Taking a MACRA view of physician independence

Physician compensation has certainly been a hot industry topic over the past few years.

Changes brought about by the Affordable Care Act (ACA), particularly the Centers for Medicare and Medicaid Services' (CMS) incentives to move all documentation to electronic medical records (EMRs) and its push for the transition to value-based billing, have seen physicians continually being asked to do more work while receiving stagnant or less pay.

It is one of the primary drivers behind the continued decline of the independent physician. Today one-third of physicians work in private practice, versus more than half (57 percent) in 2000.

The latest reimbursement rule changes threaten to erode the base of physicians in private practice even further by making fundamental alternations to how physicians and other clinicians are compensated under the Medicare Physician Fee Schedule. Yet according to a nationally representative Deloitte survey of 600 physicians, half of the doctors surveyed hadn't even heard about the changes. In addition, just 21 percent of independent physicians said they were "somewhat familiar" with it.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) offers physicians financial incentives to move large portions of their practices to risk-bearing, coordinated-care models. Currently proposed rules for the Medicare Merit-Based Incentive Payment System (MIPS), a subset of MACRA, allows eligible professionals to earn positive adjustments on Medicare Part B payments of up to 4 percent in 2019 and as much as 9 percent in 2022 and beyond. Low-performing physicians will see comparable negative reimbursement adjustments.

At first glance it may seem as though it will be more difficult than ever for physicians to maintain their independent status. Yet the reality is it could deliver a boost to physicians in private practice because it rewards quality, and the flexibility independent physicians have in running their practices enables them to make improvements more readily than those in large, centrally owned systems. In fact, as noted by Dr. Bob Kocher in a recent Wall Street Journal opinion piece, "savings and quality improvements are generated much more often by independent primary-care doctors than by large hospital-centric health systems."

While it will undoubtedly mean a change in workflow and operations, technologies that are already MACRA- and MIPS-ready can help smooth the transition and ease any administrative burden physicians might normally feel in attempting to meet the newly-established criteria. Following are some of the other advantages that give independent practices a leg up in achieving MACRA-readiness.

Referrals can be merit-based

MACRA is designed to break down barriers between care settings in order to deliver a higher level of coordinated care. Essential to this mission is being able to refer patients to the best doctors available for their conditions rather than being bound to refer to another physician in the network even if quality is reduced. That approach is acting in the best interests of the patient as well as the public at large, and ensures the physician's primary role is being a trusted advisor rather than a contributor to generating hospital revenue.

While it is generally understood that the cost of care is higher in health system settings, there is little evidence that the outcomes are superior. Independent physicians have the autonomy to base referrals strictly on medical factors and to exclude non-medical criteria.

Focus on patient service

The interests of independent physicians and their office teams generally are highly aligned when it comes to care as well as the economics of operating a private practice. Both are incentivized to keep patients satisfied and provide superior levels of care to ensure patients choose to return and refer their friends and family. All of which keeps the practice prosperous.

If an independent physician receives feedback from patients that a staff member is providing poor service, he/she can request a change in behavior or make a change. Additionally, staffing in health systems is often fluid and turnover high which can lead to inconsistency in service levels from one patient visit to the next. Independent physician practices have more freedom to do what's required to deliver the high service levels needed for high quality.

The right staffing levels

When independent practices are acquired by health systems, often one of their first moves is to trim long-term staff, especially nurses and mid-level providers, to improve profitability. This decision, however, will normally lead to declines in patient care, physician productivity and ultimately physician compensation. Doctors may also find themselves taking home more work as a result – especially to complete EMR coding for billing – because they don't have time to complete it during the day. While independent physicians must still be budget-conscious, they have more freedom to staff at proper levels so everyone can work at the tops of their licenses. This not only delivers high-quality care in keeping with MACRA and MIPS requirements. It also helps the practice deliver a better patient experience.

More choices in technology

Physicians in independent practices are not forced to accept standardized EMRs and other technology platforms regardless of their suitability. Instead, they can adopt technologies that are well-suited to their practice needs, specialties and work style. For example, rather than an appointment scheduling system designed for in-office staff, many health systems use centralized scheduling systems that lack the flexibility required by physicians and their staff. Similarly, a health system's EMR, while appropriate for hospitals, may be more complex and difficult to work with than one designed specifically for a private practice.

One of the greatest controversies around EMRs is that the complexity of enterprise-level technologies leads to a loss of productivity, which then trickles down into lost compensation. Having the ability to select technology that fits the physician's workflow while meeting MACRA, MIPS, National Committee for Quality Assurance (NCQA) and other requirements overcomes these barriers.

More effective communication

Easy, direct communication is a foundational pillar of quality healthcare. This standard is often more easily achieved within independent practices due to their size and the staff's familiarity with one another. Having a receptionist in the same office as the doctor rather than in a remote call center facilitates communication between physicians, staff and patients. Sharing information about patients, either internally or with healthcare professionals in other settings, is often much easier as well, enhancing patient care and satisfaction while reducing the risk of errors due to poor care transitions.

Taking advantage

While the announcement of any new rules from CMS is often met with trepidation and wariness, MACRA and MIPS could turn out to be just what the doctor ordered to help independent practices generate additional revenue. Both are based on what independent practices do best – deliver high-quality, patient-centered care.

With the right mindset, and the right technology in place to simplify the transition into the new rules without severely impacting workflows, private practices will have additional financial support to help maintain their independence.

Dr. Prodromos is an Orthopaedic Sportsmedicine Specialist and editor of the comprehensive textbook for Orthopaedic Surgeons on the Anterior Cruciate Ligament. He is a graduate of Johns Hopkins Medical School and trained in Orthopaedics at Rush and Harvard/MGH. He is Assistant Professor of Orthopaedic Surgery at Rush Medical College. He is also active in PRP and stem cell research.

Michael Nissenbaum is president and CEO of Aprima Medical Software, a company that provides innovative electronic health record, practice management and revenue cycle management solutions for medical practices. Aprima uses a fast, flexible design that adapts automatically to a physician's workflow and sets the benchmark for ease-of-use, speed and flexibility. The Carrollton, TX-based Aprima has an 18-year track record of success and performs all development, support and implementation from the U.S.
Prior to joining Aprima in 2004, Nissenbaum enjoyed a highly successful career at Millbrook Corporation where he oversaw five years of compounded revenue growth in excess of 80%, six product releases, and receipt of numerous product awards, including three successive MS-HUG awards. Previously he was with General Electric, where he led the commercialization of GE Healthcare – Clinical Data Services, accelerating the growth of the medical record database from 11 practices delivering 600,000 records to 57 practices providing over 2.5 million records. Nissenbaum earned an MBA from the University of Chicago and is a Certified Public Accountant and Chartered Financial Analyst®.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.​

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