Physicians frustrated, confused by final MACRA rule

Despite the Centers for Medicare & Medicaid Services’ efforts to listen to physicians regarding Medicare payment reform, many are frustrated, confused and concerned about how the final rule will impact their practices. This is particularly true for small practices that may not have the money or resources to deal with the quality reporting requirements.

While doctors understand the goal of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), some question whether it will be effective and if it’s even fair.

“I don’t think you can pay physicians for performance when we’re not the ones performing,” says Dan Logan, DO, a Dayton, Tennessee-based primary care physician. “We’re making recommendations for patients and do the best we can.” Logan points out that he has no direct control over whether his patients follow his instructions, so wonders how he can be assessed for quality on another person’s actions. “This is not a step in a positive direction,” he says.

Carla Lambert, MD, a primary care physician based in Beltsville, Maryland, says MACRA could cause physicians to gravitate toward healthier patients to avoid taking hits to their quality scores. “This creates a moral and ethical dilemma as we want to care for patients,” she says.

Focusing on healthier patients to improve ratings is something Ken Yonemura, MD, a Park City, Utah-based neurologist, witnessed under previous quality reporting programs. “I had associates in neurosurgery that were refusing to surgically treat difficult surgical problems, as any complication or less-than-ideal outcome could be counted against them due to adverse outcome accounting,” he says in an email.

Beyond the issues of holding physicians accountable for patient behavior, some doctors aren’t even sure what compliance looks like.

Leon Driss, MD, a Lakeside, Arizona-based internist, doesn’t know what to do about MACRA, what’s required or where to turn for help. “I’m trying to stay up to date and very much paying attention [to MACRA requirements], but this is a boondoggle,” says Driss. “I’m trying to figure out what to do and can’t. I’ve gone to educational meetings, but it just seems that a lot of people know in a general sense what the rule is, but no one seems to know exactly and specifically what you have to do.”

Micromanaging patient care

Frustration was a common theme among physicians who spoke to Medical Economics, as concerns grow about how additional reporting will affect patient care and if any time will be left for doctors to actually talk to patients.

“To me, the focus is on micromanaging patient care instead of leaving it between a doctor and a patient,” says Logan. “I’m not interested in finding more codes to tell CMS that this patient is not a candidate for an aspirin a day.”

Next: Penalty vs. participation

Logan says he feels fortunate to have joined a physician-led accountable care organization (ACO) last year. While there are still reporting requirements, he doesn’t have to figure out MACRA on his own and expects to avoid any penalties.

But entering data, means less time talking to patients. “We have doctors doing data entry,” says Driss. “What a waste of a highly trained professional’s time.”

The final MACRA rule lowered the exemption level to anyone with 100 patients or fewer, or with $30,000 in Medicare billing or less. But even this has ramifications for practices and patient care.

Lambert, whose practice has about 50 Medicare patients, is exempt. But she also plans on making sure she doesn’t go over the limit. “At some point, probably when we get to 80, we will probably no longer accept new Medicare patients,” she says. That number keeps her under the limit and leaves enough leeway for existing patients that age into the system to keep receiving her care.

Likewise Yonemura, who is under the exemption level with between 60 and 75 Medicare patients, sees no correlation between quality reporting and quality care, and says the cost of hiring additional office personnel to ensure compliance with MACRA requirements does not make sense.

Penalty vs. participation

Opting out is the path Howie Mandel, MD, a Los Angeles-based ob/gyn, will choose if his Medicare patient count goes above the exemption level. “I’ll drop Medicare with a note to my patients blaming Congress,” he says in an email. He also plans to provide contact information so patients can vent their frustrations directly to their representatives and senators.

Driss can’t opt out, because he has about 700 patients on Medicare. He also wonders if his practice will be financially viable as penalties increase along with reporting requirements. “You could hire a consultant and spend the money, so that if you’re successful, you don’t get the penalty,” he says. “Or, if you can’t figure it out on your own, it costs you money. You pay one way or the other.”

Driss joined a primary care-based ACO and hopes that will be enough to get him through MACRA and increase profitability. “I’m not closing yet,” he says, “but I’m already working part time as a hospitalist. I could close and do that full time. I suspect within a couple years, I may have to do that. With all the pressures coming today, it’s getting harder every year to survive.”