MACRA: Easing Physician-Practice Pain Points

In the high-stakes transition to Medicare's new value-based payment system, physician organizations face a looming deadline to attain full compliance with MACRA's data reporting requirements, which will drive payment bonuses and penalties for clinicians.

With implementation of Medicare's Quality Payment Program (QPP) shifting to high gear in January, most physician practices are either fine-tuning capabilities for the new value-based payment system or facing multiple pain points.

In 2015, Congress established the QPP through the Medicare Access & CHIP Reauthorization Act (MACRA). There are two payment tracks under QPP:

• Starting in 2019, most clinicians receiving reimbursement through QPP will be paid through the Merit-based Incentive Payment System (MIPS), which features data reporting in four performance categories that drive payment bonus and penalty mechanisms
• Clinicians participating in MACRA-approved alternative payment models (APMs) such as the Medicare Shared Savings Program can earn 5% payment bonuses.

"Pick-your-pace" reporting for QPP started this year, with associated payment adjustments set to begin in 2019. A more mandatory approach to QPP data reporting—with bigger financial consequences for clinician compensation—begins next year.

The American Osteopathic Association (AOA) is urging its members, which features more than 100,000 doctors, to view QPP as an opportunity to improve physician practices.

"We are focused on raising MACRA awareness among our physicians, and helping physicians to educate themselves about practice improvement. A lot of practice improvement strategies are not just about excelling in MIPS—they are ways to improve efficiency, have better care for patients, and have happier employees," says Laura Wooster, senior vice president of public policy at AOA.

There are several keys to MIPS success. "A good EHR is a good start. Any kind of system that helps a practice with population-health management is a great step for maximizing performance," she says.

"For example, it helps to have the capability to track all of your diabetic patients, and to make sure you have brought them all in over the past year to check their hemoglobin-A1C or conduct a foot exam. It helps to look at your patients as different groups and make sure they are getting the best care to manage their health."

The MIPS performance measures incorporate existing Medicare payment-program metrics such as the EHR Meaningful Use program the Physician Quality Reporting System (PQRS), which are sunsetting this year.

Physician organizations that have experience collecting and reporting this data for the Centers of Medicare & Medicaid Services (CMS) have an essential building block for MACRA success, says Krishna Ramachandran, chief administrative officer of Downers Grove-based DuPage Medical Group (DMG).

"DuPage Medical Group has been reporting data to CMS for PQRS, EHR Meaningful Use as well as for the Medicare Shared Savings Program ACO for a few years. We certainly appreciate the alignment created by CMS to fold these under one program under MACRA."

"In addition to external data reporting, these measures are part of our internal monthly dashboards, so that we are able to keep an eye on our performance," Ramachandran says.

The ability to measure Medicare payment-system metrics on a monthly basis is reflected in physician compensation. "Measures that have needed more attention and focus from our physician partners have typically found their way into our annual physician incentive bonus criteria, so that the priorities are aligned," he says.

Fall risk and pneumonia vaccination are examples of MIPS-related measures that have been included in physician compensation packages at DuPage.

MACRA Helps Stoke Physician-Consolidation

Administrative burdens on physician practices were already heavy before MACRA, and rising to the regulatory requirements of MIPS and APMs will likely stoke the wildfire of physician-practice consolidation activity, Wooster and Ramachandran say.

"I can certainly see instances of MIPS and MACRA being the final straw," Wooster says.

DMG is one of the largest group practices in Illinois and is pursuing a growth strategy, with more than 560 primary care and specialty physicians and more than a million patient visits annually. DMG's ability to manage value-based payment models such as MIPS and APMs is a valuable selling point to draw new physicians to the organization, Ramachandran says.

"The complexities of successfully implementing technology, modifying workflows, and producing accurate reports for MACRA have greatly magnified the challenges that have been felt by independent physicians practicing in our community."

"A key differentiator in joining a group like DMG is the opportunity for community physicians to remain independent but to take advantage of the shared value-based care infrastructure that we have created," he says.

Transparency and Physician Reputation Risk

Data collected through MACRA will appear on Physician Compare, Medicare's online clinician-comparison tool for consumers.

In the near term, rollout of the new payment system represents a step rather than a leap forward for Physician Compare, Wooster says. "I doubt it is going to be a sea change because Physician Compare already has PQRS data, so performance is already in Physician Compare."

"In terms of physicians managing their reputation risk, we have not hit the point where Physician Compare is like the Yelp for physicians, and MACRA alone is not going to get us there."

On a broader scale, MACRA's focus on key components value-based care such as cost, efficiency, and quality could boost transparency in the healthcare industry, she says. "For value transparency, I can see MACRA making a difference."

Just as is the case with rising to the administrative challenges of MACRA, capitalizing on experience is an essential element of DuPage's reputation-risk and transparency strategy for the new payment system, Ramachandran says.

"DMG began transparently reporting various quality, efficiency, and access measures across our physician community in 2010. The primary driver was to begin a cultural transformation of measuring, managing, and continuously improving ourselves before agencies like CMS or other payers published data on websites such as Physician Compare."

Cost reporting under MACRA is likely to have a significant impact at the local-market level and nationally, he says.

"Cost transparency is relatively new for us: We have been receiving interesting insights from claims data for both MSSP and commercial ACOs that have helped us identify high-quality, cost-effective settings of care for our patients. We expect cost transparency to grow under MACRA as well as with the growth of commercial ACO contracts. Cost transparency will be an important tool for us to be good stewards of our nation's healthcare dollar."