Many docs wary of Medicare reimbursement shift

HBJ PHOTO | John Stearns Dr. Timothy Chartier, a Mohs micrographic surgeon and partner with one other doctor in Dermatology Surgical Associates LLC in Farmington and Glastonbury, believes the Medicare Access and CHIP Reauthorization Act of 2015 will have a negative impact on many small practices in the state.

Matthew Katz, CEO and executive vice president, Connecticut State Medical Society

Jeff Gordon, hematology oncologist, New London Cancer Center

Dr. Courtland Lewis, orthopedic surgeon, Hartford HealthCare Bone & Joint Institute, Hartford Hospital

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By John Stearns

MACRA almost spells macramé, which is ironic given that the acronym for the new Medicare reimbursement rules doctors are facing seems to have more than a few physicians' stomachs tied up in knots.

The Medicare Access and CHIP Reauthorization Act that Congress passed last year, better known as MACRA, represents a major change in how doctors will be paid for treating Medicare patients.

The Centers for Medicare & Medicaid Services is looking at quality and cost in the new system, said Matthew Katz, CEO and executive vice president of the Connecticut State Medical Society.

“If you save the system money, you get added payment,” he said. “If you cost the system money, compared to a benchmark, you lose some money. That's essentially the structure.”

Today, doctors are paid a fee for service. That doesn't go entirely away under MACRA, but more of a doctor's pay will be tied to care quality and outcomes based on metrics, some already in place but not mandated, that some area doctors say are complicated and sometimes irrelevant to patient care. Their reimbursement could rise or fall based on those performance measures.

Connecticut doctors interviewed for this story, who were recommended by the medical society as representing a cross-section of practices, all support the need for cost savings, but not in ways they say could harm the doctor-patient relationship and care. They don't like the prospects of being penalized financially for missing benchmarks that may not apply to every patient.

Some advocate delaying implementation of MACRA and others fear it could hurt solo and small practices, forcing them out of business or to join larger groups with more resources to deal with the system.

The first reporting requirements under MACRA, for which public comment has ended and final rules are expected to be published in November, begin in January. In theory, the 2017 program year will see the shift to MACRA, with payment adjustments applied beginning in 2019, the medical society said.

Despite the significant changes looming since MACRA was signed into law last year, accounting and consulting firm Deloitte found that half the 600 doctors it surveyed recently about MACRA had never heard of it.

Sarah Thomas, managing director for research in the Deloitte Center for Health Solutions in Washington, D.C., said she wasn't surprised by that finding, but “I was surprised that even doctors with a large share of Medicare patients didn't know it.”

That highlights the need for educating doctors quickly about the law — no small feat considering its complexity.

“If we do not educate, we're going to have a mess on our hands — and that needs to happen and needs to happen immediately,” Katz said.

New rules

Between 4 and 9 percent of a provider's Medicare reimbursement in the next few years will be based on two new reimbursement structures in MACRA from which physicians will choose: The merit-based incentive payment system, or MIPS; and alternative payment models, or APMs.

In MIPS, performance and “composite scores” will be based on four categories: quality, resource use, meaningful use of electronic medical records and clinical practice improvement activities (CPI), according to an American Medical Association summary. CPI is new and the other three, which some doctors say lack evidence supporting their benefit, will have different and changing weightings in the scores.

For missing performance thresholds, there will be maximum penalties of up to 4 percent in 2019, 5 percent in 2020, 7 percent in 2021, and 9 percent in 2022 and beyond, AMA said. Exceeding the performance threshold, physicians can earn bonuses on a sliding scale, with the highest bonus at least as high as the highest penalty for that year, AMA added.

Under APM, most providers will also be subject to MIPS, but will receive favorable scoring — with correspondingly higher reimbursement rates, according to a summary by Portland, Maine-based Network for Regional Healthcare Improvement (NRHI). Providers participating in the most advanced APMs (including accountable care organizations, patient-centered medical homes and bundled-payment models) may be designated as qualifying APM participants (QPs), which are not subject to MIPS. They may be eligible for annual 5 percent lump-sum bonus payments from 2019 through 2024 and other benefits, NRHI said.

But APMs also can carry more downside risk if patient costs exceed certain thresholds and doctors have to eat the costs.

The alphabet soup is enough to boggle the mind, let alone the rules behind the letters.

“I think that MACRA could in the long run help to improve the quality not only of care provided, but the health and well being of Medicare beneficiaries in Connecticut, but it also has the potential to be the downfall of medical practice in Connecticut if it's done wrong,” Katz said.

That's a concern of most Connecticut doctors interviewed for this story.

“I would say that it's going to have a very negative impact on many small practices in Connecticut,” said Dr. Timothy Chartier, a Mohs micrographic surgeon and partner in Dermatology Surgical Associates LLC, which has offices in Farmington and Glastonbury.

Most physicians would agree with the concept of MACRA, the idea of which is to lower the cost of medicine while improving it, he said.

“I think that's where the rub is — that a lot of the measures they're instituting on practices are complex, they don't really have any real meaning to individual physician practices,” he said.

Many measures required under MACRA don't apply to his area of practice and do little to improve patient care, he said.

“It's just going to increase my staffing overhead, it's going to detract me from doing what I primarily do for my patients and it's going to result in longer wait times for patients because now I'm getting slowed down basically to measure things that really have very little impact in the care of my patients,” Chartier said.

Physicians practice evidence-based medicine, but many of the new regulations have no evidence they improve care, he said.

So what's the answer?

“Continuing to work on the concepts behind MACRA … and that they're rolled out in a way that's not punitive to practices,” Chartier said.

Jeff Gordon, a hematology oncologist who practices with two other doctors in the New London Cancer Center in Waterford, said doctors could help make MACRA better and he hopes it can be delayed to allow that.

“My opinion is that if there are no changes made with it and it's not slowed down to really try to make it a more effective program and a more user-friendly program for patients and for physicians, it's doomed to failure,” said Gordon, incoming president of the state medical society.

Small groups in peril

Dr. Courtland Lewis, an orthopedic surgeon in the Hartford HealthCare Bone & Joint Institute at Hartford Hospital, is already operating under an APM through a bundled-payment program. While his group has made significant cost improvements to patients' overall care, specifically post-discharge as more patients rehab at home instead of inpatient rehabilitation facilities, the group hired two nurses to help patients navigate from presurgery through 90 days postsurgery.

However, the group still is not able to hit Medicare price targets, meaning it's costing more to manage the program than the group is getting back through it and it won't get any easier under MACRA as price targets adjust, Lewis said.

Lewis thinks the answer is to pilot alternative-payment models until there's a high level of confidence they'll work in the real world across different geographies and patient populations.

He also fears MACRA's impact on solo and small practices. The logistics of participating in such programs are substantial, he said.

“It takes resources, it takes people,” Lewis said. “If you're in a big practice like I am, even though it's single-specialty practice, you've got a prayer of a chance because we've got some folks whose job it is to help us collect the information.”

Deloitte's Thomas said MACRA is happening, although it's possible some parts could be delayed. Additionally, health plans may want to align their quality-measurement strategies and value-based care strategies with MACRA, she said.

“So I think there's some implications for health plans and for providers and frankly even for some of our life sciences companies because they're going to need to think about what this is going to mean for them — so the whole industry is interested in this law,” she said.