and resources from the AAFP.
During the past year, I have had the opportunity to discuss MACRA with thousands of family physicians across the country. It is fair to say that many are anxious about these changes and eager to learn what the new law will mean to them and their practice. This is completely understandable. I firmly believe that the SGR was one of the worst health care policies every enacted into law and that family physicians and our health care system are far better off since it has been sent to the garbage pile of failed policies. However, I do understand that the SGR and the traditional fee-for-service system were familiar and, no matter how bad they were, you knew and understood them.
I often refer to MACRA as a historic law. Besides the fact that it repealed a severely flawed payment formula, MACRA made a substantive and meaningful shift in the ideology of the Medicare physician payment formula by shifting the concept of payment from payment for episodes of care to payment for the longitudinal quality of care provided to patients. Most importantly, the new law took significant steps to place an expressed emphasis on the importance of primary care.
Although there has long been an academic and conceptual belief that a health care system built on a primary care foundation is beneficial to patients and payers, there had never been a policy manifestation of this ideology -- until now. This law, by design and intent, places a renewed emphasis on primary care delivery models and goes so far as to protect them from financial risk in the APM pathway.
This renewed approach to primary care was set in motion as part of MACRA, but it can only be achieved as a result of the regulations issued by CMS. Therefore, the approach taken by CMS to implement MACRA is key. On May 5, CMS Acting Administrator Andy Slavitt tweeted some information, and I think you will be pleasantly surprised by what he had to say:
- "Must start with a core belief that MDs know best how to take care of patients and allow freedom"
- "Must simplify the practice of medicine: reduce burden, add flexibility, and provide support at every turn"
- "Pay more to PC [primary care] for care coordination, for dialogue, for cost of care outcomes"
I respect that some of you will disagree that MACRA holds any opportunity or value, and I look forward to hearing your thoughts, concerns, and suggestions. I can promise you this, the AAFP will do everything we can to provide you information, resources and tools that will allow you to be successful under one of the two new payment pathways.
APMs: A Primer on the New Payment Model
Each of you is now familiar, or is hopefully growing more familiar, with the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA).
MACRA was enacted April 16, 2015, and repealed the Medicare sustainable growth rate. It also set in motion the creation and implementation of two payment pathways for physicians participating in the Medicare program. Last month I shared information and insights on the Merit-Based Incentive Payment System (MIPS). In this post, I am providing an overview of the MACRA Alternative Payment Model (APM).
The AAFP views the APM as the best opportunity for family physicians, primarily due to the fact that it promotes new delivery and payment models that migrate away from fee-for-service. Our primary goal for several years has been the establishment of payment policies that promote and finance comprehensive, continuous, and coordinated primary care. We believe that MACRA creates an environment whereby these models can be implemented, and we believe the APM pathway gives these models a place to grow and mature.
Starting in 2019, family physicians participating in a qualified alternative payment model who successfully meet the quality and performance criteria and exceed the established Medicare beneficiary thresholds will be eligible for a 5 percent bonus payment on their total allowed Medicare charges. Furthermore, qualifying physicians participating in a qualifying and eligible APM will be exempt from the MIPS program. APM qualifying physicians also will receive a higher Medicare physician fee schedule update (of 0.75 percent) starting in 2026.
There are three sets of criteria that must be met in order to secure the bonus payment in the APM pathway. Those three criteria are:
Qualifying Alternative Payment Model -- MACRA explicitly outlines which delivery and/or payment models will ultimately qualify as an APM. The law states that qualifying APMs must be established through one of four ways:
- Medicare Shared Savings Program;
- Centers for Medicare and Medicaid Innovation (CMMI) programs expanded by the HHS Secretary;
- Medicare Quality or Acute Care Episode Demonstration projects; and
- demonstrations required by federal law
Eligible Alternative Payment Model -- Any APM that meets one of the four qualifying criteria listed above must also meet the performance and quality thresholds established by the law. There are three performance thresholds:
- APMs must report quality and performance measures comparable to those contained in the MIPS program.
- APMs must use a certified EHR technology.
- APMs must incur nominal financial risk for monetary losses or be a medical home model expanded under CMMI authority.
Qualifying Alternative Payment Model Physician -- The final criterion in determining if an individual physician or a group of physicians qualified for the 5 percent bonus payment is that a qualified physician must demonstrate that the required percentage of his or her payments is received through a qualified and eligible APM.
For 2019 and 2020, qualifying physicians must demonstrate that, at minimum, 25 percent of their total Medicare payments are aligned with a qualifying and eligible APM. Starting in 2021, the minimum threshold increases to 50 percent, but the law allows physicians to use a combination of Medicare and non-Medicare payments, such as those from Medicaid and commercial insurers, to meet that threshold.
A few observations on APMs:
- APMs represent the better of the two pathways, in AAFP’s opinion, for family physicians to move away from the challenges of episodic fee-for-service practice models towards more comprehensive delivery and payment models that allow for and compensate you for comprehensive and coordinated patient care.
