Breaking Down MACRA: Doctors wade through new Medicare system

Medicare currently is undergoing historic reform. The Medicare Access and CHIP Reauthorization Act – or MACRA – is federal legislation overhauling the way providers will get paid in America. With 55.5 million Medicare patients in 2015 – 1.1 million of those in Missouri – according to the Kaiser Family Foundation, it pays for doctors to understand the new plan and how it will affect their practice.

Independent physician Dr. Scott Turner currently is wading through the paperwork, hiring national electronic medial record and consultant firm eClincialWorks to gather data over the next three months.

“I’m not crazy about it yet,” said Turner, who owns Springfield’s PatientCare Family Clinic. “I’m not convinced it’s the best way to ensure quality care. Right now, I feel a bit like a data entry clerk for an insurance company.”

The response from doctors is mixed. While most agree reform was needed, not all are convinced MACRA is a better solution.

“The intention was good, but the execution isn’t as good,” said Dr. Louis Krenn, a clinic physician in Willard and chief medical information officer for CoxHealth. “That being said, we’ve been beholden to a program long before this year.”

Managed by the Centers for Medicare & Medicaid Services, it’s estimated MACRA compliance will cost the health care industry up to $1.3 billion.

“A consultant was a significant expense,” Turner said, declining to disclose the cost.
 
“But the data I collect now impacts my payments in 2019.”

What is MACRA?
MACRA replaces the 20-year-old Sustainable Growth Rate physician fee schedule for all Medicare Plan B payments, which includes plans covering services such as lab tests, surgeries, office visits and supplies.

Following years of advocacy by the nation’s physicians, Congress repealed the SGR formula and in 2015 former President Barack Obama signed MACRA, with plans to take effect this year. The American Medical Association hailed it as the most significant change in Medicare physician payment policy in over 25 years.

“Everyone knew SGR had been a huge problem for decades,” said Paul Taylor, CEO of Ozarks Community Hospital. “They were trying to control Medicare spending, but it was robbing Peter to pay Paul.”

The new PFS approach has been dubbed the Quality Payment Program and rewards the delivery of high-quality patient care through two avenues: Advanced Alternative Payment Models and the Merit-based Incentive Payment System for eligible clinicians or groups.

Those eligible to participate in the MIPS track of the QPP must bill more than $30,000 to Medicare, provide care to more than 100 Medicare patients annually and one of the following: physician, physician assistant, nurse practitioner, clinical nurse specialist or certified registered nurse anesthetist, according to CMS.

As part of the final rule released by CMS Oct. 14, 2016, MIPS replaces three Medicare reporting programs: Medicare Meaningful Use, the Physician Quality Reporting System and the Value-Based Payment Modifier — an alphabet soup of value-based arrangements, OCH’s Taylor said.

“If you choose MIPS, 2017 is your base year to collect data,” Taylor said. “If you choose not to participate, then you’ll get hit with a 4 percent penalty.”

While the penalty could seem like a lot, Dr. David Barbe said it’s actually an improvement. All three programs replaced by MIPS started as incentive programs which transitioned to penalty programs. Adding the three together, doctors could be paying as much as a 10 percent penalty this year under the old system.

“Ten percent makes you stand back and take a look,” said Barbe, vice president of regional operations with Mercy and president-elect of the American Medical Association board. “Many physicians had threatened to quit Medicare.”

Barbe said Medicare patients typically make up 20 to 40 percent of a doctor’s patient load, but every doctor varies. For independent doctor Turner, it’s only 10 to 15 percent, but in Willard, about 30 to 35 percent of Krenn’s patients are covered by Medicare.

Doctors using MIPS going forward could begin collecting data Jan. 1, but have up to Oct. 2 to start the process. The first payments of 2019 will be adjusted based on that data.

Doctors not taking the MIPS path of the QPP will use the AAPM model. Taylor said any hospital already part of an accountable care organization – or groups of doctors and hospitals who come together voluntarily to give coordinated care to Medicare patients – would choose AAPM because it most closely resembles their current system.

“OCH is an ACO, so we won’t see much change,” he said. “Mercy is an ACO, but the people at Cox are not. I suspect they would go the MIPS route.”

Krenn said he and the Cox team already are preparing for MIPS implementation.

Slated by CMS to take effect nationwide this year, the timeline already is in flux.

“There was enough concern during the public comment period that CMS gave a lot of doctors a pass,” Krenn said.

According to an article in Modern Healthcare, CMS sent letters to 806,879 clinicians earlier this month saying they will not be evaluated under MIPS in 2017. Up to 642,000 physicians were slated to submit MIPS data, but that number has now dropped to 418,849.

Doctor impact
Right now, doctors concur the biggest change is the paperwork factor.

“It takes time to record all that information for Medicare,” said Barbe. “One of the biggest objections is doctors feel like box checkers.”

Barbe said the system isn’t good about retaining information and each file comes with a specific set of questions that must be answered.

“For example, if a patient had their leg amputated, you have to write that in every year,” he said. “That’s not something that’s growing back, so it’s just troubles the doctor every year to write it in.

“Or one of the boxes to be checked says did you ask the patient about smoking? While I agree that’s a good thing, it’s not always the case. Is that overkill?”

That’s just the beginning for doctors. With no federal funding for the change, CoxHealth’s Krenn says it’s a zero-sum program creating winners and losers out of its users.

“Essentially the doctors who get bonuses will be paid by the doctors who are penalized,” he said. “When they announced it, CMS said there likely would be three times more losers than winners.”

Krenn said ensuring a win isn’t easy. Doctors are evaluated on numerous factors and given only benchmark scores as a guideline.

“Say you are focusing on raising your quality of care score and you’re at 95 percent, well above the benchmark,” he said. “But when all the scores come in, your peers are at 96 percent. You were doing so well and made improvements, but now all of the sudden you’re a loser.”

CMS estimates up to 370,000 clinicians will become qualifying AAPM participants – known as QPs – through 2018, receiving up to $571 million in APM incentive payments starting in 2019.

“Everyone will constantly be on guard,” Krenn said. “As the metrics get tighter and tighter, and people play the game better, it will be hard to stay on the winning side.”


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