The Medicare Access and CHIP Reauthorization Act, known as MACRA, will be one of the most dramatic changes to how Medicare pays physicians. But the marrying of quality-based reimbursement with demonstrated use of technologies and electronic health records has already sparked worry among not only physicians, but advocates like the American Medical Association and the American Academy of Family Physicians.
Perhaps nobody carries the burden of calming those fears more than Andy Slavitt, acting administrator of the Centers for Medicare and Medicaid Services. He's already been called to testify in front of Congressional committees about the benefits of the law change, and is currently weighing more that 4,000 formal comments about the law.
Healthcare Finance recently spoke with Slavitt about MACRA and the benefits he sees in the law changes.
"Legislation always gives us the opportunity to make historic shifts in the healthcare system and in our programs," he said. "The legislation itself isn't our destiny, it just lays out a framework."
MACRA was designed to replace the sustainable growth rate formula, or "Doc Fix," which Slavitt said required too many last-minute fixes to what would have been significant reductions in physicians' pay. The new rule passed with overwhelming bipartisan support last year.
"I don't think anybody would say they're happy with the way healthcare payments work today," Slavitt said.
MACRA, according to Slavitt, took the successful lessons learned in payment experiments like patient-centered medical homes, bundled payments and team-based models like accountable care organizations, and move them into the mainstream "by taking what works and adding some additional options for physicians who get better results," he said.
We found out the five questions every healthcare provider must ask before jumping in to MACRA.
If the law, which already is more than 900 pages long, doesn't become too complicated, Slavitt said it will lead to better care and happier doctors.
"We know that much of the good work that physicians do isn't about a test or a prescription, but rather it's the time they dedicate to spending with us as patients to really talk to us about our options and understand our health better. So the law really takes a step in shifting the payment equation from one that has them searching for codes they can bill for to one that allows them to do the job of being a doctor," Slavitt said.
Comments highlight concerns
Slavitt asked the industry for robust public comment on the proposed rule and he certainly got what he asked for. Slavitt said CMS has received more than 4,000 formal comments and had hundreds of conversations with physicians and other stakeholders in the last few months. Overall, three themes have emerged from those conversations.
First is a demand for allowing physicians to be patient-centered, and focusing on the benefits and results of care coordination and quality. This includes the bonus opportunities within the legislation, like a 5 percent bonus opportunity for participating in certain payment models.
Second, Slavitt said physicians want a sense of control and flexibility rather than one-size-fits-all program out of Washington.
"This is where it is really important for us to create flexibility to allow physicians to define what quality means for them, for their practice, for their patients and for their specialty."
Finally, the public comment period yielded pleas to help streamline and simplify wherever possible. Slavitt said CMS has already cut the number of quality measures by a third in MACRA, and they are looking for even more.
The small-practice conundrum
"We have to recognize that physicians begin this already with a significant amount of change fatigue and a significant amount of paperwork," he said. "So we do hear frustration, and it is really important to understand that the starting point people have is that they're already feeling overworked. They don't get enough time with patients and the technology they have in their office doesn't help them particularly well."
MACRA legislates more changes for a physician audience that is already frustrated, and even Slavitt himself has acknowledged that the rules may be difficult for smaller physician practices to adopt. Others argue that these practices don't have the financial or staff resources to purchase, update or implement the technology required to comply with MACRA rules for reporting and meaningful use.
In fact, a May survey by the group Blackbook Research said that out of 1,300 physician groups of five clinicians or less, 67 percent of high Medicare-volume doctors said they foresee the end of their independence due to MACRA, citing worries about lack of technology, financial resources and staff. The survey said 89 percent of remaining solo practices expected to minimize their Medicare patient volumes so they aren't required to submit reports for quality, clinical practice improvement activities or cost performance. Other reports have also predicted that while more than 400,000 physicians and clinicians will see bonuses as high as 4 percent, 346,000 practices that have between one and 24 members will be penalized.