- The AAFP is aggressively advocating for the inclusion of an advanced primary care delivery model as a qualifying APM. We view the Comprehensive Primary Care (CPC) initiative as a model that can and should be expanded on a national scale.
- APMs are more inclusive than accountable care organizations (ACO) and do not “require” family physicians to sell their practice to a hospital or health system to qualify for the APM bonus payment.
- The medical home plays an important role in the APM pathway, since medial home APMs are exempt from the “nominal risk” eligibility criteria.
- Pursuit of the APM pathway is valuable even if you fall short of the eligibility and qualification criteria since APM participation is recognized as a Clinical Practice Improvement Activity (CPIA) under the MIPS pathway. This means that those that attempted to participate in an APM will receive favorable scoring for the CPIA performance category in the MIPS program.
- The MIPS program is designed to prepare physicians for participation in an APM. For this reason, making an effort to transition towards an APM sooner rather than later is encouraged.
The AAFP is committed to ensuring that you and your practice are ready to take advantage of new payment opportunities presented by MACRA. In the coming weeks we will be launching a comprehensive member education and communications effort designed to simplify the transition and provide the guidance you need to realize the benefits of value-based payment. Please watch for additional information at this blog or on aafp.org.
On March 8, CMS announced a proposed rule to test new models to improve how Medicare Part B pays for prescription drugs and the administration of those drugs by physicians. Although most prescription drugs are paid through Medicare Part D, there is a substantial number of drugs paid for under the Part B program. Primarily, Medicare Part B covers prescription drugs that are administered in a physician’s office or hospital outpatient department, such as cancer medications, injectables like antibiotics, or eye care treatments.
The proposal issued by CMS puts in place a value-based payment model for prescription drugs, but also alters the payment for the administration of such products in a manner that is favorable for family physicians. The proposed rule seeks to test six alternative approaches for Part B drugs. The AAFP issued a statement on the proposal and will be providing CMS with substantive comments on the proposal in the coming weeks. The full proposal is available on the Federal Register.
MIPS: A Primer on the New Payment Model
Most of you are well aware that Congress repealed the flawed sustainable growth rate (SGR) in 2015 through the enactment of the Medicare Access and CHIP Reauthorization Act (Public Law 114-10). However, many of you probably have asked the questions, "What now?" and "What does this mean for me and my practice?"
Although we should celebrate the elimination of the flawed SGR, the AAFP recognizes fully that the implementation of the new delivery and payment models outlined in MACRA will require a series of important decisions and actions by family physicians. To assist you and your practices, the AAFP is launching a concerted education effort aimed at providing information and resources on how this new law impacts you and your practice and how you can best position your practice for success under this new payment policy. We will be sharing information and resources on our MACRA resource web page.
MACRA established two distinct payment systems for physicians. Those two systems are the Merit-Based Incentive Payment System (MIPS) and the alternative payment model (APM) program. This post is focused on the MIPS system, but I will be writing about the APM in an upcoming post.
As noted in my previous post, the implementation of the new payment policies is set for 2019. However, the performance year that will determine your payments in 2019 will start as early as 2017. This means we have a lot of ground to cover in the next 12 months.
MIPS Performance Evaluation
The MIPS program, by design, is based on the fee-for-service model. However, the program deviates from current practices whereby all services are paid on the standard Medicare physician fee-schedule. The law incorporates and aligns the three current physician quality and performance improvement programs -- physician quality reporting system (PQRS), value-based modifier (VBM), and meaningful use (MU) -- into a single performance program. This new program will establish a single score on a per physician basis versus continuing the fragmented three-part performance evaluation and penalty programs that exists under current law.
The MIPS program creates a robust quality and performance improvement program that will evaluate and score physician performance in four distinct areas -- quality, resource utilization, meaningful use, and clinical practice improvement activities. Each of these activities is assigned a percentage of the total composite score as follows:
|Clinical Practice Improvement||15%||15%||15%|
A few observations on the valuation of the MIPS performance categories:
- The values for meaningful use and clinical practices improvement activities remain consistent while the value percentages for resource utilization increase during the three-year period.
- The law places an increasing emphasis on resource utilization over time. Note that the values for quality measurement decrease in proportion to the increases in the values for resource utilization.
- The law allows the HHS secretary to decrease the values for meaningful use and shift those values to other categories if it is determined that the proportion of physicians who are meaningful users of electronic health records is 75 percent or greater.
- Any physician who practices in a certified patient-centered medical home will receive the full 15 percent for the clinical practice improvement activity. The law does not define "certified" and the AAFP will be working to influence this definition as the law is implemented.
MIPS Payment Adjustments
The performance threshold is established annually based on the mean or median of the composite performance scores during the performance period. The law prohibits any type of look-back at existing programs as a means of establishing the initial performance threshold and instead defers this authority to the secretary of HHS for the first two performance years.
