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Tuesday Sep 27, 2016

AAFP Advocacy on MACRA Implementation Paying Off

During the past year I have had the opportunity and privilege to listen to, and interact with, family physicians across the country -- including hundreds at the recent AAFP Congress of Delegates and Family Medicine Experience (FMX) meetings -- about the Medicare Access and CHIP Reauthorization Act (MACRA) and how it will impact their practices.

The responses from family physicians are (not surprisingly) mixed. Everyone I talked with was pleased that the sustainable growth rate (SGR) was repealed and the threat of substantial annual payment cuts were eliminated. Everyone was equally pleased with the emphasis and focus being placed on primary care as foundational to our national health care goals. Some see MACRA and the transition to value-based payments as an opportunity that will benefit primary care and patient care. Some, however, see the transition away from fee-for-service as a threat to their business model and their professional viability.

The majority sit between these two positions -- optimistic about the renewed emphasis on primary care focused delivery and payment models that support first contact, continuous, comprehensive and coordinated primary care. Scared about how it will work, what it really means for them, and how soon it will impact their practice. Regardless of whether you are optimistic, scared, or somewhere in between, the AAFP is committed to meeting you where you are and assisting you in your journey.

During my journeys and through my conversations with family physicians I have determined that there are three primary concerns:

  • The new law is complex in design and hard to understand.
  • Family physicians need flexibility in the early years to determine which of the two payment pathways is best for them and their practices.
  • Family physicians, especially those in small practices, should be exempted from financial penalties that may result from their participation in MACRA, especially those penalties that are caused by methodologies that may be biased against them due to their small patient populations.

Earlier this year, the AAFP submitted a 107-page response to the proposed regulation implementing MACRA. I would encourage you to read the executive summary, which is much shorter and includes all the best information from the larger document.

In our letter, we accurately captured and articulated the three concerns mentioned above. Our letter raised significant concerns about the complexity of the proposed regulation, and we called on CMS to re-evaluate its approach to implementing the law. We also called on CMS to implement the law in stages so that all physicians, regardless of practice size and location, could have a positive experience with the new law in the initial years. We also urged CMS to identify a process whereby physicians could participate in the new quality payment program (QPP) in a manner that challenges their current capabilities but is within the realm of achievable for all family physicians in all practice settings. We requested that CMS identify and implement a primary care advanced alternative payment model for all primary care physicians, not just those fortunate enough to be in the CPC+ program. Finally, we suggested CMS create an opportunity for solo and small group family physicians to participate but be protected from financial penalties. 

We have continued to press CMS on these items since submitting our letter and, I am pleased to report, CMS has been listening. On Sept. 8, the agency announced its intentions to provide physicians flexibility in the initial performance year of MACRA through a blog posting by CMS Acting Administrator Andy Slavitt. In the post, CMS announced the "Pick Your Pace" program that would provide greater flexibility for physicians in the first performance year of MACRA, which is 2017.

I have been telling you how engaged the AAFP has been during the past 18 months on MACRA implementation and how we continue to pursue regulations that ensure that the law is implemented in a manner that is in the best interest of our members. Obviously, we have not and will not achieve every goal, but the Pick Your Pace announcement is a big one. The CMS announcement reflects the AAFP's recommendations, and we are pleased that CMS listened and acted based on our recommendations

The Pick Your Pace approach provides four options for physicians:

  • Option 1 -- Test the Quality Payment Program. If you submit some data to the Quality Payment Program, including data for services provided after Jan. 1, 2017, you will avoid a negative payment adjustment in 2019.
  • Option 2 -- Participate for part of the calendar year. You may choose to submit Quality Payment Program information for a reduced number of days. This means your first performance period could begin later than Jan. 1, 2017, and your practice could still qualify, potentially, for a small positive payment adjustment. Like option 1, if you submit data, you avoid penalties in 2019.
  • Option 3 -- Participate for the full calendar year. For practices that are ready to participate Jan. 1, 2017, you may choose to submit Quality Payment Program information for a full calendar year. This means your first performance period would begin on Jan. 1. Practices selecting this option would be eligible for full positive payment updates in 2019, but they also could face potential penalties depending upon performance.
  • Option 4 -- Participate in an advanced alternative payment model (APM). Instead of reporting quality data and other information through the Merit-Based Incentive Payment System (MIPS), the law allows physicians to participate in the Quality Payment Program by joining an Advanced Alternative Payment Model (APM), such as the CPC+ program. If your practice receives enough of your Medicare payments or see enough of your Medicare patients through the Advanced Alternative Payment Model in 2017, then you would qualify for a 5 percent incentive payment in 2019.

The changes included in the Pick Your Pace program do not address all of our concerns, but they do create an opportunity for all physicians, regardless of practice size and location, to engage with the QPP program and avoid payment penalties in 2019. The AAFP continues to add resources and tools to our MACRA Ready campaign that can assist you in your journey towards the value-based delivery and payment programs. 

Wonk Hard

Last week, the AAFP Congress of Delegates met in Orlando, Fla. The COD considered, debated, and approved numerous policies that will guide the policy and advocacy work of the AAFP. The hottest debate of the week focused on reducing the administrative burden facing family physicians, largely due to electronic medical records and prior authorization requirements. Delegates also had serious conversations about the escalating costs of prescription drugs, single-payer health systems and maintenance of certification.  You can review the COD’s actions and read the resolutions debated at the AAFP Congress of Delegates site.

