TMA Leads Medicine's Charge to Simplify Proposal, Especially for Small Practices

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Tex Med. 2016;112(9):41-47.

By Steve Levine
TMA Vice President, Communications

To hear Dallas cardiologist Rick Snyder, MD, tell it, if his large and sophisticated practice can't make it under Medicare's proposed new pay-for-quality rule, there's no hope for the little guys.

"We pride ourselves on being cutting-edge on regulatory compliance," Dr. Snyder told a high ranking Center for Medicare & Medicaid Services (CMS) official who came to Dallas to hear what physicians think of the agency's draft rule to implement the Medicare Access and CHIP Reauthorization Act (MACRA). "There's no way in the world we are going to be ready Jan. 1. Our goal is just not to lose money."

Dr. Snyder, a member of the Texas Medical Association Board of Trustees, is vice president of his group, HeartPlace. With more than 70 physicians in more than 25 North Texas locations, HeartPlace is the largest independent cardiology group in the state and one of the largest in the nation. He says his practice has an information technology department of 10, is planning to add at least two more employees, and is changing to a new electronic health record (EHR) vendor largely due to MACRA requirements.

Dr. Snyder met in Dallas with CMS Deputy Chief of Staff Tim Gronniger, who came to Texas at TMA's invitation. TMA President Don R. Read, MD; Trustee Carrie de Moor, MD; and Council on Socioeconomics Chair John Carlo, MD, also had Mr. Gronniger's ear.

Dr. Read echoed Dr. Snyder's remarks and reinforced the message TMA sent to CMS in the association's formal comment letter on the draft MACRA rule. 

"We are light-years ahead of small practices, which are in survival mode all the time, in terms of reporting quality," Dr. Read, head of the 14-physician Texas Colon & Rectal Specialists, told Mr. Gronniger. "All these small practices are doomed to fail under this system. It's not worth their spending money to participate in a system where they're going to fail."

The chief congressional sponsor of the MACRA bill — a physician and a Texan — reminds doctors, however, that the chances and costs of failure are much lower than they would have been without the new law.

"Neither Simplified nor Improved"

Physicians cheered when Congress passed MACRA in April 2015, primarily because it finally eliminated Medicare's hated Sustainable Growth Rate (SGR) formula. The law also promised to consolidate and simplify a contorted web of Medicare programs that measure physicians on their cost and quality of care, as well as their "meaningful use" of EHRs.

"Eliminating the constant threat of Medicare payment cuts means that we can focus our energies on improving this new law," then-TMA President Austin I. King, MD, said on the night MACRA passed. "We can focus our energies on removing the bureaucratic impediments that get in the way of good patient care."

A constant TMA refrain since CMS published the draft MACRA rule on May 9, 2016, is "not what Congress ordered."

MACRA "promised to simplify and improve Medicare's costly and complex programs that purport to measure the quality of care we provide to our patients," Dr. Read wrote in a prominent national health care blog. "Unfortunately, as we review the draft implementing rule, it appears that the net result will be neither simplified nor improved.

"When MACRA legislation was enacted, TMA had no reason to expect CMS would propose to continue flawed concepts from the current quality programs along with plans to diminish a physician's worth down to a complex point system. More disappointing is to learn that CMS proposes to design a program that is stacked against solo physicians and small group practices in its first year of implementation." (See "The Game You Cannot Win.")

The concern for small practices stems in part from a now-infamous table CMS published in the draft rule. Based on physicians' performance under the current Medicare measurements, Table 64 estimates 87 percent of solo practitioners, 70 percent of eligible clinicians in practices with two to nine eligible clinicians, and 59 percent in practices with 10 to 24 eligible clinicians would see their Medicare payments cut in the first year of MACRA. 

Although CMS has dismissed Table 64 as based on outdated data, TMA staff's evaluation of the proposed rule finds plenty of reasons for small practices to worry. "TMA analysis finds that small practices frequently will face a lose/lose scenario in which they either incur more cost than they can expect to receive in financial rewards, or they absorb the crippling penalties and abandon any effort to comply with program requirements," staff wrote in a comprehensive "Texas Medical Association MACRA Position Statement" published in July. 