Once a physicians' composite score is determined, that score will be weighed against the performance threshold and a payment adjustment will be established for the next payment year. Physicians will receive positive, neutral, or negative payment adjustments up to the allowed percentages for the specific program year, which are outlined in the following chart:
|Maximum Positive Adjustment||+4%||+5%||+7%||+9%|
|Maximum Negative Adjustment||-4%||-5%||-7%||-9%|
A few observations on the MIPS payment adjustments:
- We anticipate that CMS will continue to use a two-year look back period to determine payments. This means that payments for 2019 will be based on performance in 2017. Payments in 2020 will be based on performance in 2018 and so on. The AAFP has serious concerns with the two-year look back period and will be advocating that this time frame be shortened significantly.
- MIPS adjustments are budget neutral, meaning that there will be equal numbers of positive and negative payment updates.
- Physicians scoring in the lowest quartile will automatically be adjusted down to the maximum penalty for the performance year. Physicians scoring at the threshold will receive no adjustment. Physicians scoring in the highest quartile are eligible for a potential positive payment adjustments up to the maximum outlined in the chart above. The highest performers will receive proportionally larger incentive payments, up to three times the maximum positive adjustment for the year.
- For years 2019-2024, the law establishes a $500 million bonus pool designed to provide additional incentives of up to 10 percent for "exceptional performers."
- Unfortunately, the law does not provide a definition of an "exceptional performer," so we will be working closely with CMS to establish this definition.
The law established three exemptions from participation in the MIPS program. Those exemptions are:
- The physician is participating in the Medicare program for the first time. Under this scenario, the physician is exempt from MIPS for the first year of Medicare participation.
- The physician is participating in an eligible alternative payment models and qualifies for incentive payments through that program.
- The physician does not see a large enough number of Medicare patients and falls below the established volume threshold for participation.
This is an initial introduction to the MIPS program. I understand that it will likely raise more questions than it answers, but that is a good thing. We need you to raise questions so we can develop materials and resources to assist you and your practice.
Maximizing MACRA for Family Medicine
"The pen is mightier than the sword." – English writer and politician Edward Bulwer-Lytton, 1839
In the past two weeks, the AAFP has submitted more than 60 pages of comments and recommendations on the delivery system and physician payment reforms outlined in the Medicare Access and CHIP Reauthorization Act (MACRA) (Public Law 114-10). Optimistic that the phrase made famous by Bulwer-Lytton 176 years ago still holds true, the Academy is exercising its "pen" to influence the implementation of MACRA in a manner that best benefits family physicians and their patients.
On Nov. 9, the AAFP responded to CMS’ request for information regarding the Merit-Based Incentive Payment System, Promotion of Alternative Payment Models, and Incentive Payments for Participation in Eligible Alternative Payment Models. The AAFP’s 53-page response responds directly to the 126 questions in the RFI.
On Nov. 19, the AAFP responded to the Alternative Payment Model Framework Draft White Paper published by the Health Care Payment Learning and Action Network (HCPLAN), a group assembled by CMS to assist with MACRA implementation .
MACRA was signed into law April 16, bringing to a close the 13-year drama that was the sustainable growth rate (SGR). Repealing the SGR was a significant accomplishment that created an environment whereby we can begin the transition away from episodic and fragmented delivery and payment models towards those that promote continuity, coordination and connectivity. MACRA represents the future -- albeit a somewhat confusing future.
The transition from legislation to regulation is one of the most important processes in government. It also is the arena where the AAFP must perform at the highest level on behalf of our members. We take the regulatory process very seriously. The emphasis we are placing on the implementation of MACRA is driven by our desire to realize the full potential of delivery and payment system reform and our understanding that MACRA refers decisions to the secretary of HHS more than 100 times.
The AAFP response to both documents advance the importance of increasing the overall investment in primary care and not building new delivery and payment models on the biased and inaccurate relative value data used in the fee-for-service system. Our letters strongly recommended that CMS and private payers do more to ensure that Medicare and all other public and private programs pay appropriately for primary care physician services. Appropriate, obviously, means more than current levels.
To achieve this goal, the AAFP urged CMS to use its authority and take administrative actions to increase the values of primary care services in the Medicare program. Additionally, the AAFP outlined a comprehensive payment proposal that would move a larger percentage of payments from the traditional fee-for-service model toward alternative payment models. With respect to primary care, the AAFP proposes that payments for primary care services under this advanced primary care delivery model be made on a per-patient basis through the combination of a global payment for direct patient care services and a global care management fee.
Our letters also raised concerns about several barriers that may prohibit successful participation in the new payment models. The most significant barrier is the poorly designed meaningful use program and its lack of interoperability standards, which prohibit the sharing of patient information. Family physicians continue to face significant challenges with their EHRs and meeting meaningful use standards. Until this program is improved and the EHR issues are resolved, it is difficult to foresee a large percentage of physicians -- particularly physicians in small and independent practices -- being successful in MACRA programs.
