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Tuesday Jul 05, 2016

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."

Performance Period
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 cpcplus@aafp.org. 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 tcpi@aafp.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.



Posted by MYRON ELLER on July 05, 2016 at 11:36 AM CDT #

I think that these complex proposals are going to drive us solo physicians out of business. I cannot hire someone to complete all the required reporting. Outside services are too expensive. "Virtual" groups are often just other geographically related practices. These practices can have horrible metrics and minimal interest in participating in the improvement, yet I can get clustered with them and penalized for their poor metrics. Since they are different practices, I have no influence over their day to day practice. This is not really helpful for me. Just let me practice medicine without all the interference. The other options, such as concierge or dropping Medicare altogether, are looking better every day.

Posted by Jennifer Hollywood on July 05, 2016 at 11:45 AM CDT #

I quit . . .

Posted by Mindy Miller on July 05, 2016 at 12:01 PM CDT #

We are a 2 man solo practice with 80+% Medicare. We have no PA's or NP's and see a reasonable # of patients a day. We do not have, nor do we plan to get an EHR. When and if this goes into effect, we will withdraw from Medicare and go to direct primary care or concierge model since essentially that is the type of care we are now delivering (although we are a Medicare participating practice) and we wish to continue delivering quality care to our older patients. I suspect a large percent of other small practices will do the same. We obviously are the dinosaurs of Family Medicine, and God help us all when the only choice we have for primary care, as patients, will be the large and quite often impersonal practices where we are simply a number. I have been a solo, self employed, practiioner for 30 years and would like to continue practicing,, but will retire if I am not able to continue to give quality care in a small setting.

Posted by Larry Popeil on July 05, 2016 at 12:23 PM CDT #

AAFP must listen to its family physicians. Not only are practices being destroyed, MACRA cannot discern quality. The evidence indicates that not even the best report cards can. Over a dozen studies indicate performance based pay as discriminating against those in need of care. Family physicians are most likely to be in the line of fire just as they are more likely to be seeing the Medicare and Medicaid patients where needed. Even EHR proponents see the truth of the matter and call for an end for MACRA as MACRA props up sales even of products that should die from lack of sales - because of HITECH to MACRA. Please pay attention to the evidence, to experts, to family physicians, to the need for lower cost of delivery for all rather than ever higher, and to the needs of the patients in most need of care who will suffer even more than in the last three decades of adverse payment design.

Posted by Robert C. Bowman, M.D. on July 05, 2016 at 03:39 PM CDT #

Whereby the SGR did not promise any pay increase, congress was asked due to the flaws in the formula to provide those increases. Although the increases in pay were not consistent, overall there were increases in payment through the years of SGR. What Mr. Martin misrepresents in the pay increases from MACRA is that those pay increases for physicians will come directly from other physicians who will be penalized with the creation of a larger bureaucracy to administer this mess. MACRA is suppose to be budget neutral just as was the SGR. The only difference is that there are to be penalties levied against physicians and there is no provision for congress to step in to level the payments. MACRA has been made more complex so that it will be almost impossible for small practices (who are the most cost efficient primary care providers) to avoid penalties. The result is that the largest and least cost effective will benefit. I am disappointed that our leadership has advocated this transformation and then spins it like a politician with misleading statements as the above article. If you tried to read the proposed rules (the comment period just closed) you would have found them so complex that they were virtually impossible to understand--purposely so that there will be a number of physicians who will get penalized with MACRA. Putting a finer point on this Mr. Martin, is that there will be more physicians with a pay decreases than pay increases.

Posted by Peter Lueninghoener MD on July 05, 2016 at 04:50 PM CDT #

I see this as my exit from rural family medicine and the practice of medicine. As the only primary practice in my town and one of three in the county, I don't know what to do. If I worked for free, I could hire an out of town expert to come in and make me miserable and decrease the amount of care I provide but......... as a sixtysomething, I guess it's a sign I need to go. ADIOS

Posted by Al Sayles on July 05, 2016 at 07:01 PM CDT #

MACRA and MIPs are not the way forward. They are a dead end. Value is provided by a Family Physician by doing the job of 6 other doctors for 90% of medical problems while being paid just a 99214 code level. Find a straightforward way to pay a family doc for doing the intensively complex work the system is now getting for free and med students will choose FP as a sustainable career. The big hospitals, the insurance companies and Medicare are making out like bandits on our daily work while trying to convince us and the AAFP leadership that pushing more buttons on the EMR and struggling to implement indecipherable programs will prove our "value". AAFP should tell congress to find a way to preserve the practices that are taking comprehensive care of people and lowering costs without 900 pages of regulations. Stop the government payment policies that are forcing FPs out of practice or into larger health systems where the cost of care goes up as the competition goes down.

Posted by Ben Brewer MD on July 05, 2016 at 10:06 PM CDT #

In January 2016 after 26 successful and rewarding years in semi-rural private practice as part of a group of three, I left to do locum tenens work in New Zealand. It was the EHR burnout, the defensive medicine burnout, and the Medicare/Medicaid regulatory burnout that drove me away. The latest iterations of bureaucratic "reforms" leave me disinclined to ever want to practice medicine in the States again. New Zealand, by the way, has a national health program that is working well. There is also a government-run no-fault liability insurance program that includes medical malpractice coverage, so personal injury attorneys are non-existent. National heath naysayers take note: I love working here.

Posted by Dale R Abbott, M.D. on July 05, 2016 at 11:52 PM CDT #

While I appreciate AAFP efforts to address MACRA shortcomings this is an enormous burden on all practices not run by large corporations. I find the quality reporting generated by my nationally prominent EHR to be so inaccurate it is spurious to assume the data sent and accepted by Medicare is in any way a measure of quality. The denominator is often wrong (e.g. a long term diabetic patient seen yesterday is some how not on the list). The numerator requires a fake CPT code be entered in a note, a box checked on a flowsheet or an item marked in the history in precisely the correct way - all opportunities for clerical errors. A patient who has a mammogram ordered and done by another physician has to be manually entered. My staff has to call people to find this out so I do not get punished. Ironically if I order a test and it is never done the EHR marks it as done on the PQRS reports. Of note, nothing in this paragraph has provided any health care or meaningful patient contact. More of this is ludicrous. How can Medicare not see how flawed is this “data” collection? I do not see how I can continue to participate in Medicare or with any insurance that will inevitably move in the same direction. Physicians need to have working tools (flowsheets, auto entered results, etc.) that help us manage preventive care and truly important chronic care metrics and we will use them to proactively manage care as CMS is wanting us to do. The hours we spend with duplicate documentation every week and days to compile the reports takes this time (for those of us in small practices) completely out of health care.

Posted by William B Davis MD on July 06, 2016 at 12:52 AM CDT #

My biggest concern is that the program will be paid for by other physicians and we will all be graded on a curve. CMS may say that the benchmark for one thing is at 75%. You could be at 80% but if this is below the mean, then you still have to take a penalty even though you are above what CMS is shooting for. This makes no sense to me and pits physicians and clinics against other physicians and clinics. Why should I be penalized if I'm meeting the benchmark which CMS has set?

Posted by Corrine Leistikow MD on July 06, 2016 at 01:42 PM 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.