In its formal comment on the rule, TMA made several recommendations to ease the burden for small practices. (See "50 Ways to Fix MACRA.") For example, TMA estimates physicians who bill less than $250,000 in Medicare charges will spend more trying to comply with the rule than they could ever earn in bonuses. TMA recommended any physicians who bill less than that amount be exempt from MACRA. CMS set the "low-volume threshold" in the proposed rule at just $10,000.

CMS Acting Administrator Andy Slavitt has publicly acknowledged doctors' vast discontent with the current system and has gone out of his way to solicit practicing physicians' suggestions for improvement. He sees the agency's plan, however, as consistent with congressional intent.

MACRA, Mr. Slavitt told the U.S. Senate Finance Committee in mid-July, "allows physicians and other clinicians to participate in a single, simplified program with lower reporting burdens and new flexibility in delivering quality care."

That comment drew a quick rebuttal from Gregory M. Fuller, MD, chair of the TMA Council on Health Care Quality. "Mr. Slavitt has heard what physicians have been saying is a major barrier to MACRA: increased complexity, increased bureaucracy," Dr. Fuller said. "The goal of MACRA is to improve health care quality and decrease cost, not cause physicians to drop out of Medicare or retire."

Massive Change, Short Timeline

The MACRA law, Mr. Slavitt explained in a speech earlier this year, intends "to make a wholesale change in the Medicare payment system to pay for quality." The gargantuan, 962-page proposed MACRA rule CMS published in May underscores the magnitude of that change.

In SGR's place, MACRA requires physicians to choose between two major payment paths: the fee-for-service Merit-Based Incentive Payment System (MIPS) and eligible alternative payment models (APMs) beginning in 2019. Data collection to determine each physician's 2019 Medicare payment rates begins Jan. 1, 2017.

MIPS replaces and will include similar concepts from the current Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier (VM) program, and the EHR incentive program (meaningful use). It adds a new category: clinical practice improvement activities (CPIAs). Physicians' scores on each of the four measurements will be summed, and the total compared against their colleagues nationwide. Depending on the comparison, physicians will see Medicare bonuses or penalties of up to 4 percent in 2019 and up to 9 percent in 2022 and beyond. 

TMA analysts identified a host of tasks physicians and their office staff must undertake to avoid the penalties or earn the bonuses. They include:   

  • Learn program requirements (and relearn them after frequent program revisions),
  • Investigate reporting options and requirements, 
  • Select compliance methods, 
  • Revise standard practice processes and guidelines to incorporate new protocols, 
  • Train all relevant staff, 
  • Perform related tests or interventions, 
  • Document performance or results, 
  • Report what was documented, 
  • Verify receipt or processing of reported data, and 
  • Defend the data in an audit.    

The list does not include the cost and time to install, upgrade, or replace software and to purchase or license new or custom software interfaces, electronic communication methods, or custom reports.

(TMA has developed a wide array of free and low-cost services and materials to help Texas physicians prepare for MACRA. See "TMA Prep Tips for MACRA.")

The anticipated release date for the final rule is on or around Nov. 1, 2016, with data collection to begin on Jan. 1, 2017.

"How can anyone possibly get ready in 60 days?" Nancy Bowman, executive director for Dr. Read's practice, asked Mr. Gronniger. "I mean, seriously? Seriously?"

In its formal comment on the rule, TMA told CMS that data collection for 2017 should start no sooner than July 1, with only six months of data to be collected and reported in that first year. Numerous other stakeholders pushed for similar delays.

Mr. Slavitt acknowledged that he had heard those concerns in an exchange with members of the Senate Finance Committee in mid-July. 

"We need to launch this program so that it begins on the right foot," he said. "Some of the things that we're considering include alternative start dates, looking at whether shorter periods could be used, and finding other ways for physicians to get experience with the program before the impact of it really hits them."