We continued our advocacy aimed at encouraging CMS to use the Joint Principles of the Patient-Centered Medical Home and the key functions of the Comprehensive Primary Care (CPC) initiative as criteria for determining what constitutes a medical home. The Joint Principles, when aligned with the five key functions of the CPC initiative, capture the true definition of a PCMH and its performance thresholds. The AAFP clearly states in multiple places that we do not believe a physician should be required to pay a third party to secure the PCMH recognition necessary to participate in a Medicare program.
Finally, we strongly urged CMS to streamline, harmonize and reduce the complexity of quality reporting in the MIPS and APM programs. Out letters outline a vision for quality improvement programs that promote continuous quality improvement and measure patient experiences. The AAFP expresses opposition to any approach that requires physicians to report on a complex set of measures that do not impact or influence the quality of care provided to patients. Instead, we suggest that all measures used must be clinically relevant, harmonized among all public and private payers and be submitted in a manner that is minimally burdensome on physicians.
Our letter offers recommendations on numerous additional topics, but the above information captures the major themes. Clearly, the implementation of MACRA will be a major undertaking, and the AAFP is committed to influencing this process in a manner that benefits family physicians and their patients. This undertaking will not be easy, but our team is capable and ready. I encourage you to follow our work on your behalf on our MACRA resource webpage.
I anticipate that many of you are prepared to utilize your "pen" to communicate your views on MACRA and the choices family physicians face in the next few years. I look forward to your comments, thoughts, and suggestions. More importantly, I look forward to learning from you and your experiences so that we can better serve you and your practice.
The IMS Institute for Healthcare Informatics has released a new report, Global Medicines Use in 2020: Outlook and Implications that project global spending on pharmaceutical products will increase 30 percent by 2020, resulting in a global spend of $1.3 trillion. The report notes that the spending will be driven by expensive new drugs, price hikes for existing drugs, increased use of generic drugs in developing countries and an aging population. IMS projects that, by 2020, annual use of medicine will hit 4.5 trillion doses, up 24 percent from this year. Additionally, the report projects that more than half of the world’s population -- currently 7.6 billion -- will be taking more than one medicine dose per day. Finally, IMS projects that roughly 90 percent of U.S. prescriptions dispensed in 2020 will be for generic products.
AAFP Advocacy Promotes Compassionate Care
On July 9, CMS released its proposed rule for the 2016 Medicare physician fee schedule. As part of this rule, CMS is proposing to pay physicians for advanced care planning services -- better known as end-of-life counseling -- through two codes.
“CMS proposes to establish separate payment and a payment rate for two advance care planning services provided to Medicare beneficiaries by physicians and other practitioners," the agency said in the proposed rule. "The Medicare statute currently provides coverage for advance care planning under the 'Welcome to Medicare' visit available to all Medicare beneficiaries, but they may not need these services when they first enroll. Establishing separate payment for advance care planning codes provides beneficiaries and practitioners greater opportunity and flexibility to utilize these planning sessions at the most appropriate time for patients and their families.”
Under the proposed rule, CMS is proposing to pay for CPT codes 99497 and 99498. These codes, if implemented, will provide compensation for complex advanced care planning, which involves one or more meeting(s), lasting 30 minutes or more, during which the patient’s values and preferences are discussed and documented, and used to guide decisions regarding future care for serious illnesses. These consultations are voluntary on the part of the patient, and the patient may choose to include family members or caregivers in the meeting.
The AAFP has long advocated for Medicare to pay for advanced care planning services, and we applaud CMS for including this policy in the proposed rule. It is long overdue, and we promptly communicated our support of this policy proposal in a press statement following the release of the proposed rule.
In 1789, Benjamin Franklin stated, “…in this world nothing can be said to be certain, except death and taxes.” The problem is we, as a country, are much more comfortable having a conversation about taxes, than death. Conversations about death are difficult. They are especially difficult at the time that the outcome is imminent. However, as Mr. Franklin stated, death is certain. Our collective reluctance to discuss death doesn’t prevent it from happening; it only makes needed conversations and decisions harder.
This issue has always been wrought with political undercurrents and challenges. In 2009, as part of the health care reform debate, our country was starting to have a serious conversation about the importance of patients, caregivers and physicians engaging in a meaningful conversation about death and, more importantly, how we as a society could begin to openly discuss those difficult decisions that each of us will ultimately face. Sadly, the political discourse of the day reduced these conversations to a ridiculous talking point comparing advanced care planning to “death panels.” Thankfully the mastermind of this dreaded talking point has seen her 15 minutes of fame expire.
