New Medicare reimbursement rules will focus on uniqueness of independent practices vs. single them out, says administrator.
For months, small practice physicians feared the final word on how federal regulators plan to change Medicare reimbursement, moving away from traditional fee-for-service to quality-based payments.
In releasing the changes under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) earlier this month, the man leading the initiative has a simple message to these doctors that feel their practice will go out of business or lose its independence.
“It won’t. MACRA won’t do that [close small practices],” Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services (CMS) recently told Medical Economics. Citing reduced regulatory burden, flexibility in how and when physicians report data, Slavitt says he’s aware that any new regulations can be seen as bad regulations.
“The practice of medicine had gotten harder,” he said. “There are more distractions and … we understand what every change feels like to physicians. A lot of that has nothing to do with MACRA-it may have to do with CMS or other things-but we recognize it is out there and it is an important concern for us.”
In an exclusive interview, Slavitt discussed how small practices can benefit from participation in MACRA’s Merit-based Incentive Payment System (MIPS), why in two short years, 25% of small practices will actually be in an Advanced Alternative Payment Model (APM) and where this latest regulation will succeed where Meaningful Use failed.
Medical Economics: Where do you think the fear of MACRA by small practices comes from?
Slavitt: There are people who actually have an interest in saying that they want small physician practices to feel [MACRA] is complicated and close. If you are a hospital who wants to buy a physician practice-or any aggregator-this is another thing you put in your pitch deck. If you are a consultant, that’s also in your interests.
I think we have tried extremely hard to listen to the realities physicians feel that they are in and talk frankly about their concerns, acknowledge their concerns and we’ve acted on them. So I don’t think there is anything to the substance, but I understand why people can play on this perception.
… Let’s look at it this way. There are probably three sets of [physicians] out there. A set of people who are well informed already and who are seeing the information that’s available at qpp.cms.gov and get themselves fairly comfortable fairly quickly.
Then there are … a set of people who know some things and have some trusted, reliable sources to go to …specialty societies or state societies … those who’ve invested time and understanding. They’ll get the support they need and understand that quickly. The conclusion they will reach quickly is: “CMS wants us to focus on our patients and our practices, not on [MACRA]. It’s something that’s a payment program in the background and there are some adjustments, but it won’t overwhelm us.”
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There’s a third group out there who’ve never heard of MACRA, don’t know anything about it, because … they are focusing on what they are doing every day. For those people-and the second set-I think there will be plenty of slide decks that start to move forward which talk about and try to inform people in ways that are very helpful and then there will be those out there that will be less than helpful.
ME: What was the impetus for releasing the reporting options for MIPS prior to the final rule? Were small practices a factor? How does it help them?
Slavitt: Our data tells us smaller practices can and do provide high quality care to the same extent that larger practices do. The difference is that if you don’t report, because it is too complicated, too costly, not worth it, then obviously, you don’t do very well under this program and that’s a shame. We want to take responsibility not just to say, “Here’s the rule, let’s see who reports and who doesn’t,” but to find a way to make it easiest for folks to do that.
[During out listening sessions], I’d go out to a city and meet with different practices and get their input and people were very honest with me. Sometimes, I’d go to a large practice and in addition to the six physicians, they had five support staff who’d focus on quality metrics for them. And then I’d go an hour later and meet with a one-physician practice whose spouse would be the person answering the phone and making the appointment and that’s all they had, and a great doctor who people in the community loved and loved their work. It became a mission of ours, and it still is, that anybody who is practicing good quality care should be able to do just as well.
The theory we subscribe to is: Instead of looking at MACRA as regulation, look at it as deregulation. Instead of measuring and measuring [physicians], we said what if we give [physicians] back an additional 30 minutes in their day and what if, instead of making them feel like they were measured and people were looking over their shoulder, they felt supported and recognized and that their input mattered? And the bet that we are taking is that this is going to be good for patients. Physicians will use that time well.
It doesn’t mean we don’t want to have high-quality care, it means by setting up a process whereby we have a set of measures that physicians can select, a smaller number that they can decide is just right for their practice, that they [don’t] have to report on anything they don’t feel is right for their practice. They can pick their path to how they report and how frequently they report … and gradually improve. That’s going to send a very different message and we believe, lead to a better longer-term outcome.
ME: Are you concerned that just as small physicians have decided to skip attestation of their electronic health record through Meaningful Use, many will also simply forgo reporting data through MACRA and take the penalty? (In 2019, physicians would face a 4% payment penalty if they don’t report any data in 2017.)
Slavitt: We want every physician to feel like they can report and we’re very optimistic that people will find the right path for them to report.