A nationwide survey of physicians released the same day as the Senate committee hearing underscored the need to move more slowly. The Deloitte Center for Health Solutions 2016 Survey of U.S. Physicians found that only half of non-pediatric physicians in the country had even heard of MACRA, and 32 percent said they just recognize the name. 

Better Than What Could Have Been

U.S. Rep. Michael Burgess, MD (R-Lewisville), the primary House author of the MACRA bill and an obstetrician-gynecologist, admits "there have been a couple of surprises" in how CMS is proposing to implement the legislation. Dr. Burgess made SGR repeal his primary goal through seven terms in Congress, and he reminds physicians of the significance of that achievement.

"People are forgetting what brought us here," Dr. Burgess told Texas Medicine in an exclusive interview. "I get criticized a lot for what's going to happen in 2019. ‘My gosh, there could be some reductions in reimbursement.' Yes, if you do nothing as far as any quality reporting between now and 2019, a doctor's practice in Medicare could receive a reduction of 4 percent. Current law, as it was a year and three months ago, that could have been 30 percent with the SGR and, of course, PQRS and meaningful use, value-based modifier, all of those things aggregated to a significantly larger cut — maybe as much as 10 times as much as a nonparticipating physician might see in 2019."

He also points out that both the Obama administration and Republican leaders in Congress have been quick to blame the fee-for-service system as the primary cost driver in Medicare. "On the right and the left, that notion exists and persists," he said. That increased the political costs and the trade-offs needed to keep a fee-for-service Medicare option for physicians in the MACRA law.

Dr. Burgess says he also worked hard to include a new performance measure — the CPIAs — in the bill. 

"It's really simple stuff," he explained. "Do you have an email address? Do you have a Saturday clinic from time to time? Do you have nighttime office availability? When we were writing it, there was a lot of criticism. ‘You might as well just call this bill Everybody Gets an A. You're making it too easy.'"

It's up to organizations like TMA, Dr. Burgess says, to show physicians how to be successful in the post-SGR world. "My hope is, people will look at 2019, see the risk of a ding, and realize with a little bit of work they can get a payment bump up," he said. "So instead of a ding, you get a bump. How's that? That would be good."

A Headlong Rush to Consolidate

For physicians like Dr. Snyder, whose HeartPlace group will make every effort to succeed under the new system, a more insidious devil lurks in the details. Given the administrative requirements, costs, and hassles of compliance, he says, many practices "won't be able to resist the temptation" to sell out to hospitals and large health systems that will manage the problem for them.

"In Texas, more than 60 percent of patient care physicians are in very small practices of one to three physicians," according to TMA's MACRA position statement. "MACRA is very likely to levy penalties on most of them, pushing some or all of them over time to retire, or join large groups or hospitals. ... Such a huge disruption in the ambulatory care environment might be justified if there were evidence that the changes would result in better or more efficient care, but the evidence that exists does not support that notion."

Dr. Snyder says his practice is intrigued by the possibility of following the APM path under MACRA. That path offers bigger bonuses to physicians engaged in alternative payment models, such as eligible accountable care organizations, certain patient-centered medical homes, and some bundled payment models. 

But even for large practices such as his, Dr. Snyder foresees an "accelerated consolidation of independent physicians going into hospitals." He pushed Mr. Gronniger to come up with an "independent practice pathway" for success as an APM.

"We as independent physicians want to stay independent," he said. "Make it friendly so we can increase quality, reduce costs, and remain independent because we think that's the best model."

Steve Levine can be reached by phone at (800) 880-1300, ext. 1380, or (512) 370-1380; by fax at (512) 370-1629; or by email.