Looking for a little more information on the COD meeting? AAFP News is your best source of summaries and analysis of the work done by the COD.


How about really advocating for us and saying "No way," to CMS and so-called value-based reimbursement models (whatever that means, anyway). We spend four years of med school and multiple years of residency learning to provide high quality care. If the government wants data so badly, they could mandate that EHR companies produce smart technologies that automatically collect the data for us.
We know that we will go down this road for several decades before everyone comes to the same conclusion that it is just more busy work and doesn't keep patients healthier. FP's are not the source of high costs in medicine.

Posted by Alex Tien on September 27, 2016 at 11:23 AM CDT #

The recent FM meetings and media coverages always place FM in a good light as opposing discrimination. Unfortunately AAFP, Leaders, and Delegates fail to fight the discrimination against FM docs and against our patients and communities. Anyone listening to family physicians across the nation would realize the challenges facing most family physicians and their patients - because of discriminatory payment designs. We need to end Discrimination by Design in health care payments, education payments, and other areas to resolve disparities. MACRA is the Sixth of Six Degrees of Discrimination in my latest Basic Health Access blog. MACRA may be the most discriminatory of all. It was implemented despite the lack of evidence basis, despite exceeding the will of Congress and the specifications of the consultant (RAND), despite known discrimination, and despite CMS published data regarding greater punishment of small practices. True reform boosts the payments for federal patients to provide sufficient workforce instead of forcing other patients, communities, and other plans to supplement local care by design. True reform balances cognitive vs procedural payments and shifts more dollars where disparities in access, care, and outcomes are most obvious. True reforms must bust up cherry picking, not reward it. Innovation Discrimination (MACRA, Readmission Penalties) - True Reforms must not divert spending away from places and populations with the most disparities resulting in more disparities by payment distribution impacts. We have come to the end of the Era of Medical Error focus. The grandiose claims continue despite the lack of evidence in the reality facing Americans. Large scale studies join many others as indicating huge costs for no change in quality - the opposite of value. Robert Wood Johnson Foundation invested 300 million dollars to improve quality via Aligning Forces for Quality and admitted failure after 10 years of efforts. Just about every publication on quality and pay for performance and Primary Care Medical Home indicates that quality measures are greater where patients are more advantaged and lesser where patients are less advantaged. Over a dozen studies document the discrimination of Pay for Performance based payments. We need investments in team members to deliver the care, not distractions and diversions of funding away from team member support. AAFP needs to lead the charge against discrimination by design and against payment designs that lack and evidence basis other than causing discrimination.

Posted by Robert C. Bowman, M.D. on September 27, 2016 at 12:07 PM CDT #

I must ask the author how MACRA and specifically the MIPS benefits or promotes primary care? The American Geriatrics Society reports that CMS estimates that it will shift even more money from primary care physicians to the specialists. To call a shift in money to specialists 'refocus on primary care' is at best puzzling. http://www.americangeriatrics.org/files/documents/MACRA_Comments.pdf
" However, we note that CMS’s assessment of the MIPS proposals
indicates wide variations by specialty in the percentage of clinicians expected to receive positive
adjustments under MIPS and the difference in the dollar amount of the negative and positive
adjustments. For example, just over half of all geriatrics specialists (51.6 percent) are expected to
receive a positive adjustment and the dollar value of the negative and positive adjustments for geriatrics
is roughly equal ($7 million). In contrast, 62 percent of cardiologists are expected to receive positive
adjustments and those positive adjustments are expected to total considerably more than the expected
negative adjustments ($127 million in positive adjustments for cardiologists compared to $35 million in
negative adjustments)."

Posted by David Zetterman on September 27, 2016 at 03:34 PM CDT #

After years of being part of a practice that was a PCMH and then also part of an ACO, I opened my own Direct Primary Care (DPC) practice in January of this year. I have never been so happy and grateful to be a family doctor. Now I spend my time caring for patients by providing high-quality, evidence-based, personalized care, not by checking boxes on a computer screen. I would love to see the AAFP include a mention of DPC as an alternative for family docs in clinics that are facing a future of MACRA. MACRA, in my opinion, will further undermine and devalue the physician-patient relationship and the profession of family medicine. I encourage any physicians potentially interested in DPC to join the AAFP Direct Primary Care Member Interest Group.

Posted by Maura McLaughlin on September 27, 2016 at 03:41 PM CDT #

I also have changed my practice to a modified DPC. I take one insurance: Medicare since I didn't think a DPC model was fair to my Medicare patients.
I have been a solo practitioner. I have been in practice for 30 yrs.
I also participated in the Pennsylvania initiative for chronic care/ medical home from 2008-2013. I understand the frustrations of the previous physician. I know that the quality of care I deliver far exceeds the "quality measures" that medical homes and the insurance companies wrongly believe improves quality care.
It is criminal that insurance companies and Medicare are able to "take" our hard earned money for the excellent services that only we know how to provide.
One of the biggest impediments to quality care is the waste of time required by insurance companies and Medicare to prove that the physician is providing
" quality Care " as determined by bureaucrats ! They are systematically turning physicians into clerks and pressuring physicians to become automatons instead of professionals. I am particularly angry with the AAFP for kowtowing to the whims of
the insurance companies and government. Maybe its time to change these people who seem to be ineffective. Maybe its time to unionize. Where is the fight for the small practices ?

Posted by Daniel Orr on September 28, 2016 at 09:37 AM CDT #

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About the Author

Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.