One option is described as a “get-out-of-jail-free” card for small practices unprepared for full data tracking on Jan. 1.


Sept. 15—The “Pick Your Pace” approach to implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was cheered by physician groups, even though it doesn’t include the delay for which some were looking.

Maybe the most important aspect of the policy change was that it aimed to keep physicians engaged in the process, said one physician CEO.

Pick Your Pace was announced in a Sept. 8 blog post by Andy Slavitt, acting administrator for the Centers for Medicare & Medicaid Services (CMS), and includes four implementation options. The first, which was cheered the loudest, allows practices to submit data as a test of their reporting systems in preparation for broader participation in 2018 or 2019 and not face penalties.

The second option permits practices to submit data for only part of 2017 while still being eligible for a “small positive payment adjustment.” The third option is for participation for the full calendar year starting Jan. 1. And the fourth covers participation in alternative payment models.

The proposed new approach was a thoughtful one that better reflects the diversity of the nation’s medical practices and allows the flexibility that physicians were seeking, Andrew Gurman, MD, president of the American Medical Association (AMA), said in a release. Slavitt’s announcement also was praised in a post by the American Academy of Family Physicians and a statement by the American College of Physicians.

Hearts, Souls & Interest

Physician in the field agreed the changes were critical.

“There are a lot of physicians who are not ready,” Joseph Vasile, MD, CEO of the Greater Rochester (N.Y.) Independent Practice Association, a commercial accountable care organization (ACO) with 1,300 physicians, said in an interview. “If CMS didn’t find some solution to easing these requirements, it may have lost the hearts, souls and interest of physicians for this program.”

In addition to an initial lack of preparation, physicians did not know how to prepare for the Jan. 1 implementation because the final rule was not expected to be released until November, Vasile said.

“The primary concern we hear from physicians is that it’s ‘one more thing,’ one more requirement to worry about,” Vasile said. “Put that all together and it’s a lot of change for physicians who already feel over-worked and burdened.”

The nation’s largest state medical society was one of the loudest critics of the proposed rule on MACRA implementation that CMS released in the spring.

Don Read, MD, president of the Texas Medical Association (TMA) and a colon and rectal surgeon in Dallas, credited Slavitt and CMS for listening to physicians and acting on some of their concerns. The previously proposed requirements for them to have quality reporting systems in place on Jan. 1 would have “killed off small practices,” Read said in an interview.

‘Reverse Robin Hood’

But further changes are needed, said Read, who refers to MACRA as a “reverse Robin Hood” measure that would penalize small practices and reward larger practices with the resources to fulfill its information technology requirements.

“Andy Slavitt addressed one little slice of the puzzle,” Reid said. He was “guardedly optimistic” that the final rule will reflect the rest of physicians’ concerns.

Physicians will need to invest about $10,000 to build the IT infrastructure required to comply with MACRA, Read said. So, TMA has proposed optional participation in MACRA’s merit-based incentive payment system (MIPS) for physicians earning less than $250,000 from Medicare and no penalties for non-participation.

In its comment letter to CMS on the proposed rule, TMA wrote that physicians earning $250,000 from Medicare would face a 4 percent MACRA penalty for noncompliance, which would equal about $10,000—or roughly the cost of the IT investment needed for compliance.

TMA also would like CMS to exempt physicians from penalties when noncompliance is the fault of electronic health record (EHR) vendors, Read said.

“Overall, MACRA costs a lot of money for doctors to comply with, but has no proven benefit for patient care,” Read said. “The intent of the legislation was to simplify things and make it easier for doctors, but what they’ve done is make it more complex.”

Not Going Away

Terry McGeeney, MD, president of Care Accountability, a Kansas City, Mo.-based healthcare consultancy, said the new Pick Your Pace approach offers smaller practices a “slower ramp” to MACRA implementation.

MACRA readiness and implementation is likely to be tiered along practice size, McGeeney predicted, adding that “cost is not insignificant to a small practice.”

McGeeney said many small practices use inexpensive cloud-based EHRs that are not able to generate the quality reports MACRA requires and are faced with three choices: Buy a whole new EHR system, buy a “bolt-on” IT product, or join a larger system.

Making the right choice is made even more difficult because there is “so much smoke and mirrors” regarding EHR differences, McGeeney said.

The first Pick Your Pace option allowing practices to get started without penalties was like a get-out-of-jail-free card for small practices, McGeeney said.

While Read said many Texas physicians were willing to accept the penalties for nonparticipation, McGeeney noted that MACRA legislatively lowered pre-exiting Medicare programs’ penalties from “north of 11 percent” to a maximum of 4 percent.

“That was a big win for providers that didn’t get a lot of attention,” McGeeney said.

MACRA contains many payment reforms that physicians have been advocating for since 2007, McGeeney said. Because it was enacted by Congress, rather than administratively, physicians should not think it will be repealed after the November elections.

“Physicians have to understand that it’s here and it’s not going away--no matter who wins the election,” McGeeney said.


Andis Robeznieks is a freelance writer based in Chicago. Follow Andis on Twitter at @AndisRobeznieks.

Publication Date: Thursday, September 15, 2016