The AAFP played a prominent role in this policy being included in the 2016 proposed rule. In the years following health care reform, the AAFP worked closely with other physician and patient organizations to promote advanced care planning policies in the legislative and regulatory environments. We worked closely with Rep. Earl Blumenauer, D-Ore., on his legislation, the Personalize Your Care Act and Sens. Mark Warner, D-Va., and Johnny Isakson, R-Ga., on their Care Planning Act. We also worked closely with the Pew Charitable Trust as part of its Improving End-of-Life Care Initiative to develop and promote advanced care policies.
In 2014, the Institute of Medicine issued a report, “Dying in America,” which cited payment for advanced care planning as one of its five recommendations. The report states that “payers and health care delivery organizations should adopt these standards and their supporting processes, and integrate them into assessments, care plans and the reporting of health care quality.” Building on the recommendations of the IOM, in May of this year, the AAFP joined more than 50 other organizations urging CMS to provide payment for advanced care planning services.
The importance of this policy is well understood. Demographics are rapidly changing, and our population is growing older. The aging of our population is to be celebrated, but it does present challenges. By 2050, the number of people who are 80 and older will triple, and the number of people in their 90s and 100s will quadruple. Roughly 6 percent of Medicare patients die each year, and they consume approximately 30 percent of Medicare resources. As noted earlier, death is certain.
My question is this: How do we want the health care system to treat us or our loved ones in our final days and hours of life? I would suggest that there is not a more appropriate place for this conversation to take place than a family medicine practice. You are the trusted advisers and the facilitators of communication on these difficult issues with patients and their caregivers, and it is time that Medicare paid you for these services.
AAFP policy states, “supporting a patient’s care decisions at the end of life is part of the family physician’s responsibility in his or her partnership with the patient. The American Academy of Family Physicians (AAFP) believes that each individual has the right to decide what medical treatment he or she will receive. This right includes decisions about what life-sustaining treatment should be provided at the end of his or her life.” If this proposed rule is finalized, we will have successfully aligned public policy with AAFP policy, and patient care will be improved.
American Family Physician has volumes of resources on this topic that are well situated to assist you with end-of-life issues.
Final Thoughts on the SGR; A Look Ahead at MACRA
A strange thing happened recently in Washington, the U.S. Congress passed meaningful and impactful legislation in an overwhelming, bipartisan manner -- and the President signed it into law!
On April 16, the President signed into law the Medicare Access and Children's Health Insurance Program Reauthorization Act of 2015 (MACRA) (Public Law 114-10), bringing to a close one of the more frustrating and disruptive health policies of modern times. After 13 years. and 17 short-term fixes at a cost of nearly $170 billion spent, we can now shout from the mountain tops that the SGR IS REPEALED!
A round of applause and a heartfelt thank you to those who engaged with us on this important victory. Although we in Washington like to believe that we can make things happen, we understand fully that it is constituents who drive change, and we thank you for all you have done.
The enactment of this legislation was made possible by historic votes in the House of Representatives and Senate. All told, 484 members of Congress -- or 91 percent -- voted for the bill. AAFP News has an excellent story on the legislative actions and the official AAFP reaction.
For the AAFP, the enactment of this law brings to a close a sustained advocacy campaign that has spanned more than a decade. I want to publicly congratulate AAFP Director of Government Relations Kevin Burke and his team on this great accomplishment and thank them for their relentless pursuit of this legislative objective. It is hard to articulate or quantify the work done by Mr. Burke and his team, but I assure you it was significant.
So the question that likely is on many of your minds is, "what does the law do, and how does it impact me?" Great question. I encourage you to visit the Academy's MACRA resources. This Web page will be your one stop for information on MACRA and the resources the AAFP has available to assist you in your pursuit to implement and comply with the provisions of the law. Start with the Frequently Asked Questions document that provides a top-line summary of the law.
The most important provisions of MACRA are those that extended coverage and access to care for our nation’s children, seniors, and disabled. Extending coverage and access to physician services for these populations was a priority for the AAFP, and we are pleased that they were included.
For our members who see Medicare patients, the most important provision is the one that repeals the flawed sustainable growth rate (SGR) effective immediately. The elimination of this failed payment formula should be celebrated. Family physicians no longer face a lingering threat of losing one-fourth of their income due to the actions, or inactions, of Congress. The SGR not only impacted Medicare payment rates, but also influenced payment rates for commercial insurers who typically pegged their payment rates to a percentage of Medicare. This direct association between Medicare and the commercial insurers meant that a cut initiated by the SGR would reverberate throughout a physician practice. The annual threat of substantial reductions in payments due the SGR was unsettling for physicians.
Starting on July 1, physicians participating in the Medicare program will receive a .5 percent increase in their payments. The .5 percentage increase will continue, annually, through 2019. All physicians participating in the Medicare program will receive these annual updates. Starting in 2019, physicians will have the option of pursuing their payments through an alternative payment model (APM) such as the patient-centered medical home or by staying in the fee-for-service system and participating in the Merit-Based Incentive Payment System (MIPS).
