SAN DIEGO -- Though many clinicians remain in the dark, a new menu of quality measures affecting their Medicare pay arrived January 1, with yet another steaming bowl of alphabet soup for them to digest with help from their EHRs.
The for MACRA, the Medicare Access and CHIP Reauthorization Act, has been on the table since October.
Now physicians, physician assistants, clinical nurse specialists, dentists, optometrists, and chiropractors must learn about MIPS and APMs, the merit-based incentive payment system and alternative payment programs that are dictating the size of their future Part B claims.
They'll ponder an ACO or PCMH, CCJR, OCM or CESRD model, with one- or two-sided risk, in a patient-centered medical home, or a joint replacement, oncology or end-stage renal disease collaboration.
All that's parsed by a 2,400-page MACRA . Failure to participate in MIPS (merit-based incentive payment system) in 2017 carries a financial risk: the loss or gain of as much as 4% in 2019 depending on their 2017 participation, rising to plus or minus 9% in 2022. Some 642,000 clinicians are eligible. (See this for breakdowns by specialty.) For APMs (alternative payment models), potential gains are even higher and so are the losses.
Many affected doctors attending the annual meeting here last week expressed a mix of exasperation and fear, to the extent they understand its complexity and price tags.
During the rollout year, compliance is easy. Still, there's widespread concern for 2018 and beyond, when stricter rules set in.
"It's going to cost a huge amount of money that's not getting reimbursed," said of Hammond, La. "We have to hire additional people to comply and it's overwhelming."
of Grand Rapids, Mich., wonders "how practical will it be" for his small, five-physician, two physician-assistant practice. "The big hope is that it will make patient care better, that people will live better and longer. But the concern, especially for a small practice, is, can we negotiate these different hoops without it being too cost ineffective?"
Docs as Experiment Subjects
Ironically, even federal officials administering the program aren't absolutely sure all the effort will improve quality of care for patients.
During one ACP session with the Centers for Medicare & Medicaid Services (CMS) chief medical officer for Region IX in San Francisco, one beleaguered physician asked the question that may have been the elephant in the room.
"Is there any evidence that all this activity is truly going to improve care?"
As attendees chuckled and squirmed in their seats, Wolfe replied, "That's a question I hear a lot. And I think personally, if you read the literature, the jury is still out on whether value based payment policies truly do allow us to reach the aim."
Nevertheless, she said, "Congress has made a guess that value-based payment policies will help us get to improved quality care and better managed costs." She added, "We're still learning."
Despite other fast-moving policy changes in the current administration, MACRA does appear to be here to stay, although adjustments are predicted down the line. It was passed with solid bipartisan support in a move to the Medicare sustainable growth rate, which annually threatened to cut physicians pay by as much as 21%. In exchange, Congress sought to make physicians more accountable for their quality of care, reduce waste and overutilization, and lower costs.
The new rule in effect three previous payment mechanisms into MIPS: meaningful use, the physician quality reporting program and the value based payment modifier.
During the 2017 measurement year, clinicians are scored 60% on quality reporting, 15% on improvement activities such as whether they expanded their practice access or integrated behavioral and mental health, and 25% on advancing care information such as use of an electronic information exchange. In later years. The formula will include a percentage on physician spending based on claims data.
Clinicians who bill $30,000 a year in Part B allowed charges a year or less, those in their first year of Medicare participation, those who participate in an a qualified APM, and those and provide care for fewer than 101 Medicare Part B patients a year are excluded.
Yet of Gatesville, Texas, thinks the system is still an unfair way to assess a good doctor. "For us to get our patients' blood pressure and diabetes control at certain levels to prove we're good doctors is so inaccurate," he said. In South Texas, the patient mix includes "indigents who don't take care of themselves or don't take their medicine," he said. "And if their diabetes isn't controlled, then you're terrible and you'll get dinged. Ding. Ding. Ding."
of Staten Island, said that for some doctors the road will be impossibly tough. "There are unfortunately doctors who are still not electronic. These doctors are unfortunately so far behind the eight-ball, not only are they not going to garner benefits for how they're practicing -- their practice quality may be great -- but there's no way to measure it, collect the data, submit it, and so they will be hurt in terms of their Medicare reimbursements. It's not fair, it's just the way it is."