I think the fair criticism of Meaningful Use and why a lot of people chose not to report was that [physicians] were at some stages asked to report on activities that really had nothing to do with patient care, a lot of activities and it was fairly cumbersome.
We are at a different stage now. We are at the stage where we shouldn’t be measuring tasks. We should essentially be doing what we are doing now, which is asking physicians to tell us: ‘What is it going to take to improve your practice? What are the activities you do that you’d say can prove the [quality of the] care you provide? What are the measures, of all those available created by third parties, that you can select from a shopping cart on our website so they are easy to find? What are the ones that are right for you?”
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I think that’s a fairly dramatic change in tone and approach and I’m hopeful that every physician will feel “I participate in the Medicare program, I care about my Medicare patients, this is a new way of doing things, yes, but it is not burdensome. I know why it is happening and being done in a way that is flexible enough and customizable enough for me and my practice.”
ME: CMS also increased the exemption for physicians who don’t have to participate in MIPS or MACRA. Those who bill $30,000 or less to Medicare and have 100 Medicare patients or less are exempt. Are you worried about physicians scaling back their patient base to meet the exemption vs. meeting the mandates?
Slavitt: I just don’t think [physicians] feel that way. I’m not going to make policy and don’t think we should make policy assuming the worst in people.
There are a lot of physicians, maybe they see two or three Medicare cases a year, or maybe they are physical therapists and they don’t make a lot of revenue. So to say to those people, you need to … go through the motions of someone with hundreds of thousands of dollars or hundreds and hundreds of patients in Medicare doesn’t make sense.
When you figure out you can allow a large number of smaller practices not to report and still capture about 93% of Medicare patients [with an exemption in place], it makes all the sense in the world.
I’d also add that I think physicians and anybody who is associated with the Medicare program in any way feels a sense of ownership, or at least I hope they do. I think there’s a sense of, I hope, patriotism for what Medicare has done for our country over the last 50 years.
MEC: When announcing the proposed rule, CMS said that most small physicians were going to be in the MIPS track. Now it seems that you are pointing them to APMs. Is that correct?
Slavitt: If you were to ask me the biggest change between the proposed rule and final rule, I’d say in the proposal, we did talk about how most physicians were going to be in MIPS and I think I’d give you a different message now. I’d say to the small practice community that we are setting up advanced APMs explicitly for small practices now. That is one of the biggest and most impactful changes.
MIPS will be right for a lot of physicians. It will be the right option. But we are now encouraging the formation of both primary care-based and specialty care-based advanced APMs that have much lower [risk levels] and easier to participate in.
We announced a new accountable care organization Track 1+, a more modest amount of risk to participate in and still qualify for an advanced APM.
And we are now going through the CMS Innovation Center, looking through all their models and looking particularly at those that small [practice] physicians participate in and “retrofitting” them to reintroduce them and open them up wherever possible so that physicians who want to participate can do that and qualify for advanced APM. We estimate that in 2018, 25% of physicians will be in an advanced APM. I think that’s only a start. I think it will ramp up from there, but I want physicians to know that there are models especially designed for smaller practices.
MEC: Do advanced APMs preserve the independence of private practices or is CMS moving these practices toward larger groups of physicians?
Slavitt: I think the idea is actually to have what I’d call “homegrown” forms of the practice of medicine take shape, get submitted to CMS Innovation Center and for us to say, “This looks like it is good for patients, it is good for the Medicare program, and we should pay you for it.” That is essentially what this is.
Look at what a medical home is –which in our model is called Comprehensive Primary Care Plus (CPC+) I visited a number of physicians in those practices and a lot of them would tell me the best thing about this [program] is you’ve given me the freedom to practice the way I want to practice. They are no more integrated into other practices. What they do have is the ability to coordinate care better. They’ve taken the per member per month (PMPM) fee they are getting and hired care coordinators and they are able to track when their patients go into a hospital, so they know right away and they are able to reach out to other specialists. One physician told us he created a Skype social network for all his patients. He has a lot of geriatric patients who would come in and he felt it was an important way for them to socialize and even set it up with heir children in other cities. He used his PMPM fee to do that. For him, that works. For him, that’s what CPC+ is. For someone else I’ve met with, CPC+ meant they had the ability to co-locate with a behavioral health specialist because they felt like in their small practice, they weren’t clear always and very good at making sure the handout worked when someone had a behavioral health issue.
What they wanted was that every time someone had a behavioral health issue, not have the patient have to leave the office until they talked to somebody. That’s what they chose to do and how they achieved it.
So is it giving up independence? I don’t think so. In those examples, and there are plenty more, it is about a way of working with their particular patients that they think works better and saying “Why don’t you pay us for that versus for piecemeal ordering another test?”