With the first participation year of the Medicare Access and CHIP Reauthorization Act's Quality Payment Program well underway, many physician practices need to identify short- and long-term compliance strategies. However, physicians may feel they have limited time and financial resources to throw toward compliance with yet another set of regulations.
Becker's caught up with American Medical Association President David Barbe, MD, to discuss how physicians can satisfy the basic requirements under MACRA for the first performance year, while preparing for more involvement in the future.
Here Dr. Barbe offers tips on how to get started with Merit-based Incentive Payment System despite limited resources, how to position practices for participation as an Advanced Alternative Payment Model and when MIPS may be the more appropriate choice for physicians.
Editor's note: This interview has been edited lightly for length and style.
Question: From your point of view, what is the "state of the union" among physicians about MACRA and MIPS? How ready are physicians; what is their understanding and sentiment towards it?
Dr. David Barbe: The AMA and other physician organizations have worked really hard since the passage of this legislation in late 2015 to get physicians ready. Part of the problem has been the final rules on this were not out until very late in 2016, so everyone was just kind of waiting. We could get some generic information out there, we could speculate what might be in the performance requirements, but we didn't know until November. We have pivoted, if you will, after those rules were made available to be more specific and help physicians assess their readiness to perform successfully under MIPS. We have a payment model evaluator physicians can use that helps them assess their readiness and where the gaps are. We have an interactive MIPS action kit that helps them monitor their progress in terms of performing to MIPS. We have pushed a lot out there.
In spite of that, the awareness level among decision makers in practices is less than 50 percent. A few months ago, less than a fourth of decision makers in practices felt they were well-versed in MIPS and how their practices would comply. It is somewhat better now that we are over halfway into this first performance year. Many physicians will be exempted from it, for one reason or another. Of those remaining, we are hopeful that many of those practices now have devoted the attention necessary to report under MIPS for the 2017 performance year.
There are multiple levels at which a practice can report, even reporting for 90 days — we still have 90 days to go in this calendar year — not only would exempt them from a penalty, but might also give them an opportunity for an upside bonus. There is hardly any reason now for a physician or practice to receive a penalty. What I tell physician audiences around the country is "You can run, but you can't hide." This is here to stay. We want to help you find a way to participate successfully, whether that's as an individual physician, a small group or a large integrated group, and we have the tools and resources to help physicians be successful.
Q: What is your advice for a practice with limited time to prepare for MIPS?
DB: The easiest way to start is to go the AMA's website for MACRA, and that opens up access to various tools and resources. We have a video that walks a physician through step-by-step how to report one measure on one patient. They can do that next week: one measure, one patient. Then they are exempt from the penalty, and that gives them a little breathing room to begin to gear up for whatever they choose to do in the 2018 reporting year.
The other advice I give to physicians is if you feel overwhelmed by this, or you feel like some of this stuff isn't relevant to your practice, pick things that are relevant. Pick something you are excited about. If you are excited about diabetes management in your practice, pick the diabetes measures. There's a whole list from which the physician can pick. Start at your comfort level, whatever your practice is capable of, and work up from there.
As an aside, part of the problem is some of this data gathering and reporting requires new or different tools and often requires additional personnel in an office. Some, I would even say many, practices are just barely getting by now. For them to expand their IT resources or add a part- or full-time individual to work on these projects is a financial strain. Our belief is the upside or bonus opportunities probably should be more generous because the cost involved to comply is significant.
If you think about a practice that has $100,000 in Medicare revenue, if the maximum bonus you can get is 4 percent, the maximum you are going to get is $4,000. I can tell you it costs multiples of $4,000 to gear up and participate in these programs. So while it is the right thing clinically, it is the right thing to do for patients, it has been a difficult business proposition for many practices.
Q: How can practices chip away at the larger goal of moving into an APM?
DB: APMs are probably the end game here. They are probably the best long-term approach to dealing with a coordinated, value-based payment mechanism. The problem with APMs is there are literally only a handful of programs you can participate in to take advantage of that arm of MACRA.
If you are a small group, or an independent practitioner, there is essentially no way, or almost no way, to participate as an Advanced APM. We are hoping in 2018 there will be a mechanism for small groups to band together for this purpose — to form a virtual group, collect data and report together. That will allow physicians to have some economy of scale as they ramp up to perhaps participate and qualify as an Advanced APM. We are working diligently with CMS to expand the opportunities for groups that are ready to participate as an APM, instead of staying down at the basic level of MIPS. The APMs are a much more sophisticated and more rational approach than MIPS.
Q: You mentioned APMs are probably the best choice under MACRA. Is there a scenario where they wouldn't be the best choice?
DB: If the physician isn't ready to go all in, for business or economic reasons. If the physician is near the end of their career — they've only got a couple more years and they could never recoup the investment, for instance — they may want to participate under a defined program, like MIPS, and maybe perform at the lowest level to avoid penalties. If it's expensive to ramp up to do MIPS in your practice, it's even more expensive to ramp up to perform as an Advanced APM. It does make sense to go that direction, if the practice has the resources, and if the physician is inclined to go all in. For those who don't want to go all-in, MIPS is probably the simpler path to take.
Q: Do you think we will see more physicians gravitating toward hospital employment because of MACRA?
DB: The AMA is very interested in providing both practice tools and resources, as well as advocating with CMS, Congress and the administration, to maintain viable alternatives for physicians who don't choose to join larger groups. We believe that is very important, that pluralistic approach to practice models. Whether the trend continues is less important to us than making sure the environment of care will allow physicians to practice for their own professional satisfaction and for the needs of their community in whatever setting they find most appropriate. We see the trend toward consolidation, and probably much of that is being driven by programs like MIPS and various other payment-related issues. It is a harder task for small groups now than it used to be. But again, our interest is trying to preserve a path for small and independent practitioners if that's their choice of practice style.
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