Family Medicine Physician Shares Doubts on MACRA

KrisEmily McCrory practices full-spectrum family medicine and teaches in a family medicine residency in upstate New York. Because she believes that advocacy is the only way to effect real change - she is a member of her state chapter of the American Academy of Family Physicians (AAFP). McCrory also blogs regularly for Practice Notes, an online blog on PhysiciansPractice.com. (You can read her blogs at bit.ly/krisemily-blogs.)

Physicians Practice recently spoke with McCrory about her initial reaction to CMS' proposed rule governing the new Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APM) and how she envisions her own role in meeting these regulations. Below are excerpts from part two of this conversation.

Physicians Practice: Will all physicians who participate in Medicare be affected by the new payment systems created through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)?

KrisEmily McCrory: The exemptions for MIPS are providers in their first year billing for Medicare, providers whose volume of Medicare payments fall below the threshold (which they haven't defined), and then providers who qualify for payment under the APM. For example, I'm part of an ACO - so if I'm part of an ACO and am employed by an ACO, then I'm going to fall under that APM model. Federally qualified health centers and people in rural health clinics are also exempt from MIPS. ... So it seems like the way they are looking at it, most physicians, particularly smaller physicians, are not going to qualify to be an APM because there aren't as many APMs at this point. And then they'll start with MIPS. When there are more APMs available either through ACOs or various things that happen, then people will go in that direction.

PP: Would employed physicians be exempt from MIPS?

KM: I don't see that ... being employed in and of itself wouldn't prevent you from being part of MIPS, but being employed always ends up being interesting. … There were ultimately going to be three levels of Meaningful Use, but they scrapped that with MACRA, prior to us really getting into Stage 3 of Meaningful Use. Part of the incentive of Meaningful Use, if you met certain benchmarks, then you would be able to claim a certain financial incentive. And even though the place that you worked for would be the one that would set up all the stuff you had to do to meet Meaningful Use, each individual provider had to attest to their own Meaningful Use. And the legislation very specifically said that individual physicians would be the ones that got the money, not the practices. You couldn't give the money to the practices, unless the doctor said, "Yeah, that's OK to give it to the practice." I don't know how that will pan out with MACRA.

Of course the interesting thing about this is it will only affect Medicare payments. So one of the biggest concerns is, and this happened with Meaningful Use, which only affected Medicare and Medicaid payments, how many people are going to stop taking Medicare patients? We already have a shortage of providers for those patients. 

PP: CMS predicts that 87 percent of solo practices will receive a negative payment adjustment in the first year. Are you concerned about this?

KM: The small private practice physicians, particularly the solo physicians, especially those that are closer to retirement, just the amount of overhead that they would have to invest in EHR-type of things and invest in the personnel-type of things that they need to run their offices in ways that they didn't have to before, is overwhelming. We've actually had a couple of docs in upstate New York who said, "You know what, I'm just going to retire early. Because I just can't do it." And there's really just not a lot of funding to help doctors get that stuff integrated. It is not inexpensive to have an approved EHR and [while] the EHR is required with Meaningful Use too, not only do you have to have it, but you have to continuously upgrade and maintain it. And there is really a very big cost associated with that, and no help with that.

PP: Why are physicians especially concerned about the proposed quality benchmarks?

KM: Some of the concerns expressed at the [AAFP Annual Chapter Leader Forum] that I was at is that oftentimes with the changing [standards] and research in medicine, the benchmarks don't always make sense. For example, Meaningful Use had benchmarks related to hemoglobin A1C, which is a measure for diabetes control. It was across the board, "How many of your diabetes patients have an A1C less than seven?" Because less than seven is the goal. But the reality is, the research and guidelines support this, as you get older patients and patients with a lot of comorbidities, that seven is actually not a good number. You are really looking at more like an eight. And maybe even an eight and a half - because if you get them close to a seven or less, you run the risk of having a significant hypoglycemic event that could kill them. So the doctors say, "Well I can either do what is best for my patient, which is not control them to a seven (and lose out on that potential benchmark) [or follow potentially bad clinical guidelines] ... but I think doctors are really concerned about any benchmark that is outside the control of the doctor. 

PP: What were you hearing about MACRA from other physicians at the AAFP meeting?

KM: They did end up having a session where someone from CMS was on the phone and they had a town hall Q&A session. The lines of people asking questions were quite enormous. People were asking questions related to the cost of doing this…"How are we supposed to deal with metrics that we don't even know what they are yet?" And a lot of people are concerned that people who have never been in an exam room are making decisions about what we should and shouldn't do in an office. How is that is OK? There are people (according to comments on the AAFP website) who are really trying to force the AAFP [to eliminate MACRA], they don't think we should have anything. But I don't think that is a reality. These value-based payments and new models have been coming down the road for a long time. This has been where things are going. I think people are very frightened about having metrics they have no control over, that may not be evidence-based at all, and the politics that are involved in developing them. And what that ultimately is going to mean for people in practice. [Physicians] are certainly talking about just not taking Medicare anymore. Certainly when Meaningful Use came in we did see a drop in people taking new Medicare patients.