50 Ways to Fix MACRA

TMA sent the Centers for Medicare & Medicaid Services (CMS) a detailed formal comment letter with 50 recommendations to improve the agency's proposed rule to implement the Medicare Access and CHIP Reauthorization Act (MACRA). The most critical of TMA's 50 recommendations are:  

  • Significantly expand the low-volume threshold. According to TMA's analysis, physicians who bill less than $250,000 in Medicare charges will spend more trying to comply with the MACRA rule than they could ever earn in bonuses, if they hit the quality targets. CMS set the low-volume threshold at $10,000 in Medicare allowed charges. TMA told CMS to set the threshold at $250,000. Doing so would exempt physicians who have no possibility of a positive return on their investment in the cost of reporting. For physicians with less than $250,000 of Medicare revenue, reporting should be optional, and physicians who attempt compliance should be exempt from any payment penalties. 
  • Delay the start. The rule will be finalized around Nov. 1. Practices will have to begin collecting data and making big changes in their operations on Jan. 1. This gives physicians only two months to prepare. TMA told CMS the measurement period for 2017 should be reduced to six months and start no sooner than July 1. (The data collected in 2017 affects physicians' Medicare payments in 2019.) 
  • Set the performance threshold low. The performance threshold (PT) is the most important factor affecting MACRA's overall impact on small practices. CMS has complete discretion to set the PT, which is the score a physician must earn to avoid penalties. The threshold also will determine how much MACRA will shift Medicare payments from smaller physician practices to larger groups and health care systems. To reduce the negative impact on small practices, TMA urged CMS to set the PT at 15 percent in the first year of implementation.  


"The Game You Cannot Win"

TMA President Don R. Read, MD, uses this metaphor to describe what the draft MACRA rule would mean for physicians:

"This is how MACRA comes across to me. With original Medicare, we were playing checkers. There were some rules we didn't agree with, some that were truly stupid, but you pretty much understood the rules. Then with PQRS and meaningful use, we started playing chess. Kind of easy chess, but we were starting to play chess. 

"And now you say, 'Well, we're going to change the game.' It's not checkers; it's not chess; it's something new. The board's got two more columns and two more rows. Some of the chess pieces are the same, but we've put new ones out there. And we've written rules. We started to write them in Mandarin Chinese, but we figured you'd be able to get an interpreter and interpret them, so we've written them in Mayan hieroglyphs to make sure you don't understand.

"But you have to start playing right away, and don't worry about the fact that you don't understand the rules because we have deliberately set the game so that you cannot win.

"And by the way, two years from now you're going to get penalized because you did not win."

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TMA Prep Tips for MACRA

While the details of exactly what the Medicare Access and CHIP Reauthorization Act (MACRA) will require of physicians must wait for the Centers for Medicare & Medicaid Services (CMS) to issue the final rule, TMA has developed a wide array of free and low-cost services and materials to help Texas physicians prepare. Stay up to date on the latest at the TMA MACRA Resource Center.

TMA's Five-Step Checklist for MACRA Readiness covers the research you can undertake, decisions you can make, and steps you can take now to get your practice as ready as possible. The October issue of Texas Medicine will cover this material in greater detail. For health information technology (HIT) questions — including help on purchasing an electronic health record system for your practice — see TMA's HIT Resource Center, or contact the TMA HIT helpline by email or by calling (800) 880-5720. 

The TMA Education Center offers live and on-demand courses at special member prices. MACRA-related education includes courses for those who plan to take part in MACRA right away and suggestions other practices can take to offset the 4-percent Medicare penalty that will come in 2019 for those who don't participate in 2017.

Created by TMA in 2015, TMA PracticeEdge helps physician practices as they transition to value-based payment models. If you are a primary care physician interested in forming an accountable care organization (ACO) or joining an existing organization, contact info[at]tmapracticeedge[dot]com, or call (888) 900-0334. TMA PracticeEdge clients include ACOs with Medicare Shared Savings Program, commercial, and Medicare Advantage contracts.

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Last Updated On

September 09, 2016

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Steve Levine

VP, Communication

(512) 370-1380
Steve Levine

A former statehouse reporter, political press secretary, and state agency spokesman, Steve Levine has directed the Communication Division at TMA since 1997. He oversees Texas Medicine, Texas Medicine Today, TMA's media and public relations activities, and the TMA Knowledge Center, website, and social media activities.

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