With MACRA looming, doctors can't afford waiting to plumb its intricacies

This is not a time for procrastinators as Medicare physician reimbursement undergoes its biggest change since its launch in 1965.

Final game-changing rules for the value-based reimbursement schemes contained in MACRA (short for Medicare Access and CHIP Reauthorization Act of 2015) won't be issued until as late as November. Acting CMS Administrator Andy Slavitt has hinted there could be delays in final implementation, at least for some physicians in small and rural practices.

But experts who have pored over the complex proposal issued in April said physicians and physician groups need to plow ahead.

The clock is ticking because MACRA goes into effect Jan. 1. The data collected starting next year will affect pay in 2019.

Dan Golder, a principal at Impact Advisors, a healthcare IT consultancy in Naperville, Ill., said the new regulations are daunting. “Meaningful use is first-grade arithmetic and MIPS and MACRA are college-level calculus. It's very, very complex,” he said, referring to the Merit-based Incentive Payment System.

“There's over 200 quality measures folks have to review and pick from. There's over 90 'clinical practice improvement activities,' which is another part of the MIPS. The complexity of MIPS is going to be very difficult for physicians to stomach. They're going to be really challenged to read and understand the rules and to perform at a high enough level,” he said.

But enough is known about the broad strokes to enable physicians and groups to proceed. They can adjust to any curveballs that may come their way.

“MACRA essentially mandates provider risk in Medicare Part B. That's a game-changer, even revolutionary,” said Chet Speed, vice president of public policy for the Alexandria, Va.-based AMGA, formerly called the American Medical Group Association, which represents larger group practices and integrated systems of care, such as the Mayo Clinic and Cleveland Clinic. “Physicians have been in fee-for-service since 1965 and now providers in 2019 will be at risk for plus or minus 4%.”

Laura Wooster is vice president of public policy for the American Osteopathic Association, which represents many rural and primary-care physicians. “MACRA shifts Medicare away from fee-for-service, which incentivized volume of services. Instead, MACRA moves toward a system that rewards physicians for the quality of care they provide,” she said.

Christian Shalgian, director of the Washington, D.C., office of the American College of Surgeons, said most physicians are not yet ready for MACRA: “I don't think there's enough education. We're continuing to educate our members and telling them that the world is going to change. They just have to be prepared for the fact that at the end of this year they're going to have to have a very hard look at their individual practices.”

Speed said all the physicians in a group—as well as other clinicians such as the registered nurses, advanced practice nurses and physician assistants—need to know what MACRA is about and what the implications are, including putting some of their compensation at risk based on the new quality and patient experience measures. “How we treat the patients becomes much more important,” he said.

What is changing?

The agency lists three major changes to Medicare payment:

• Ending the sustainable growth-rate formula, which over the past decade mandated sharp cuts in physician pay based on productivity—a process that Congress consistently postponed with its routine “doc-fix” legislation.
• Creating a new framework for rewarding healthcare providers for giving better care, not just more care.
• Combining existing quality reporting programs, including meaningful use, used to certify electronic health records, into one new system, dubbed the Quality Payment Program.

Medicare says most groups will fall into the Merit-based Incentive Payment System. A minority, mainly large groups, will follow advanced Alternative Payment Models, or APMs.

“With the MIPS mode, there are some heavy quality of value reporting efforts,” Shalgian said. “The alternative is the APMs, which have upside risk and downside risk. If you're in an APM and you're providing care to a group of people, then you're saying, 'I'm going to provide that care at a certain cost.' ”

If costs are higher than estimated, then the group is left holding the bag.

“How that's done and what that means is very much an open question because if you look at any given patient for any condition they may have, there are multiple physicians that are potentially caring for that patient at any step in the process,” Shalgian said.

Wooster explained that a physician currently in Track 2 of the Medicare Shared Savings Program, or MSSP, under the Affordable Care Act, can share in up to 60% of savings when their expenditures are less than the benchmark. Under MACRA, Track 2 of the MSSP is recognized as an Advanced APM, and those same physicians will continue to be able to share in up to 60% of savings when their expenditures are less than the benchmark, plus they could get an additional 5% annual bonus from 2019 to 2024.

“While the Merit-based Incentive portion of the law is designed to be budget-neutral in general, there are new opportunities for additional bonuses,” Slavitt told the annual meeting of the American Medical Association on June 13. “The goal of the program is to return the focus to patient care, not spend time learning a new program.

“Medicare will still pay for services as it always has, but every physician and other participating clinicians will have the opportunity to be paid more for better care and for making investments that support patients—like having a staff member follow up with patients at home,” Slavitt said. “In MIPS, in addition to the 4% positive payment adjustment, there is the potential for much higher payments through $500 million in funding over six years. Physicians earn a 5% lump sum bonus for participating in an Advanced Alternative Payment Model.”

But, Golder said, because MACRA is designed to be budget-neutral, some groups will receive bonuses, while others get penalized to pay for the bonuses. He predicted that some physicians may retire early or stop seeing Medicare patients rather than cope with MACRA.

Shalgian is concerned that there won't be enough time to inform doctors of what's going on, since the final rules are due by November and implementation begins Jan. 1.

He said he believes the change in regulations could encourage more surgeons to join larger groups. “More and more surgeons will move from private practice into employment models, where they're employed by a group, by a hospital, because the system has gotten so complicated and the administrative burdens have gotten so great, they're throwing their hands up and saying, 'I'm going to let somebody else deal with this. I'm going to practice surgery.' ”

Shalgian said a major issue is how to attribute care—and reimbursement—to the many physicians involved in caring for individual patients.

“You might start with a primary-care physician seeing a patient and then referring the patient to a surgeon who then has multiple physicians involved in the process. There might be an anesthesiologist involved, a pathologist, a radiologist and then there's the post-acute care following the operation. How do you attribute the risk? Surgery is very different from primary care.”

Dr. Jeffrey Bailet, president of Milwaukee-based Aurora Health Care Medical Group, with more than 1,600 physicians, said front-line physicians may not be aware of MACRA and its payment implications because most practices are involved in fee-for-service arrangements. But he said typical medical practice leaders are preparing for the change.

“Small group practices, larger multispecialty medical groups or high performing integrated care delivery systems must make significant investments to succeed in a risk-based environment,” he said.

Wooster stressed that it begins with having a certified electronic health record, since the MIPS and APM tracks require it. But that's only a starting point. Groups need to review the menu of 91 clinical practice improvement activities in the proposed rules that can serve as a useful road map for practices. “Many of the proposed activities recognize population health accomplishments, which can benefit practices and begin to move them toward a value-based system,” she said.

Bailet, chair-elect of the AMGA, said EHRs and other health information technology systems must be analyzed to ensure they produce meaningful and actionable data. “There are several other software or data systems needed to maximize the full potential of one's EHR, such as a predictive analytic tool that can stratify patients by their diagnosis and severity of illness, allowing the focus of resources to the patients needing them most.

Also, applications that provide accurate cost and quality data by disease, treatment and procedures and by patient demographics are essential as we move toward population management, value-based care delivery and financial risk,” he said.

Groups will be caring for populations and will have to demonstrate they are improving health to qualify for incentives. Bailet said Aurora has partnered with the AMGA to develop a predictive analytic tool to more effectively manage severe heart failure and chronic obstructive pulmonary disease patients.

Sidney Welch, a MACRA expert at Polsinelli, a Kansas City, Mo.-based law firm, said, “The deadline for implementation seems somewhat far away (2019); however, the payment mechanisms will be based on data from 2017—next year. So, it is imperative that physicians get their data in order and start implementing changes to best position themselves to avoid negative financial consequences.”