I appreciate that there is anxiety with the transition to APMs and the MIPS program, but remember that this transition does not happen for five years. Furthermore, the law provides resources -- $100 million -- aimed at assisting small and solo practices in the transformation process, ensuring that these important care settings have resources to succeed under the new payment models. This $100 million will be leverage alongside the more than $800 million available in the Transitioning Clinical Practice Initiative (TCPI) launched by the administration last fall. All told, almost $1 billion will be invested in assisting physicians, especially those in solo and small practices, succeed in alternative payment and delivery models.
We also are pleased that starting in 2019 the meaningful use, Physician Quality Reporting System (PQRS), and value-based modifier programs will be consolidated into a single program under the MIPS. This will result in harmonized quality measures and a reduction in the administrative burden of quality improvement programs for those participating in Medicare. The AAFP has long been concerned about the complexity of CMS's programs and the administrative burden they placed on small family medicine practices. This burden often prevents small practices from maximizing opportunities in incentive programs.
This law includes three provisions aimed at assisting solo and small practices remain independent, but also maximizing their ability to achieve full potential in alternative delivery and payment models. Those provisions will allow unaffiliated physicians to be evaluated in the MIPS as a virtual group, helping them lessen the burden of program’s requirements without sacrificing their independence; the Independent Risk Manager model, that would allow independent physicians to share risk without having to affiliate with a large system or accountable care organizations; and provisions that specifically look at ways in which fraud and abuse laws like the Anti-Kickback Statute may unintentionally be making it difficult for physicians -- particularly independent physicians -- to share risk in value-based models.
I know that change is both disruptive and daunting, but I contend that the provisions of this law are both good for family medicine and good for our health care system. The SGR was a truly horrible payment methodology that disrupted practices and perpetuated poor policy-making in Washington. Good riddance to this horrible payment formula, and may we never speak its name again!
March Madness Goes Into Overtime
Last week, in an overwhelming display of bipartisanship, the House of Representatives approved the Medicare Access and CHIP Reauthorization Act (H.R. 2) by a vote of 392-37. After 12 years of temporary patches, the House stated that the failed sustainable growth rate (SGR) formula should be eliminated from the Medicare program.
The AAFP issued a statement that praised the House for its overwhelming support of H.R. 2 and called on the Senate to follow the House’s lead and pass the legislation prior to adjourning for the annual spring recess.
Upon House approval, the AAFP swiftly informed members through an AAFP News article and direct emails to our state chapters and members regarding the House vote and called for aggressive advocacy targeted at the Senate. AAFP members and our state chapters answered the bell and made several phone calls to key Senate offices urging immediate action. AAFP President Robert Wergin, M.D., was in Washington when the House voted on March 26 and personally called several Senators during the course of the day, urging them to pass H.R. 2 prior to adjourning.
Unfortunately, the Senate didn’t share the House's sense of urgency and failed to consider the legislation prior to adjourning. The Senate is scheduled to return April 13. In a positive sign, Senate Majority Leader Mitch McConnell, R-Ky., said before the Senate adjourned on March 27, “It is encouraging this [H.R. 2] passed the House with such a large bipartisan majority, and I want to assure we’ll move to it very quickly when we get back. … I think there is every reason to believe it’s going to pass the Senate by a very large majority.”
In a statement the Academy expressed its disappointment that the Senate failed to follow the House’s lead and protect Medicare patients and children’s access to care prior to adjourning. We called on senators to promptly approve H.R. 2 upon their return, thus preventing disruptions in care for millions of Medicare beneficiaries.
The Senate’s failure to act on HR 2 prior to adjourning means that the 21 percent cut scheduled for April 1 will take effect. As a result, all services provided by Medicare participating physicians on or after Wednesday, April 1 – continuing until the Senate passes HR 2 and the law is enacted into law by the President – will be subject to the 21 percent cut. CMS has instructed its carriers to “hold,” for 10 business days, any claims for services provided on April 1 and beyond, until legislation can be passed and signed into law that reverses the 21 percent cut. The 10-day hold means that April claims will be held through Tuesday, April 14. Under current law, no claims can be paid sooner than 14 calendar days from their receipt, so this hold will have a minimal impact on Medicare remittance in the short-term.
However, the claims hold period does complicate billing for co-payments and claims reconciliation. Family Practice Management has created a resource, “Preparing for a Medicare Fee Cut,” that is designed to help you and your practice prepare for any reductions in revenue that may occur as a result of the cut.
Since it is spring, I am going to offer a golf analogy. It is often stated that the Masters is “won or lost on the back nine on Sunday afternoon.” Well, my friends, it’s Sunday, and we are on the back nine of the SGR issue. The only remaining question is whether we win or lose. I want to win, and I believe you do as well. The AAFP has engaged you on this issue multiple times during the past two months, and you have responded. The advocacy engagement of our members is one of the reasons 392 members of the House voted to repeal the SGR. We thank you for all of your great work, but we need more.
