The recent tweaks announced to the new Medicare payment model did not address key concerns of small practices, some physicians say.


Sept. 22—A large national survey found only one-fifth of physicians are “familiar” with a looming Medicare payment overhaul that goes into effect in less than four months.

The annual national survey for The Physicians Foundation found 56.3 percent of physicians are very or somewhat unfamiliar with the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA replaced Medicare’s previous physician reimbursement system and will require physicians to participate in either the Merit-based Incentive Payment System (MIPS) or a designated Alternative Payment Model (APM).

Among the 17,236 physicians surveyed, 19.9 percent were either somewhat or very familiar with MACRA, while 23.8 percent said they were neither familiar nor unfamiliar.

“A lot of people are not as aware as they need to be of MACRA,” Wanda Filer, MD, board chair of the American Academy of Family Physicians (AAFP), said in an interview.

There was little difference in MACRA awareness among different types of physicians. For instance, 62 percent of employed physicians were unfamiliar with MACRA, as were 58 percent of owner-physicians.

The recent survey followed a July survey by Deloitte that found about 50 percent of practicing physicians had heard of MACRA. However, that survey had a much smaller sample of 600 physicians.

The low awareness levels followed months of outreach by the Centers for Medicare & Medicaid Services (CMS), including training sessions with about 75,000 attendees and more than 400 events, according to a spokesman. CMS Acting Administrator Andy Slavitt has underscored that “unprecedented” outreach and cited the subsequent submission of about 4,000 comments during the summer MACRA rulemaking process.

“CMS’s focus for the first year of MACRA is to get all eligible physicians aware and participating,” a spokesman said when asked about the survey’s MACRA results. “That’s why for 2017, we’re planning to gradually implement these changes at a pace that physicians choose. The bulls-eye for this policy is not what happens in the next year, but how it changes the trajectory of Medicare so that Medicare continues to fulfill its promise to America, its elderly, and its disabled.”

The final rules implementing MACRA are expected by November. Physician advocates have repeatedly warned that there is too little time to get all physicians up to speed on the law, which will require physicians to start reporting data in 2017. Many individual physicians and physician advocacy groups have called for delaying MACRA’s implementation—and Slavitt previously said in congressional testimony that a delay was a possibility.

Instead of a delay, CMS recently announced that the final rules will include new options, called Pick Your Pace, which will allow practices to submit data as a test of their reporting systems in preparation for broader participation in 2018 or 2019, and not face penalties. However, it was unclear what would happen to physicians who do not submit test data.

A second MIPS option will allow providers to participate for only part of the initial reporting year and receive prorated penalties or bonus payments.

“There are some good things about it, and it is an improvement, but it doesn’t go far enough to help solo practicing physicians,” Ralph Nobo, MD, a board member of the Physicians Foundation, said in an interview, referring to the planned MACRA changes.

Adverse Outcomes

Nobo said a MACRA delay or a range of additional changes is needed to prevent unintended outcomes. For example, physicians at small practices facing steep MACRA cuts could end up joining large practices or becoming employed by hospitals. The MACRA proposed rule estimated that the law would cut Medicare pay in 2019 for about 60 percent of practices with between two and nine eligible clinicians and for 87 percent of solo practices.

The share of hospitals employing a share of their physician workforce increased from 29 percent in 2003 to 42 percent by 2012, according to new research.

Both during a physician-hiring boom in the 1990s and during a recent surge in practice purchases by hospitals, “The observation has been that physicians don’t work as hard” when they are employed, Robert Berenson, MD, a fellow at the Urban Institute, said during a payment reform meeting this week. However, he noted that a few health systems, like Kaiser Permanente, have managed to maintain high productivity among employed physicians. 

Among the changes sought by some state medical associations was for a practice to be excluded from the MACRA requirements if its annual Medicare revenues are $100,000 or less, instead of $10,000 as proposed.

Another potential downside that CMS is eager to avoid is the possibility that more small practices will stop accepting Medicare patients due to the program’s regulatory burden. Nobo, a Florida OB-GYN, is considering such a step for his own solo practice because of MACRA rules.

The new rules are significant even for physicians without large numbers of Medicare patients, given that private payers are likely to follow the new reimbursement system, according to some physician advocates.

Outreach Help

Billy Wynne, managing partner of TRP Health Policy and a former congressional health policy attorney, described the proposed MACRA tweaks as “a delay of sorts.”

“Otherwise, I think CMS has a lot of work to do to help docs know what they need to know,” Wynne said in emailed comments. “I think they are depending on the [American Medical Association] and other specialty societies to help out.”

Physician group outreach has included the AAFP’s MACRA-specific website for members, which includes step-by-step instructions on how practices can ensure they are prepared for the first performance year under MIPS or for qualifying as an APM. Member communications also have included primers of the MIPS and APM payment models.

Filer said AAFP needs to wait for the release of the final rules to launch a more aggressive push to its 124,000 members.

“That’s why we were hoping for a delay,” Filer said.

AAFP has urged physicians in regions where Medicare’s upcoming Comprehensive Primary Care Plus payment model is located to participate as a way to get into MACRA’s APM track, which is considered more straightforward than MIPS.

Asked about further CMS efforts, the CMS spokesman underscored an initiative announced in June to help small practices prepare for MACRA’s quality reporting requirements. Additionally, the law provided $20 million for on-the-ground training and education for Medicare clinicians in individual or small group practices of 15 clinicians or fewer.

Additionally, CMS plans to release a new web tool to help clinicians assess the potential impact of MIPS on their Medicare pay, according to published reports. Additionally, the tool will help them evaluate their performance under the system and suggest ways to improve their scores.

Nobo was not optimistic that the tool will help practices much because it would not address the crucial need for practices to be notified of mistakes in real time so that the problems can be corrected.

“Right now with the way it is, you have to wait a year and then you get hit with the penalty,” Nobo said.


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

Publication Date: Thursday, September 22, 2016