AMA physicians surprise CMS chief with standing ovation and by interrupting his talk with applause.


June 17—Many who attended the American Medical Association’s (AMA’s) annual House of Delegates meeting, June 11-15 in Chicago, left a little less worried about a pending Medicare pay overhaul, even though a multitude of concerns and unanswered questions remained.

Andy Slavitt, acting administrator for the Centers for Medicare & Medicaid Services (CMS), had a lot to do with that. Slavitt spoke about the 962-page proposed rule implementing the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and organized medicine’s concerns about implementation. Slavitt assured them that an overarching goal was to simplify the regulations “wherever and whenever possible so that we can reduce the noise from the signal and give physicians time back to spend with patients.”

That comment was one of about a dozen that was greeted with applause by the AMA audience who gave Slavitt a standing ovation at the end of his remarks.

Applause Line

Given the apprehension over MACRA before the meeting, Slavitt seemed pleasantly surprised by the warm reception.

“You can clap any time you want, and I’ll pause,” Slavitt said. “You can tell I’m not used to it in this job.”

With 49,000 physician and medical student members, the Texas Medical Association (TMA) is the nation’s largest state medical society. It distributed a 20-page booklet at the meeting outlining its concerns with the proposed implementation rule. They described it as “far more costly, complex, and confusing than the costly, complex, and confusing program it is replacing.”

David Henkes, MD, a San Antonio pathologist and chairman of the TMA’s contingent of 17 delegates and 17 alternative delegates, gave his assessment of Slavitt’s talk.

“He sounded convincing, he sounded genuine, but I don’t think he gave concrete answers,” Henkes said. “But at least he appeared to be listening, so I do feel more confident.”

Timing Is Everything

This attitude was shared by Don Read, MD, president of TMA and a colon and rectal surgeon from Dallas, who noted that a new presidential administration will be in charge of implementing MACRA, so it would be best if any promises made by Slavitt could be put in writing.

“Slavitt is going away,” Read said. “So, no matter what he says, if it’s not codified, it can go away, too.”

Chief among physicians’ concerns is the timing. A final rule is expected to be released in the fall, giving practices only a few months to get ready for 2017 performance measures from which their 2019 compensation will be based.

Read suggested that maybe the 2019 payment could be based on the second six months of 2017. Henkes thought that 2017 could be a transition year where physicians work to get in compliance and receive feedback on their performance, but would not be penalized if their implementation comes up short.

J. Mack Worthington, MD, chairman of the University of Tennessee College of Medicine in Chattanooga, applauded Slavitt for going to physician offices and seeing firsthand the challenges they face.

“He seems to understand the issues and has the willingness to take them on,” Worthington said.

Slavitt summed up four CMS MACRA priorities as: Being patient-centered with the least disruption for physicians; allowing practices flexibility in how they use the program to support the unique needs of their practices; simplifying wherever possible; and focusing on the unique needs of small practices as well as those in rural and underserved areas.

Table Troubling

Concern over MACRA’s potential negative impact on small practices was heightened after a table in the proposed rule estimated that 87 percent of practices with 24 clinicians or fewer would receive negative pay adjustments in 2019. The table used 2014 data from the Physician Quality Reporting System (PQRS)—even though most small practices didn’t participate in PQRS that year.

In response to a backlash to the estimate, CMS released a six-page document listing options for small practices and available resources to help them with implementation, and noting MACRA’s provision of $100 million over five years in technical assistance.

The AMA held two continuing medical education programs on MACRA on June 10 prior to its House of Delegates meeting. Cynthia Brown, vice president of government affairs for AMA, addressed the table at one of these sessions. The table “took ripe apples, added unripe apples, and threw in some oranges,” Brown said.

“Don’t take that table too seriously,” Brown said. She described it as “worse than useless” and “harmful.”

At the other session, Richard Deems, senior vice president for advocacy for AMA, described the organization’s overarching aims for MACRA as allowing more choice, being more flexible, simplification, maintaining clinical relevance, and adjusting the implementation timeline without giving the appearance that physicians were obstructing implementation.

Choices the AMA would like to see include opening up medical home payment options beyond primary care and into specialties such as oncology.

Expensive Divorce

Deems noted that  passage of MACRA and repeal of the Medicare sustainable growth-rate payment formula (SGR) was achieved through a rare bipartisan effort and the AMA would lose political capital if its members now sought repeal of the new law.

If that happens, “it’s going to be an expensive divorce,” Deems said, noting that the physicians can’t expect to go back to fee-for-service payment models.

MACRA-related policies approved by delegates at the meeting included one calling for exemptions and flexibilities for “fragile practices” and those in health professional shortage areas. Another called for a reduced reporting period in 2017 and that CMS validate and test the quality scores it uses to assess physician performance.

During debate on the second policy, it was noted that delaying implementation until 2018 would present another set of problems, which included resurrecting health information technology meaningful use stage three requirements that MACRA folded into other quality programs.


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

Publication Date: Friday, June 17, 2016