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A Conversation on MACRA with a Family Physician: Page 2 of 2

A Conversation on MACRA with a Family Physician: Page 2 of 2

PP: What are some of the specifics that are prompting concern from physicians?

KM: One of the things that people were excited about with MACRA is that [it] got rid of the Sustainable Growth Rate (SGR). Which was good because the estimation was over the next few years, if that hadn't gone away primary-care doctors could have seen reimbursements go down by 20 percent. So hopefully the passing of MACRA will supposedly make things a little bit better. I mean, it is going to use a lot of things that already exist. So while the Physician Quality Reporting System (PQRS), value-based payments, Meaningful Use [are ending as individual programs], none of that is really going away.

They are all just kind of being consolidated into one program. And I think that is where people are becoming concerned that this is just throwing lipstick on a pig. This is not necessarily going to be the big change that we need. And it really does remain to be seen.

PP: What will physicians need to do to meet quality metrics so they can receive incentive payments from Medicare?

KM: Doctors are going to be able to pick between two tracks: this Merit-Based Incentive Payment System (MIPS) and then these Alternative Payment Models (APMs). MIPS has a lot of things that are based on Meaningful Use and PQRS — these are kind of geared at people who have already achieved Patient-Centered Medical Home (PCMH) status. Theoretically they are already doing some of these things. It's going to include some clinical practice things, but it is not clear how that ultimately is going to work. But there is going to be this threshold, where if you achieve above this threshold you can get a positive payment adjustment, and if you get below that threshold you can get a negative payment adjustment. So there is this concern that doctors are not meeting whatever threshold will be, and we don't know what those metrics are yet. We know [CMS will] start counting in 2019, but they've already suggested that they are going to use data before 2019. We don't know what they are looking at, but it's what we are going to be judged on. So there are a lot of concerns about how that will work. You are going to need a certain number of Medicare payments and a certain volume, again not a lot of things defined. So there's just a lot of concerning things involved with that. 

PP: How will choosing the APM track differ from choosing MIPS?

KM: The APM, I don't understand that quite as much, but [CMS is] looking at things like the Medicare Shared Savings Programs, like Accountable Care Organizations (ACOs). I'm currently in an ACO. The hospital that I work with has partnered up with another hospital in the area to form this ACO. It's not real clear that it works well. There are a lot of challenging aspects to an ACO, you have to maintain certain quality metrics, while saving money, and maintaining a certain patient satisfaction rate. And if you don't do all three of those things, you don't get to share in the savings that you would otherwise get to share in. It just gets to be a lot to it, so I think that's a lot of the concerns; what is that ultimately going to mean and how are we going to do it. And not feeling like ... doctors already feel like they have no control over this, so this just makes it a little bit more complicated.

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