Doctors urge Congress to eliminate MACRA opt-out policy

AMGA board members asked congressional lawmakers Tuesday to overturn or scale back CMS exemptions that let thousands of doctors opt out of MACRA.

So many doctors have been allowed to sit out from reporting under the Merit-based Incentive Payment System that it may no longer meet Congress' goal of helping move Medicare from a fee-for-service to a value-based system, according to representatives from Prevea Health, UnityPoint Health and Oregon Medical Group. They met with lawmakers from both chambers and parties Tuseday, including members of the House Ways and Means Committee and Senate Finance Committee.

"Yes, some practices would face penalties, but isn't that the point in order to get them to make the change to value-based care?" said Dr. Ashok Rai, AMGA's board chair and CEO of Prevea Health. "Right now, as things are now, MACRA will not achieve its purpose."

The CMS initially proposed to allow practices with less than $10,000 in Medicare revenue to sit out from complying with the law. The goal post then rose to those with less than $30,000 in charges in the final year 1 MACRA rule. The goal post moved again in 2018 with those making less than $90,000 in Medicare revenue getting an exemption.

Between alternative payment models and small practice exemptions, only 39%, or around 621,700 of the 1.5 million clinicians now billing under Medicare, are eligible to report under MIPS.

Under MIPS, doctors are eligible for incentive payments if they perform well. However, as more doctors get a pass, the number of practices paying into the bonus pool has shriveled substantially.

Under the proposed rule for the first year of MACRA, practices were initially eligible for $833 million in incentive payments under MIPS in 2019. The amount dropped to $199 million once the low-volume threshold hit $30,000. For 2020, practices are eligible for up to $118 million in incentive payments now that the low-volume threshold is $90,000.

That's an 85% decrease from the original incentive payment pool for doctors who performed well under MIPS under the originally planned low-volume threshold.

The cuts make the pool inadequate to help practices recoup the hundreds of thousands of dollars each may have spent on staffing, care model planning and population health software to implement MIPS, according to Dr. Karen Weiner, CEO of the Oregon Medical Group.

CMS officials have claimed the continuous change in the low volume-threshold has stemmed from many practices' concerns that they didn't have enough Medicare patients to justify the cost of overhauling their electronic health record systems or buying new ones to track and report quality measures.

Practices could end up spending as much as $50,000 to extract their data from one system and move it to another that complies with MACRA requirements, according to the West Texas Health Information Technology Regional Extension Center, which studies EHR costs. Implementing a system from scratch could cost $163,765 for a single doctor practice and $233,298 for a practice of five, according to American Action Forum, a think tank in Washington.

Practices could also see their annual maintenance and upgrade costs go up. Practices already have seen these costs rise. From 2015 to 2016, physician-owned practices spent nearly $2,000 to $4,000 more per physician on IT operating expenses than they did the prior year, according to the Medical Group Management Association.