MACRA positioning will be a key factor in future hospital credit ratings, according to one ratings firm.

July 5—About half of hospital-based physicians said they were not knowledgeable about the Medicare physician pay overhaul that began earlier this year, according to a recent survey—a larger share compared with physicians in other settings.

The high rate of confusion about the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and its Quality Payment Program (QPP) was identified in a KPMG and American Medical Association survey of 1,000 practicing physicians. The survey also found that 44 percent of hospital-based physicians were “somewhat knowledgeable” of MACRA and QPP, while 8 percent had “in-depth knowledge” of both.

Seventy-nine percent of the hospital-based physicians described themselves as “somewhat prepared” for the MACRA requirements that began at the start of 2017, while 16 percent were “well prepared” and 5 percent were “not well prepared.”

Between the two payment arms of MACRA—the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs)—most respondents (53 percent) expected to participate in MIPS for 2017. Twenty-four percent of all respondents expected to participate in an APM.

Many expected good results from MACRA, with 47 percent anticipating bonuses based on 2017 performance, while only 10 percent expected MACRA-related cuts.

Hospitals have plenty of incentive to focus on the physician payment overhaul, given that MACRA’s financial impact on hospital Medicare revenue in 2015-30 is projected to be anywhere from a $32 billion increase to a $250 billion decrease, according to an April study in Health Affairs. The losses would result from physician responses that reduce the use of hospital care, such as implementing steps to avoid admissions and readmissions, according to comments by an author of the study.

Hospital advisers underscored the need for organizations to educate their staff on MACRA, and on key areas of focus, during presentations at HFMA’s ANI 2017 in Orlando.

Among MACRA preparation tools available to hospitals is one issued by HFMA in October 2016.

Hospital efforts to educate their employed and affiliated physicians also were evident in the survey. Almost half (45 percent) of the responding physicians reported receiving educational or training sessions on QPP from their practice, hospital, or health system, compared with only 22 percent from a medical society.

The findings followed the June release of 2018 MACRA proposed rules that included several initiatives to minimize the short-term impact on physicians.

An optional facility-based scoring mechanism, based on the Hospital Value Based Purchasing (VBP) program, would allow facility-based clinicians who perform at least 75 percent of their services in the inpatient setting to convert their hospital’s Total Performance Score under VBP into a MIPS score in 2018, according to a CMS fact sheet.

The hospital-related provisions of the proposed rule generally drew praise from hospital advocates, although some sought further tweaks.

Meanwhile, Fitch Ratings issued a report (login required) this week that concluded that hospitals “with a high level of physician integration, a solid financial profile, and good market position will be better positioned for MACRA” and thus improve their credit standing.

Other Physicians

The share of hospital-based physicians who reported knowledge gaps about the law was larger than in most other settings. A lack of knowledge about MACRA was reported by 44 percent of physicians in solo practice, 41 percent in single-specialty group practice, and 35 percent in multispecialty group practice.

The findings appear to be an improvement over an annual national survey conducted in 2016 for The Physicians Foundation, which found that 56.3 percent of physicians were very or somewhat unfamiliar with MACRA. 

However, lower shares of non-hospital-based physicians felt they were either “somewhat prepared” or “well prepared.” For instance, only 22 percent of solo-practice physicians described themselves as well-prepared and 56 percent as somewhat prepared.

Similar shares of physicians in all practice settings expected to participate in MIPS for 2017, while the only group that expected to participate in APMs at as high a rate as hospital-based physicians was physicians in multispecialty group practices.

A recent analysis from Avalere found that physician specialists have more than 700 measures available for reporting under MIPS through Qualified Clinical Data Registries (QCDRs).

“Some physicians have expressed concern about the lack of meaningful specialty-focused quality measures available for reporting,” said Nelly Ganesan, a senior director at Avalere. “The QCDRs are one way to alleviate some of that concern.”

Potential MACRA Changes

Many of the 2018 MACRA implementation tweaks in the recent proposed rule were aimed at easing impacts on physicians in smaller and rural practices. For instance, the rule expanded reporting exemptions to include physician practices with less than $90,000 in Medicare revenue or fewer than 200 unique Medicare patients. The 2017 waiver applied to practices that earned $30,000 or less from Medicare or that had fewer than 100 Medicare patients.

Fitch noted that “MACRA could provide the nudge needed for markets with less physician employment and integration to consolidate and integrate physicians, disrupting long standing referral patterns and increasing costs as these markets sort themselves out.”

The moves by the Centers for Medicare & Medicaid Services to further ease the implementation of MACRA were seen as favoring less-prepared practices over those that have moved more aggressively into value-based payment, said Chris Stanley, MD, director of healthcare strategy for Navigant. He expects some pushback over that concern.

Another change in the proposed rule would allow individual clinicians to join Virtual Groups as a new channel to participate in MIPS with other solo or small-group practices.

However, Stanley noted that virtual groups remain unpopular with physicians because they are seen as too time-consuming for small practices to establish.

“They’re better in concept than reality,” Stanley said in an interview.


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Wednesday, July 05, 2017