Addressing Physician Concerns about MACRA and APMs

May 10, 2017

Uncertainty about the future of the ACA means continued concerns about initiatives already underway.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is one of the biggest shifts in physician payment in decades. Yet for such an industry change, the impact on most physicians will be modest and incremental. Take stock now of the challenges facing physicians and then scale an effective and lasting approach for your group or organization.

What is MACRA?

MACRA, a related but distinct legislative byproduct of the Affordable Care Act (ACA), seeks to incentivize improved outcomes and overall quality of care. Centers for Medicare & Medicaid Services (CMS) created guidelines that tie provider reimbursement to cost-effective, high-quality care. MACRA replaces the unpopular Sustainable Growth Rate (SGR) and provides incentives to physicians for the quality of care they provide. Physicians who outperform their peers on measures of quality, health record interoperability, care improvement, and cost may see higher payments, while under-performing or non-reporting physicians will be penalized. These changes will be incremental and take several years before fully implemented. Physicians and groups participating in Medicare Advanced Alternative Payment Models (APMs) are exempt from MACRA incentives.

Most physicians are not yet familiar with MACRA, according to the Deloitte Center for Health Solutions 2016 Survey of U.S. Physicians. The survey revealed that 50 percent of physicians have never heard of the law, and 32 percent recognize it by name but are not familiar with its requirements. The study found employed physicians were less likely to be familiar with MACRA than independent physicians.

The impact of MACRA on individual physicians and groups

MACRA’s impact on individual physicians and groups is variable, as the law mostly affects physician practices who care for seniors and who bill Medicare under traditional fee for service. The law has limited or no impact on providers who care primarily for children and younger adults, and who provide services predominantly to patients insured under Medicaid and commercial health plans. Managed Medicare Plans are not affected by MACRA, although this could change in the future. 

Practices most likely to benefit from the new law are those that previously invested in EHR, quality measurement and reporting, care process improvement, and providing low cost care. MACRA also rewards practices already participating in demonstration projects with quality and cost incentive programs, such as advanced medical homes and Accountable Care Organizations (ACOs). 

Physician impact is not limited to reimbursement. MACRA builds upon and refines existing quality incentive programs (Meaningful Use and the Physician Quality Reporting System PQRS). Some specialists will want to take advantage of new and more pertinent quality metrics. New options exist for group rather than individual reporting, reducing administrative burden for many practices. Physicians who see fewer than 100 Medicare patients annually or less than $30,000 in annual charges are excluded. Most importantly, performance on quality scores will now determine whether physicians are financially rewarded or penalized. Physicians need to expect their quality scores will be reported publicly and integrated into star ratings. When communicating with physicians, be prepared to describe specifically how each physician and group will be measured and what choices face the practice about selecting quality metrics.

How to get physicians on board

It may seem ironic that a program intended to reward physicians for doing the right thing – providing higher quality care at a lower cost – might not be perceived positively. Providers are increasingly burned out and frustrated by issues such as EHR adoption, administrative burden, and inability to provide patients the quality of care they need. When it comes to pay for performance programs, the devil is always in the details. 

To help keep physicians engaged with the process:

•Create open dialogue and empathize with your providers. Don’t just tell them what needs to happen to succeed under MACRA, but affirm you understand the challenge and ask for their advice.

•Use proven data-informed techniques such as Lean, pioneered at Seattle’s Virginia Mason and Wisconsin’s ThedaCare  to guide improvement. Seek out providers interested in being involved with these techniques and learning more about improvement. 

•Break large initiatives into smaller pieces that are more likely to succeed.

•Celebrate progress and express your appreciation. Recognize providers not just for succeeding under programs like MACRA but for providing compassionate, high-quality care every day.

•Shadow your providers, understand their pain points, and offer improvement assistance when you can. 

•Recognize the signs and symptoms of burnout and support at-risk providers.

•Don’t assume that every physician and group can or should be a top performer under MACRA right away. Pushing too hard or too fast may jeopardize long-term success.

ACA repeal and impact on MACRA 

With repeal and replacement of the ACA in progress, many are concerned about what that means to initiatives already underway. MACRA will evolve, as does any new federal program, but repeal is unlikely. MACRA passed with broad bipartisan support. Secretary of Health and Human Services Tom Price supports MACRA with more flexibility and less burden on physicians. 

During discussions with your providers:

•Acknowledge the uncertainty, but also that MACRA is current law and in effect now.

•Agree to make a plan together and commit to adjusting the plan if and when the regulations change. 

•Describe the steps you will take to monitor and track any changes to the rule. Many physicians receive information on MACRA and other policy matters from professional associations and other outside organizations. Ask them to forward and share this material to help keep one another informed. 

MACRA is complex, and understanding the detailed final rule is just the beginning. Communication and engagement with physicians and providers must be tailored and succinct.  Be specific about the impact and ask for help designing and planning change. Be empathetic to other challenges affecting the current practice environment, and stay flexible to adapt as the environment continues to evolve.

Steve Gordon, M.D. is a national principal healthcare consultant with Point B Management Consultants. Steve has three decades of progressive healthcare experience as a clinician, educator, executive, and board member. Steve trained in internal medicine at Massachusetts General Hospital and attended Harvard University for his Bachelor, Master in Public Policy and MD degrees.