A Conversation on MACRA with a Family Physician

KrisEmily McCrory is a family medicine physician who teaches and practices at Ellis Medicine, a 438-bed teaching health system in upstate New York. In addition to teaching and mentoring residents, seeing patients, and parenting her three children, she is active in physician advocacy and is a member of her state chapter of the American Academy of Family Physicians. McCrory also blogs regularly for Practice Notes, an online blog on PhysiciansPractice.com, about the continuing challenges of dealing with government regulations and what it means to be a physician in today's environment. (You can read her blogs at bit.ly/krisemily-blogs.)

McCrory recently attended the AAFP's 2016 Annual Chapter Leader Forum in Kansas City, Mo., where AAFP president Wanda Filer gave a brief response to CMS' recently released proposed rule on the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

Physicians Practice spoke with McCrory about her initial reaction to the proposed rule and how she envisions her own role in meeting MACRA regulations. Below are excerpts of part one of this conversation.

Physicians Practice: Can you tell me about the AAFP national conference that you attended?

KrisEmily McCrory: So the conference that I attended wasn't specifically about MACRA, but the American Academy of Family Physicians (AAFP) has this national meeting every year. It is basically a conference of constituency leaders. … The current president, Wanda Filer of the AAFP, gave a short address about MACRA at this conference that was actually streamed on the AAFP website. … The AAFP, along with some of the other groups as well, is really trying to spearhead education particularly for family physicians about what MACRA is, what they are trying to do. Although MACRA was passed back in April of 2015, the reality is it is not completely done yet. So some of the guidelines, some of the metrics are still being figured out. There is still some time for the different professional societies to continue to kind of weigh in, and obviously the Academy of Family Physicians is doing it on behalf of primary care and family doctors.

PP: What was the AAFP's initial reaction to the proposed rule?

KM: I think that the thought process that has been set up by Wanda Filer, acting on behalf of the AAFP, is that there is great opportunity here to really take some challenging things that came out of meaningful use and things that were related to the previous legislation and make it more flexible and possible for doctors to provide quality care, without feeling like they are overburdened with checking a bunch of check boxes. That being said, because it is not completely finalized yet, it is still just an opportunity. We don't know in the long run that it will really do what they are hoping it's going to do. The Academy is really putting forward a very optimistic face right now, but I can tell you just based on comments (there's a lot of comments on the AAFP website) … family physicians are very concerned about MACRA, the requirements, what they may or may not be, how they are getting paid. A lot of people are very concerned about this whole idea about a value-based payment system and moving away from fee for care, and [wondering] how is this any different from the HMOs that we did with capitation in the 90s that failed miserably. So there are a lot of things that are concerning to family doctors.

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.