Small Practice Doc Speaks Out Against MACRA

The proposed rule is less than a week old but Linda Girgis, a family medicine physician in South River, N.J., is not too pleased with the Medicare Access and Summary CHIP Reauthorization Act of 2015 (MACRA).

If CMS' own projections are accurate, in two-and-a-half years, she'll be joined in her dissent by many other small practice docs across the country. By next year, MACRA will change the way physicians are reimbursed for Medicare, combining and configuring the Physician Quality Reporting System (PQRS), the Value Modifier Program, and the Medicare Electronic Health Record (EHR) Incentive Program (Meaningful Use).

For more on MACRA, read this breakdown of how the proposed rule would work and impact practices.

Yet, the cost could come at the expense of solo and small practice physician practices. CMS projected that in 2019, 87 percent of solo practices will be hit with a negative Medicare payment adjustment as will almost 70 percent of practices with two to nine eligible docs. The overall financial impact on solo doc practices will be $300 million and for two- to nine-doc practices, it will be $279 million.

For that reason, Girgis is already speaking out against the proposed rule and hoping other small practices will join her advocacy efforts. She spoke with Physicians Practice on the rule, what it will mean for small practices, and why it's not easy to opt out of Medicare. Below are excerpts from their conversation.

Physicians Practice: You have not been shy in your criticisms of MACRA, what are your biggest problems with the proposal?

Linda Girgis: It's penalizing small practices and solo doctors. It was supposed to be based on quality initiatives, and [CMS] has already revealed how many bonuses they're going to give, how many negative adjustments. I thought this was supposed to be about quality, but it's obviously about balancing their budget rather than improving quality healthcare.

PP: Is any of it salvageable in your eyes?

Girgis: I think [CMS] is going about it the wrong way. I think patients need quality medication, but they are serving their political agendas, rather than have it be about clinical outcomes. They said they are making it patient-centric, but that's not true. They have it so people are focused on the data, rather than the patients.

The metrics [look at patients as data points]… there are patients who are sick with multiple diseases [that won't be looked at positively in terms of data analysis] but you can improve their health. Under this incentive system, you get penalized for spending a lot of time with those patients who are never going to get better.

For instance, the Merit-based Incentive Payment System is based on metric for clinical outcomes, such as an HbA1C measurement for a diabetic patient. If a certain percentage of patients get that measurement, the doctor will receive a higher reimbursement. This model neglects patients with co-existing diseases…which has an impact on diabetes control. Some patients are sicker and will never get to the goals [set out by MIPS]. These patients require much more time and attention. And the doctor caring for them will probably be negatively adjusted based on the metrics reported. The extra time and care is not rewarded, but rather penalized.

If, for example, you have a healthy patient with diabetes, you don't need to spend as much time with them. They may just come in for refills. And they are likely to have better [metrics]. So, the doctor who does the less work here will get rewarded, just because they have healthier patients. And the doctor really spending quality time with patients trying to make them healthier loses money just based on a metric. 

PP: Do you feel there is a way to pay for quality, which seems to be what MACRA is trying to accomplish?

Girgis: It's hard for small practices – hospitals and big systems have IT departments and a whole staff that's hired to carry this out. In private practice, we have to do that ourselves. It's costly and time consuming. It's hard for doctors to pay this the attention it needs. The regulations they are making, it's not helping.

If you look back at Meaningful Use's original goal, they didn't change it to make it better, they changed it because they weren't able to make it work. Systems need to interoperate with each other, but they don't do that. Meaningful Use had to go away because it couldn’t do what it supposed to do. We're not going to fix anything if we're spending billions more and trying to salvage what was not working to begin with.

PP: One of the things that should be noted is that it seems a lot of physicians aren't even aware of MIPS – do you find this to be the case and why?

Girgis: Most doctors aren't aware of what's coming. Doctors are so pressured, we don't have time to be reading up on this. The (MACRA) document, it's more than 900 pages. It's hard to know what's going on. I think doctors are getting used to getting beat up, so they don't care anymore.

PP: What would a 4 percent adjustment on Medicare payments do for some practices?

Girgis: Some practices have huge Medicare populations, so this could destroy them. If you look at reimbursements over the last decade, they've stayed the same but overhead costs are going through the roof. We're not getting reduced in our payments, but we are when you try to keep up with cost of living. This will reduce it even further. If this goes on … you'll see fewer doctors in private practice.

PP: On Twitter, you suggested opting out of Medicare, but for some practices, is that feasible? What if most of their patients are older?

Girgis: It's a big movement, taking insurance out of the picture, just having doctors and patients work together. In a larger sense, this won't solve the problem because patients won't have access to care. For me, I feel I need to serve those patients. That's why I'm [speaking out] against the system rather than walking away, but these are people with real problems, they need medical care.

PP: What message do you have to your fellow small practice physicians?

Girgis: One of the problems is doctors are so isolated and are not allowed to collectively bargain for our rights. This has put us in a lot of trouble. We need to come together, fixing things that need to be fixed, rather than stay in our own bubbles. We need to come together and find real solutions.