'MACRA? Never Heard of It'
Many doctors in the ACP conference hallways said they never heard of MACRA or the new alphabet soup, or if they had, didn't know if it would apply to them.
"I have no clue what you're talking about. I just see patients," said a University of California San Diego Medical Center endocrinologist and one of the ACP conference speakers. "I don't know even one of those acronyms."
That's not that unusual, said the ACP's vice president of governmental affairs and medical practice. "There's a significant number of physicians who I think are not aware of the program," she said, adding that ACP is planning a "big educational" effort to get the word out to Medicare participants, and has a full of tools for doctors wanting more information.
But one thing to note about this program, she emphasized: "It's not overly onerous. This year, you only need to report on one measure, one clinical improvement activity or one set of measures related to the advancing care information component" to avoid a negative payment adjustment.
ACP's immediate past president, said the awareness gap is particularly acute for doctors in smaller practices who "don't have an idea of what's going on, but who need to the most," as well as providers in larger health systems and employed clinicians in academic centers "who also don't know what's going on and really don't want to know because it's being taken care of for them" (by their administrators).
Variation in physicians scores that cost those systems money in penalties down the road will probably result in quality reviews that could eventually be reflected in the salaries or bonuses of doctors who failed to measure up, Damle said. Even though those doctors are not directly managing the implementation, setting up infrastructure, "it is going to trickle down to them because (to the larger organization) it's a matter of dollars and cents. And if they start suffering losses and see quality measures are not being met," that could affect individual physicians' salary adjustments.
One big hospital system administrator weighed in. president of the 1,000-bed University of Michigan Health System, which is now in a one-sided risk accountable care organization, agreed that especially in large systems, individual doctors are unaware of the law's impact because measure reporting is done for the group.
But if some of their 2,000 physicians are under-performing, it "might" affect bonuses or payment, especially if the system moves to a two-sided risk model next year.
a physician assistant in Greenwood Springs, Colo., said that while quality measurement is good, there is a risk that clinicians will "practice to meet the measures, like teaching to the test" for one measure like hypertension. That might result in a doctor inadvertently ignoring another potentially serious symptom or condition. "You can make the case either way."
Treating the Computer Screen
Said Walker, the South Texas physician: "I tell my patients, I don't treat them anymore. I treat the computer screen, and check the boxes in the right order in the right way to make the federal government happy."
The idea beyond all this rulemaking is that by using electronic health records to report quality measures in their practices -- physicians can pick between one and six out of 270 measures on -- doctors will be better able to control their patients' hypertension, diabetes, or other chronic conditions, and make sure they receive vaccines and tests for preventive care that keep them out of the hospital, lowering Medicare's costs.
an ACP regent and chair of the medical practice and quality committee, said many doctors may not care about MACRA because they liken it to previous individual payment programs such as the physician quality reporting system in which they didn't have much at stake. They don't realize that MACRA consolidates three payment programs with more than three times the hit.
That's why, he said, MACRA calls for a culture change in the way doctors think about the way they treat patients. Take for example checking a diabetic patient's hemoglobin A1cs, or not giving patients antibiotics for viral respiratory infections.
"We're not accusing you of not doing this stuff, maybe you are. If you are, you need to show you're doing it," he said. "That's a culture change."
Another potential end result is that patients will be much more engaged with their clinicians, through e-mails, potentially more appointments and appointment reminders, phone calls, and more interaction with their care recommendations through evolving electronic portals, McLean said.
McLean thinks MACRA will drive physicians to give better care "in a systematic way," though it will be tougher for some.
"Will it be a challenge for physicians to actually use the technology well? If someone has really been avoiding the EHR bus for awhile, they're going to have a sharp start-up curve."