Concerns with MACRA requirements include an expectation that physicians will need to buy new EHR systems.

Oct. 18—The release of the final rule governing implementation of an overhaul of Medicare physician payments was met with some relief and much skepticism from practicing physicians worried it will not  be as simple or flexible as promised.

A leading concern was that existing electronic health record (EHR) systems are incapable of meeting the reporting requirements of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), so new system purchases will be necessary.

“My first impression of the final rule was ‘They listened to us,’” John Meigs, MD, president of the American Academy of Family Physicians (AAFP), said in an interview. “It’s still going to be a headache, but it could’ve been worse.”

Meigs said the final rule is an improvement over the proposed rule issued in the spring.

“It’s better than the SGR (sustainable growth-rate formula), and it does move Medicare to alternative payment models (APMs) that hopefully will be beneficial to family physicians and primary care,” Meigs said.

Specifically, Meigs said he likes the “ pick your pace” options which allow physicians to enter the new Quality Payment Program (QPP) either through an APM or through three different tiers of the new Merit-based Incentive Payment System (MIPS). MIPS includes two options that won’t require physicians to start reporting their performance on quality measures on Jan. 1, 2017.

Also drawing praise from Meigs was that MIPS lumped into one common acronym the existing Medicare Meaningful Use (MU), Physician Quality Reporting System (PQRS), and Value-Based Modifier (VBM) quality-reporting programs, and that should lessen the administrative burden.

The final rule’s changes to exempt more physicians from MACRA quality measurement requirements by increasing the amount exempt physicians can earn from Medicare from $10,000 to $30,000 was not expected to benefit Meigs, who sold his solo practice several years ago to join a larger practice, where he is now employed.

Goal: Avoid Penalties

Meigs eventually would like to practice in as an APM. But, as “Alabama is still a fee-for-service world,” Meigs said his practice probably will ease into MIPS with an eye toward becoming an APM sometime in the future. First, Meigs will aim avoid penalties and then to qualify for a MIPS bonus.

A lack of interoperability and other limitations has prompted his organization to switch IT vendors, Meigs said, because its EHR system “doesn’t do what it’s supposed to do” and forced him to become a “very expensive data-entry clerk.”

A long-time advocate of EHRs, Meigs said the technology may lead to him getting penalized for matters out of his control.

Another EHR advocate with concerns is Bernd Wollschlaeger, MD, a family physician and addiction-medicine specialist in a solo practice.

Wollachlaeger said he’s become disillusioned with how physicians are being “forced to use systems that are not practice friendly.”

The Centers for Medicare & Medicaid Services (CMS) has proposed—although not yet finalized—public reporting of physicians’ MIPS data on) its Physician Compare website. Wollschlaeger is concerned that his current EHR will be incapable of performing all required tasks and he may need to buy a new system.

“We don’t have the tools to assess the quality in as sufficient a manner as is required,” Wollschlaeger said in an interview. “It’s not always a click of a button and it’s automatically done.”

His frustration is increased when trying to coordinate care for diabetic patients by sharing information from ophthalmologists, gastroenterologists, and nephrologists. Also, he said the care his patients receive is scattered between getting a flu shot at CVS, a pneumonia vaccine at Walgreens, and a colonoscopy somewhere else with no guarantees that the information will be shared with him.

“The data is often not in a digital format or, at best, it’s in a PDF and I need to extract it and put it in the right tables and format,” Wollschlaeger said.

Focus on Quality

Wollschlaeger’s MACRA strategy will focus on quality measures, and he may need to restrict new Medicare patients. Medicare patients only make up 10 percent to 15 percent of his patient population, but their multiple chronic conditions require more time than most patients.

“They don’t come in with a sore throat or sore muscles, they come in with three, four, or five complex problems,” Wollschlaeger said.

Kathy Saradarian, MD, a solo practitioner in Branchville, N.J., said she was frustrated with the massive rule, which she described as “2,300 pages and no details.”

“I guess ‘Pick your Pace’ is OK as, in the past, it's been so all or nothing,” Saradarian said in an e-mail. “They still haven't told [us] what the quality measures are or how the Advancing Health Technology component will be done, what the requirements are, and how they are to be reported.”

Saradarian will probably be one of the 380,000 small-practice clinicians exempt from MACRA.

What’s the Point?

“Since I am exempt based on size, and many solo/independent doctors will be, I don't have to pick a pace,” Saradarian said. “But, on the other side, even if I am a high-quality, high-performing doctor, I can't get a raise—my income is flat. So, in a way, it's a punishment.”

Saradarian also is in a Track 1 Medicare accountable care organization (ACO) but was uncertain how that would impact her quality reporting requirements.

“If the method of reporting costs thousands of dollars to comply, and then you run the risk of getting audited and having it all taken back if they don't like your documentation, then really what is the point?” Saradarian asked. 

John Bender, MD, an AFFP board member and CEO of Miramont Family Medicine in Fort Collins, Colo., said in an interview that his Track 3 ACO participation will earn him a 5 percent Medicare increase in 2019—regardless of how well his ACO performs.

Though Bender’s ACO will be under pressure to increase savings next year while being subject to more quality-reporting requirements, Bender said he doesn’t mind.

“I don’t have to worry about MIPS, that’s not the path I chose,” Bender said.

To illustrate the impact of the final rule on ACO physicians, Bender said if, for example, his ACO—Physicians Accountable Care Solutions—saved about $30 million next year, then Medicare would probably keep about $15 million, the ACO’s private equity investors would get around $7 million, and $8 million would be split among the ACO’s 25 “pods.” Some pods have up to 100 physicians, while Bender’s has 10.

“If the ACO loses money, investors would suffer a loss, but physicians will still get $1.05 on the dollar,” Bender said. “The incentive is there for independent physicians to join an ACO.”

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

Publication Date: Tuesday, October 18, 2016