Between today and April 13 you need to communicate your strong support for the House-passed Medicare Access and CHIP Reauthorization Act (HR 2) to your senators. Please visit our Speak Out page, and send a letter to your Senators. After you send a letter, call your Senators. The AAFP has a toll-free phone system that allows you to do this conveniently. Simply call (866) 629-5269, provide your state, and you will be connected to your senate offices. Once connected, simply tell them you are a family physician practicing in their state, and you urge them to vote yes on HR 2 when it is considered by the Senate. That’s it – simple. Call them every day. Tell your colleagues to call. Tell your patients to call.
The AAFP has worked tirelessly on this issue for more than a decade, and with your continued help, we can finally repeal the flawed SGR formula. Victory is in sight, but we must stay focused and engaged for these final days.
SGR Deadline Looms; ACA Faces SCOTUS Challenge
In my previous In the Trenches post, I implored (some might say begged) you to write a letter to your members of Congress urging the full repeal of the flawed sustainable growth rate formula. I want to thank those of you who took the time to communicate with your elected officials. For those who haven’t yet sent a communication, I continue to urge you to do so.
A full repeal and replace bill is expected to be considered any day now, and your elected officials need to hear from family physicians who support this legislative proposal. This is not a test, this is real. And we need your help.
I urge you to watch this passionate communication from AAFP President Robert Wergin, M.D., and then Speak Out.
ACA Turns 5. Will It Turn 6?
On March 23, the Patient Protection and Affordable Care Act (ACA) will celebrate its fifth anniversary. This date is a cause for celebration for many in our country and a reminder of one of the darker days in our nation’s legislative history for others.
Regardless of political affiliation, there was a strong bipartisan consensus in early 2000s that our health care system was broken, wasteful and a drag on individual and business economic growth. It is often difficult to recall the context in which policy decisions were made, especially in a society that consumes and disregards information at such an alarming rate. This is why I think it is important that we look back at the decade prior to the enactment of the ACA to remind ourselves of the challenges we faced as individuals and as a country.
In 2001, 39.8 million people, or 14.1 percent of the population, were uninsured. By 2006, the number of uninsured had increased to 47 million or 15.8 population of the population. In 2010, the year the ACA was enacted, there were 49.9 million people uninsured or 16.3 percent of the population. Ponder those numbers for a moment.
According to the Kaiser Family Foundation, in 2000, a family of four paid an average of $6,438 for its health insurance. By 2010, this same family paid more than $13,000 for the same policy. Insurance costs for individuals also increased dramatically going from an average of $2,471 in 2010 to more than $5,000 in 2010. Between 2000 and 2010, health insurance costs increased 159 percent, and wages increased 42 percent. As a result, the number of uninsured and underinsured exploded.
By 2008, both presidential candidates and a large swath of the U.S. Congress were calling for comprehensive health reforms. In 2010, Congress delivered a bill to President Obama, and he signed it – with cheers of jubilation from most corners of society (and over loud cries of opposition from others). In 2011, the law survived a Supreme Court challenge and implementation began. It didn’t go so well, but it began.
So where are we today? In the latest open enrollment period, 11.4 million people enrolled in an insurance product sold through a state or federal Health Insurance Marketplace. Medicaid expansion, in those states where it has been implemented, has expanded health care coverage to more than 7 million people.
Although it would seem that a fifth anniversary would signal stability, the ACA is far from stable. On March 4, the Supreme Court heard oral arguments in King versus Burwell, which seeks to establish that the tax subsidies created by the ACA and aimed at assisting low-income individuals in the purchase of health insurance, are not applicable to individuals purchasing an insurance policy in the federal Health Insurance Marketplace. The plaintiffs in the case argue that the law only allows such tax subsidies for individuals who purchase a health insurance policy through a state-established Health Insurance Marketplace.
The immediate and real-world implication of a ruling in favor of King is that 13.4 million people would become uninsured immediately. Now, there are pathways for those individuals to retain their health coverage, but those pathways require action by Congress, but I wouldn’t look for white horses to come galloping to the rescue. It also would send the insurance market in many, if not all, state into chaos. Neither of these events is good for our health care system.
The AAFP has advocated for universal health care coverage since 1989 when the Congress of Delegates approved a resolution entitled “Health Care for All: A Framework for Moving to a Primary Care-Based Health Care System in the United States.” With few modifications, this policy has stood the test of time. At the core of this policy is the following statement, “Ensuring that all people in the United States have health care coverage is essential to moving toward a healthier and more productive society.” This policy is central to the AAFP’s advocacy efforts and, in my opinion, to family medicine.
