Top 9 MACRA threats that could become reality for doctors, patients

As implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) draws near, the Center for Medicare & Medicaid Services (CMS) is drafting the rules that will accelerate the transformation of U.S. healthcare towards a so-called “value-based” model. 

This complex piece of legislation (962 pages!) affects more than 800,000 physicians and their millions of Medicare and Medicaid patients.  The program  uses reimbursement to drive a continued restructuring of the American healthcare system and a new generation of technology to support it.  CMS has emphasized the potential positives:

●      Reimbursement based on value to patients, not volume

●      EHR metrics focused on performance, not process

●      More comprehensive care integrating multiple providers

However, the “devil is in the details.”  How the final rule will address the excessively complex and burdensome reporting of quality measures remains to be defined. The goal of improving interoperability of EHRs has drawn recent comment from the AMA and multiple specialty societies, who are urging adoption of new benchmarks that focus on clinical value to patients rather than just the number of pages exchanged.

 As the rules for MACRA are written, we are again at a critical juncture in U.S. healthcare. The risks to both physicians and their patients is real.

9. Risks for Physicians: Loss of autonomy

Central to the transformation to value-based care is implementation of evidence-informed clinical decision support to reduce inappropriate testing and treatment. However, implementation and "enforcement" of standardized protocol-based care that limits flexibility or is even perceived to penalize noncompliance  risks suppressing physician critical thinking and problem solving. 

Clearly, many physicians would rightly perceive excessively standardized, guideline-driven care as a form of micromanagement that threatens their autonomy in making decisions in the best interests of their patients. Deviation from protocols should be expected based on individual circumstances and physician judgement. Standardized care shouldn't be a straitjacket.

8. Burdensome documentation

Under MACRA, “meaningful use” (MU) morphs into “Advancing Care Information” (ACI). Current rules for MU are widely viewed as requiring documentation of clinically irrelevant information rather than real patient-centered outcomes.

Currently, reporting quality metrics is estimated to cost physician practices $15 billion dollars annually with individual physicians devoting almost 800 hours annually to this task.  It’s no surprise that interaction with the EHR is a major source of physician dissatisfaction. 

A recent study of emergency department physicians found data entry during a typical shift required about 4,000 clicks and consumed 44% of their time vs. 28% on direct patient care. The current lack of clinically relevant EHR interoperability further adds to the frustration. 

Will MACRA and ACI really cut the clicks?  It remains to be seen. 

7. Solo and small practices pressured

MACRA is intended to be budget neutral.  There will be winners and losers with adjustment of reimbursement for services based on a complex Merit-based Incentive Payment System (MIPS) that ranks physician performance in four weighted metrics. Winners receive reimbursement incentives of 4% to 9% with a corresponding negative hit for losers.  

Many solo physicians and smaller group practices are concerned they will get the short end of the stick, as they are less likely to have the costly robust data reporting capability of the larger groups.  CMS itself projects 87% of solo practices will face negative adjustments of reimbursement in 2019 totaling $300 million dollars. If these figures are even remotely accurate, a continued reduction in solo or small group practice is likely. 

6. More burnout

A recent Mayo Clinic study reported 54% of physicians were experiencing at least one symptom of burnout. Burnout includes several dimensions such as loss of enthusiasm for work, increased feelings of cynicism, and a feeling of being more callous with co-workers.  Beyond purely personal concerns, burnout clearly has implications for the healthcare system with premature physician retirement and reduced access to medical care.

 Burnout is a consequence of multiple factors including increased non-clinical paperwork, dissatisfaction with the current state of the EHR, perceived loss of autonomy, and ultimately less time for recreation and family. Physicians are concerned the proposed rules will actually add to already burdensome reporting requirements and are rightly skeptical that MACRA will give back lost time.

5. Risks for Patients: Standardized, not customized care

 Greater physician adherence to evidence-informed clinical practice guidelines has the potential to improve patient outcomes and reduce unnecessarily costly care. 

Analogous to the statistical "regression to the mean," most patients will receive appropriate evidence-based routine care.  However, as all seasoned clinicians know, medicine is not an exact science and all patients don't fit neatly into diagnostic and therapeutic boxes.

Physicians must recognize atypical and uncommon presentations of common disorders that may require investigation outside of any guideline recommendations. Thus, encouraging physicians to provide “customized evidence-based care” is better for all patients.

4. Increased risk of medical errors

Burdening caregivers with complex rules for documentation, particularly for EHRs that don’t talk to one another, increases the risk of inadvertent medical mistakes.  

Crude attempts to integrate clinical decision support into EHRs in the form of innumerable “best practice alerts” (BPAs) increase the “hassle factor” and are often ignored, paradoxically increasing the risk of a mistake.

 It’s no surprise that recent studies of clinical decision support for upper respiratory infections and pneumonia show that fewer than 50% of physicians actually use the tool!  Intended changes in antibiotic use are disappointingly small. 

 If implementation of MACRA adds to the non-clinical bureaucratic workload, stealing physician time better devoted to thoughtful patient interaction and decision making, the risk of error will increase. Psychologists call this risk “cognitive scarcity,” and it’s bad for patient care.

3. Decreased access to care

MACRA’s potential consequences for harried, burnt-out physicians coping with a blizzard of documentation using dated, unfriendly EHR technology are clear.  Premature physician retirement is already widespread. 

In addition, some physicians will opt out of Medicare.  Many are already exploring alternative models such as concierge medicine.  All of these developments could potentially result in decreased access to medical care, particularly in rural or underserved areas. 

2. Less “glance time”

“Glance time” refers to the time the physician spends making eye contact with the patient.  According to a 2014 study at Northwestern University (Montague E, As an O, Intl J Med Informatics 2014; 83:225-234), during a typical visit, physicians using current EHRs spend 30% of the time gazing at the EHR and 46.5% making eye contact with the patient.

In contrast, doctors using paper records spend only 8.75% of the time looking at the chart.  Reduced glance time is associated with lower levels of patient satisfaction and a perception of “less authentic engagement” with the physician.

1. MACRA done right

Evidence-informed, value-based care is the future direction of U.S. medicine and MACRA is a principal driver. 

As the rules are finalized, physicians need to work to ensure the primary goal is improved quality of patient care by focusing on three key areas:

●      Spot the zebras: Preservation of physician autonomy to exercise clinical judgement in individual patients and deviate from standardized care if appropriate

●      Cut the clicks: State of the art IT to streamline clinically relevant data capture with seamless clinical decision support and increased “glance time”

●      Performance, not process: Patient centered quality metrics as the bottom line