The Case For and Against Hiring for MACRA

While practices are in the first year of reporting under the Medicare and CHIP Reauthorization Act (MACRA), the hard part has yet to come. That's because the first year of MACRA reporting includes flexible requirements that make it easy for practices to not get hit with any financial penalties.

In MACRA's Merit-based Incentive Payment System pathway, practices only have to report on one quality or practice improvement measure, or minimum advancing care information requirements this year, to avoid a 4 percent payment penalty in 2019

But that won't always be the case. As physicians have to provide more data, they may be feeling anxious about whether or not they need to bring on additional staff to prepare for this shift to quality-based reporting.  MACRA represents a shift not only from volume to value, but has the potential to reshape a physician's staffing practices as well, depending on the direction a practice chooses to take. While larger practices may be well equipped to make the shift to the MACRA, smaller practices may find themselves less prepared.

According to the Physicians Practice 2017 Staff Salary Survey, based on more than 1,000 respondents, many physicians have already made up their minds: 87.2 percent of practices said they will not be adding additional staff to meet MACRA regulations.

Experts agree that a practice can pave their own way through this transition without hiring new staff, so long as they get adequate education and take proactive steps to prepare..

Ask the Right Questions

Whether to hire new staff for MACRA may not actually be the right question to ask, says Adam Weinstein, MD, a vice president for clinical IT services at DaVita Kidney Care, which operates nearly 2,500 dialysis centers across the U.S., and a speaker to other physicians on MACRA for the Renal Physicians' Association. "MACRA is largely about practice transformation and the question that comes is: 'What am I transforming from, and what am I transforming into?'"

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He says that a practice first needs to assess the quality measures that reflect the care it offers its patients, and translate those into quantitative data. "Where your practice is today is going to be the driver of where you can go tomorrow, and thus what resources you need to get there," Weinstein says. On the most basic level, this is looking at what your practice does well and assessing your gaps and weaknesses.

After this, he suggests practices look at its EHR, especially how well it organizes data for reporting and whether a practice has a good relationship with the vendor in case issues crop up If a practice has a lot of room for improvement in this area or an already burdened administrative staff, this may be an opportunity to bring on new staff or seek educational resources for existing staff.

Meaningful Use, the government's effort to get physicians to begin using EHRs, has paved the way for MIPS' advancing care information category, and the early adopters of EHRs will most likely be the best equipped for the coming changes. In fact, Randy Buchnowski, an executive for the Halley Consulting Group, a physician practice management and consulting firm, says that much of what practitioners already had to learn to adapt to EHRs carries over into the reporting measures for MACRA. Thus, many practices already have staff in place that can take on MACRA's challenges. "CMS is not looking for practices to increase their administrative burden," he says.

Of course, this assumes that their EHR is already doing a good job of data collection and calculation of these measures. "Many practices will find that [collecting data] and reporting it is a labor intensive exercise and may require chart reviews," according to Charles Saunders, MD, CEO of Integra Connect, a technology and service provider specializing in value-based care.

When to Hire for MACRA

Saunders is one of the few experts that says hiring staff may be necessary. He says this is the case if a practice chooses to participate in the other MACRA pathway, an advanced alternative payment model (APM). These models have requirements for certain activities such as care coordination and quality improvement programs, which can't simply be automated. "To be successful in driving savings, some investments in these activities will be required for care coordinators and case managers," he says. This is because, as with MIPS measures, reporting on them can be a labor-intensive exercise requiring chart reviews, depending on the ability of the EHR to automate this process.

Other experts disagree, suggesting that MACRA shouldn't radically change the way physicians staff their practice or collect information from their patients. "In effect, MACRA simply is a requirement that physicians document that they've actually performed the next step in terms of a slightly more complicated process of documentation," says Stuart Hochron, MD, JD, chief medical officer and co-founder of Uniphy Health, a physician's communication and collaboration app. He says the changes won't require new staff, just more staff education. He recommends turning to CMS's extensive online resources on the topic, as well as medical societies that offer MACRA education as a start. "I'd either attend a respectable conference that was targeted as your organization is focused, or hire a consultant," he says.

Mike Piper, senior manager with the Berkeley Research Group, which specializes in healthcare consulting and hospital improvement practice issues, says he has seen other strategies be more effective than hiring new employees, such as forming a clinically-integrated network, in which a practitioner can "align with primary-care sub-specialists." He says that so long as the practice manager or executive director of the medical group has a good understanding of the components, a practice can be successful without new staff. Though he does caution, "It's a very different skill set than a biller or collector, and needs to be resourced appropriately."

Hochron also suggests that practices "find their own sphere of influence” within their own practice environment. “Who are the practices that they really respect that run well, have great practice mangers, and are tied into national organizations?"

Keeping Up With the Competition

MACRA does change the playing field for all practitioners in one key way, inherent in MIPS scoring - all practices will be measured against each other in terms of reporting. By the time MACRA is fully underway, Weinstein points out that a practice will have to score 100 percent to even show up in the top 10 percent of performers. "If you're not on the ball with all your data all the time, it's going to be hard to perform successfully at the highest level because you can rest assured there will be organizations dedicating resources to doing so," he says.

Buchnowski makes an even stronger case. "If you don't continue to improve, you're losing ground,” he says. “If you were doing well five years ago, and you've continued to do so, you've still lost ground, because your competitors have improved."

Thus, he recommends practices make sure their practice manager gets educated quickly. Citing the fifth annual Health IT Industry Outlook Survey, he says a shockingly high number of practitioners - 64 percent - are underprepared for MACRA and QPP.

Hochron fears that a lot of practitioners have "buried our heads in the sand" as a result of a constantly changing stream of rules, requirements and administrative burdens. But now, he says, practices can't keep doing that and hope to thrive. "The writing has been on the wall for at least five years. We knew it would be here. In another year or two it will really be the turning point for physicians.”

Right Person for the Job

Typically the clinical and administrative leaders within a practice will partner together to set the overall MACRA agenda and then identify a point person with project management chops to design and oversee the execution plan, says Saunders. However, he makes the bold case that "handling MACRA is ultimately everyone's job. CMS envisioned MACRA as a catalyst for practice transformation -to reorient patient care around outcomes rather than inputs - so every existing staff member has a critical role to play."

There are a couple of roles that will probably need to be filled or shifted onto an existing staff person, experts say. Weinstein calls this person the "data wrangler," whose primary responsibility is identifying the metrics related to the activities the practice is reporting and how the practice is capturing this data prior to sending to CMS.

Piper adds while there should be someone dedicated to taking the lead on MACRA, it “should not be the only strategy or reason for employment."

At the end of the day, staffing is just one pillar in support of value-based care success. Saunders emphasizes, "Practices must reassess their processes, tools, and technologies."