Each of you understands the importance of health care coverage because you see it every day in your practices. Of course, people with health insurance sometimes still face challenges accessing health care services because insurance companies aren’t always the most helpful partners. But despite some administrative burdens, individuals with health care coverage have better opportunities to be healthy than the uninsured.
Decades of research shows that there are two leading drivers of a quality health care system: health care coverage and a continuous relationship with a physician, most often a primary care physician. These two indicators, when combined, have demonstrated the ability to improve the health of individuals and do so in an economically efficient manner. Regardless of your political stripes, 13.4 million uninsured is an undesirable outcome.
SGR: Time to say goodbye to a familiar foe
In politics, as in many things in business and life, the hardest tasks often are those that come at the end. This is where we find ourselves on a familiar and extremely frustrating issue -- the Medicare sustainable growth rate (SGR).
In less than 30 days, Medicare will implement the largest and most damaging payment cut in its history as a result of the flawed and failed SGR formula -- unless Congress intervenes. Should Congress fail to act and this draconian cut is realized, many of you will face trying questions about your future participation in the Medicare program, and Medicare beneficiaries across the nation could face challenges in securing access to care.
The AAFP is focused on preventing both of these scenarios. In fact, we are committed to ensuring you and your Medicare patients never have to face this dilemma again. Last week the AAFP Board of Directors was in Washington advocating on your behalf. Now, we need your help. We need you to raise your voice and advocate for your patients, yourself and your colleagues. I will tell you how later in this post. For those that can’t wait, please go to Speak Out, and send a letter to your representative and senator today!
During the 113th Congress, a bipartisan group of representatives and senators introduced the SGR Repeal and Medicare Provider Payment Modernization Act of 2014. This legislation was supported by the AAFP and endorsed by an overwhelming majority of physician and health care organizations. Additionally, it secured the support of the two House committees and one Senate committee with jurisdiction over the Medicare program.
The support for this SGR repeal legislation was bipartisan and solid. Sadly, negotiations on how to finance the legislation prevented its consideration by the full House and Senate, and -- for the 17th time in 12 years -- Congress enacted a safe, comfortable and cowardly short-term patch.
The AAFP continues to strongly support this proposal. On March 2, we wrote to House and Senate leaders urging the immediate enactment of this policy.
There are plenty of provisions in this proposal that will cause some to gnash their teeth, but on the whole, this proposal is a significant step in the right direction and is good for family medicine. The proposal not only repeals the flawed and failed SGR formula, it also puts in place a path for the implementation of new delivery and payment models that transition our health care system from an episodic and volume-driven model to a longitudinal and quality-driven model. Additionally, it provides family physicians practicing in advanced practice models enhanced payments and a simplified administrative burden.
We applaud the work that led to this policy and work that is ongoing to pursue its enactment into law. The 17 short-term fixes Congress has enacted have cost the nation more than $169 billion. We urge Congress to move beyond the short-term, stop-gap measures that have become the accepted course of action on this issue.
The Medicare program relies on access to a robust primary care physician workforce, yet payment and regulatory policies make it difficult for each of you to provide care to your patients. Since the establishment of the SGR, physician payments have fallen greater than 20 percent below medical inflation. These stagnant payments have come during the same period that Congress piled more than 20 rules, regulations and new programs on you. Today, each of you are asked to comply with a complex web of regulations that prevent you from focusing on patient care and push you to a level of frustration that elicits some non-printable comments.
Family physicians are not only providers of essential health care services; they also are small businesses that create well-paying jobs and contribute to the economic viability of communities small and large. Family physicians are economic engines for your communities. On average, each of you employ five full-time employees and directly produce nearly $1 million in economic activity. Collectively, family physicians nationwide employ more than 350,000 people and generate more than $46 billion in economic activity. It is improbable to believe that any small business can endure a 21 percent reduction in its revenue and an explosion in mandatory compliance to regulations.
Your frustration with this issue is understandable and I don’t blame you for being annoyed that I am asking you to once again take action in support of repealing the SGR. However, I am asking for you to take action, and I am asking you to channel those 12 years of frustration at your elected officials. I am asking you to SPEAK OUT on behalf of your patients. I am asking you to SPEAK OUT on behalf of yourself and your practice. I am asking you to SPEAK OUT on behalf of your colleagues. Finally, if it helps, I am asking you to SPEAK OUT simply as a means of venting your frustration. I don’t care which of these factors motivates you to write a letter, but I urge you to do so.
Meaningful Use and PQRS Extensions
On Feb. 25, CMS and the Office of the National Coordinator (ONC) announced an extension in the reporting and attestation periods for eligible professionals participating in the EHR Meaningful Use and PQRS programs. Practices now have until March 20 to complete their attestations and reporting. The AAFP worked closely with CMS and ONC on this extension and is pleased that they made a decision to extend the reporting periods. We were concerned that widespread winter weather events would prohibit many family physicians from meeting the deadlines.
About the Author