But Slavitt is quick to point out that MACRA's quality payment program actually combines, and in his view simplifies, a "patchwork" of programs that are already in use separately, which reduces the amount of reporting required. That's something he says will be important for small practices that struggle to handle high volumes of reporting.
He said there are a few specific ways that MACRA diminishes the reporting burden for small practices. For starters, the law allows physicians to attest for more items/metrics so that they don't have to submit actual reports. CMS is also taking available data from claims and wherever they get data automatically which they are not requiring physicians to report. For physicians that are already submitting data for any other purpose such as a clinical registry, or if they are participating in a model where they already submit quality data, wherever possible CMS will use that data so data is not submitted twice. MACRA also creates additional flexibility with the meaningful use program to reduce reporting burden and is investing $20 million a year in technical assistance to aid small practices in reporting.
While Slavitt admits practices with smaller staffs are hit harder by major changes, he insists small practices have an equal chance for success under MACRA.
"We are cognizant of the concern. We are going at it and investing pretty heavily in it, and we are inviting additional comments and ideas for people who have other thoughts on how best to address these issues," Slavitt said.
Slavitt said there are a few things providers should do to prepare for MACRA implementation.
First, if there is an opportunity in the community to participate in something like a patient-centered medical home, an ACO or bundled payment program, then explore that option… that's almost universally true but specifically true in relation to MACRA, Slavitt said. The law gives providers two tracks for payment: The Merit-Based Incentive Payment System or participation in an advanced payment model like the ones mentioned above.
"It's a choice that gives them some financial opportunities and it also reduces some of the reporting that they'd have to do." He also pointed out that's an option that's going to make sense for some but not all.
Second, if you're using a certified electronic health record, keep doing it, Slavitt said. It's a requirement of the program.
"We always think that's a good idea. I think the state-of-the-art of electronic health records is going to get better and gets better all the time. So I think physicians today making decisions about an EHR will have an advantage over physicians that made decisions four or five years ago when they were less developed," Slavitt said.
Third, Slavitt said physicians have a unique opportunity to get rewarded for things that they are probably doing already in their practices, an area that the law describes as practice improvement. MACRA contains a long menu of 90 activities like expanding office hours, and various methods of using shared decision-making with patients.
"Explore the list, and see which ones you can incorporate into your practice," Slavitt said.
Finally, Slavitt said learning more about the quality measures should be a priority.
Once MACRA is finalized in November, providers may have to implement practices by January 2017 if CMS keeps to the original proposed schedule. Reimbursement rates and bonuses in the year 2019 will be based on metrics from 2017.
Bu Slavitt recently suggested when he testified before the Senate Finance Committee on July 13 that MACRA implementation could be delayed. Slavitt told the committee CMS is "open to multiple approaches", including alternative start dates, shorter reporting periods, and other ways for physicians and clinicians to get experience with the program before "the impact really hits them."
One thing that Slavitt and other officials have made clear is that MACRA is evolving, and Slavitt listed three things that are important to address as a country once MACRA is fully implemented if success is to continue.
First, he stressed the importance of making sure the infrastructure and innovation to support physicians with things like interoperability is maintained, such as the ability to track what happens to a patient when they are referred out to another practice or hospital.
"The innovation and the infrastructure has to catch up to the needs of physicians and today, candidly, the technology is behind," Slavitt said.
Second, there needs to be more models available for physicians who want to participate in them.
Most importantly, Slavitt said, it is crucial to stay on top of the latest innovations in medicine.
"There will be unintended consequences of every implementation. There always is. What we can't do is allow ourselves to get far away from what actually are the impacts. There will be some positive ones, there will undoubtedly be some negative ones, and we must make sure we make adjustments along the way to fix the things that could work better," he said.
"I'm very confident that if we do that, we can really reverse the sort of cycle people feel they are in now of regulation and compliance, to a system that works smarter and is more collaborative. We're going to need everybody to make the system work better over the next five to 10 years to make that happen."