Despite looming Republican-led healthcare reform that could lead to the undoing of the Affordable Care Act, experts at large medical practices are still preparing for MACRA since many face unique issued tied to their size.
According to Chris Timbers, chief information officer for NorthBay Healthcare, a large California system, the biggest issue is coordinating training for the 110 physicians affiliated with the system. About 50 percent of their payer mix is in government reimbursement.
In addition to the daunting task of training, NorthBay also needs to create communication workflows to support conversations with individual physicians about their performance under MACRA's merit-based incentive payment system, which is very complicated with its four weighted performance categories.
"It's going to have to mean getting them to a base understanding of how their scored and what we need to do to improve those scores and what it means to the organization financially," he said.
While physicians will have the desire and dedication to adapt to the new payment formula since most are motivated to improve care quality, Timbers fears that new frustrations coupled with change fatigue will bog doctors down.
"When we talk about improving quality, that resonates with them and that will be a motivator. I think when we talk about composite scores and performance thresholds I think that's the piece that's going to frustrate them and alienate them a little, so the challenge for us is to tie those two together."
Michael Munger, a physician with St. Luke's Health system is Kansas City and president-elect of the American Academy of Family Physicians, said the system is hard at work trying to understand every facet of the complicated law.
St. Luke's employs 400 doctors, including 100 primary care physicians and 300 other specialists.
According to him, St. Luke's has already found gaps in performance that need addressing and is figuring out how to communicate the importance of the workflows that will be put in place for success.
For starters, their electronic health records platform will need an expensive upgrade, bringing additional need for training and education for hundreds of staff on new workflows, and changes around how data is entered and referrals are managed. Munger said those efforts will take time, which takes away from potential productivity.
"The complexity of that is overwhelming to say the least. The bigger the system, the more complicated compliance and implementation will be," Munger said.
Another symptom of larger systems is the variety of facilities, specialties and services that inevitably mean multiple reporting burdens around MACRA compliance. Timbers said that Medi-Cal, California's Medicaid program, and his hospital are still tied to the old meaningful use program. Even though MIPS may not be a radical departure from where MU is going, Timbers said they are now tracking under two different programs, and that has added more overhead in terms of monitoring performance. The fact that both inpatient and ambulatory settings are on Cerner, the administration of the plans and the scoring is now different between the two settings.
For systems already struggling with the overall complexity of the 2400-page new rule, this adds an unwanted level of concern and urgency to getting the reporting right, especially where the hospital is concerned. Meaningful use under MIPS will be scored differently, with points for performance. For the hospital's MU program, it's all or nothing when it comes to compliance.
"In a hospital, the stakes are much higher. If you miss a measure you would forego any incentive or instantly be put into a penalty if you miss one of the measures on the inpatient side. That same measure on the outpatient side, if you missed it you would just miss out on getting points toward your composite score," Timbers said.
For Munger, the fact that the Kansas City area is one of the 14 areas where the CPC+ innovation model is available areas was a point of celebration for them, but if it is successful in their system, that means some physicians will be on MIPS and some will be on the advanced APM track under MACRA.
"For many systems around the country, this a definite shift around the way reporting on care needs to happen. Just the move from volume to value, that's necessitating change in workflows down to point-of-care," Munger said.
The cost of labor
As a fee-for-service market like Kansas City prepares to integrate their world with that of MACRA, Munger said another challenge lies in putting value on work that does not involve seeing patients and charging for services, and building that work into a compensation model. Their physicians are paid for productivity, and patients still need to be seen in the MACRA world. The question is how to adequately compensate and incentivize physicians to make sure they are managing populations, and doing work that doesn't necessarily put you face-to-face with a patient, but is needed or at least encouraged or rewarded under MACRA, Munger said.
That includes population health programs like nutrition, diabetes education and chronic disease management outreach. Participating physicians have to meet with and direct the teams. The big questions is how a system creates value in those functions that don't involve seeing patients and charging.
"If you've heard from anybody around the country that has the perfect model, I'd love to hear about it because we're struggling with that," Munger said.
That concern carries over to the time spent on reporting and administrative work, said John Meigs, MD, president of AAFP. With more desk work, he said, there are fewer patients being seen and less money being made.
"If I've got to spend half a day proving that I actually provided value so that my productivity is cut, if you pay me $5 more but I can only see half as many patients I don't think you've done me a favor."
Meigs said the fears of small practices are shared by many AAFP members who work for large practices: things like EHR upgrades, the overwhelming complexity of the law and potential loss of productivity thanks to reporting burdens.
"MACRA is anywhere from perfect. It is extremely complex, overly burdensome. To even define what pathway you go down, it's needlessly complicated and I think that's going to be the frustration for physicians moving forward, whether you're a small system or large system," he said.
Timbers said some long-term effects won't be truly understood until MACRA is a little older. He called out a caveat in MIPS that says scores and payment adjustments must follow a provider into their organization.
"If we bring on board a new primary care physician in 2019 and they were below the performance threshold in 2017, that's going to affect their reimbursement coming into our organization. They may be a great physician, a great cultural fit but by virtue of hiring them there's a financial penalty that comes. We won't know how big of an issue that is until we get further into the program."