Small practices need allies

Dr. Joe Schlecht started out as a country osteopathic physician 43 years ago in the small town of Jenks, Okla. Today, he runs a two-doctor primary-care practice in what has become a fast-growing suburb of Tulsa.

Schlecht isn't afraid of MACRA, although he knows the design of the new Medicare payment system will be challenging for small practices like his. “Most primary-care physicians are still practicing like they did 10 years ago. They don't even know how to spell MACRA,” he said.

MACRA will provide technical assistance to eligible professionals in small practices and to practices in health professional shortage areas. MACRA has allocated $20 million a year from fiscal 2016 through 2020 for this assistance.

Schlecht thinks his group, which is affiliated with the 70-member multispecialty Warren Clinic in Tulsa, and other small practices, even in rural areas, can come out on top with MACRA.

He has confidence because his group benefited from participating in Medicare's experimental Comprehensive Primary Care initiative offering population-based care-management fees and shared-savings opportunities to participating primary-care practices. Similar population-based incentives will be offered through MACRA.

Schlecht said a key to success is hiring a care guidance nurse, whose sole job is to monitor the quality outcomes of patients. He said his group's nurse has developed registries of patients with conditions such as diabetes and chronic obstructive pulmonary disease so the nurse can follow them and ensure they receive recommended care. The nurse also tracks patients as they transition from hospitals into other settings.

Schlecht said this population management approach documented improved care of his patients and resulted in modest increases in reimbursement. “Payment has pretty well covered the cost of us putting the care guidance nurse in place and the infrastructure to support her,” he said.

The CMS said it will provide accommodations to small practices and those in rural areas. For example, clinicians with 100 or fewer Medicare patients and no more than $10,000 in Medicare charges would be excluded from the Merit-based Incentive Payment System's pay adjustment.

Schlecht expects many small practices in rural areas and small towns to “virtually integrate” with larger practices, such as Warren Clinic.

“Our group is already going to some of the rural practices to try to strike deals. We will supply to them, for a reasonable cost, the electronic health record. We will supply to them a care guidance nurse, who would work with two or three practices. That is where I think the future for the small rural practice is going to be,” Schlecht said.