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Small orthopedic practices aim to succeed with implementation of MACRA
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On Jan. 1, 2017, physicians and other clinicians will begin collecting patient performance measures as part of the requirements for the Quality Payment Programs under the Medicare Access and CHIP Reauthorization Act of 2015. However, as decisions are being finalized, many physicians have expressed their concerns for small practices that may not be equipped for the changes.
“[The Medicare Access and CHIP Reauthorization Act] is a complex reimbursement system, and I think everybody is going to have to learn a whole new way of doing things. I think it is harder for somebody in a smaller practice who does not have people who can help them learn about these complex changes,” Thomas C. Barber, MD, chair of the Council on Advocacy for the American Academy of Orthopaedic Surgery and orthopedic surgeon in Oakland, Cali., told .
CMS has released a proposed ruling for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) with plans on releasing the finalized ruling later this fall, which CMS hopes will provide better support for physicians and better outcomes for patients.
Image: Lee D
“The program is geared to fix Medicare to be better, smarter and healthier,” Tim Gronniger, deputy chief of staff at CMS, told Orthopedics Today. “We have historically not paid doctors to provide the best care that they know how. We have not supported the time that they need to spend with their patients and to provide support for the services we know improve patient care. For example, consultations between specialists and primary care [doctors] and out-of-office phone conversations, drug management — that type of thing. By shifting payments over time to support that type of care, we are going to be expecting better outcomes for patients and better support for the type of care clinicians like to deliver.”
Options under QPP
The Quality Payment Programs (QPP) being finalized include the Merit-based Incentive Payment Systems (MIPS) and the advanced Alternative Payment Model (APM) as well as four data reporting options. Through MIPS, physicians would have to meet certain measures starting on January 1, including quality measures, cost-to-resource use measures, clinical practice improvement activities and meaningful use or use of electronic medical records (EMRs), which will be implemented in 2019 “to regulate CMS-based payment to physicians,” according to Richard Iorio, MD, chief of adult reconstruction at NYU Langone Medical Center, Advocacy and Health Policy Chairman for the American Association of Hip and Knee Surgeons, and Williams and Susan Jaffe professor of orthopedic surgery at NYU. CMS noted payments will be calculated to begin with a 4% positive or negative adjustment in 2019, with additional bonuses for the highest performances and increase to a 9% positive or negative adjustment by 2022.
“[CMS is] not going to adjust our payments based on the price per case. They are going to adjust them based on these quality measures,” Iorio said. “That is going to affect every practice that [uses] Medicare-based total joint replacement or orthopedic surgery, and unless physicians participate in an advanced APM, which is going to be difficult for a small practice or small hospital, [they are] going to have to participate in MIPS.”
Orthopedic surgeons who qualify for advanced APMs will be excluded from MIPS and would qualify for a 5% Medicare Part B incentive payment, according to CMS.
“[If] 25% of your revenue from Medicare falls under an APM, [then] you can get a bonus from Medicare and you can avoid a lot of the MIPS and MACRA regulation [because] you have fewer reporting requirements,” Barber said.
According to CMS, advanced APMs include CMS Innovation Center models, Shared Savings Program tracks or a statutorily required demonstration and must generally require participants to bear a certain amount of financial risk, base payments on quality measures comparable to those used in the MIPS quality performance category and require participants to use certified EMR technology.
CMS recently released four data reporting options for the first year of QPP under MACRA, which include test the QPP, participate for part of the year, participate for the full year and participate in an Advanced Alternative Payment Model. According to CMS, these options allow physicians to pick their pace of participation. The test the QPP option permits physicians to submit some data, including data from after Jan. 1, to the QPP to avoid a negative payment adjustment. This option determines if a practice’s system is working and if the practice’s system is prepared for future participation.
The participate for part of the year option allows physicians to submit information to the QPP for a reduced number of days, which means that a practice’s first performance could begin later than Jan. 1 and will still be able to qualify for a small positive payment adjustment. The participate for the full year option enables fully prepared practices to submit QPP information for a full calendar year. These practices could qualify for a modest positive payment adjustment. The participate in an Alternative Payment Model option, such as Medicare Shared Service Track 2 or 3, allows practices to participate in QPP and allows physicians who receive enough Medicare payments or see enough patients through the alternative model in 2017. These practices could qualify for a 5% incentive payment in 2019.
Complications for small practices
Louis F. McIntyre, MD, orthopedic surgeon at Northwell Physician Partners and Orthopedics Today Editorial Board member, noted the requirements that must be met requiring either MIPS or advanced APMs present several challenges for small and private orthopedic practices, including time restraints and the expense of getting an EMR and using it meaningfully.
“[CMS] is trying to push all of our reimbursements for Medicare toward being involved with MACRA and that is going to mean [orthopedists] are either going to have to be part of the MIPS or some type of APM, including bundled payments, [accountable care organizations] ACOs — things like that,” McIntyre said. “It is going to be hard for smaller groups to become involved in APMs because the infrastructure for such methodologies are expensive [and] time consuming and requires a hospital partner in many instances.”
Small and private orthopedic practices may not have enough people in their office who can track patient outcomes and other data or access registries that hospitals have access to, and most small or private orthopedic practices may need to partner with a hospital or another larger practice in order to meet many of the requirements for MIPS, according to Barber.
“For a practitioner in a small practice to make this work well, their skills and collaboration with the hospital and other practitioners would have to be fairly strong,” Barber said.
However, he noted partnering with a hospital or another practice may be difficult for a small practice due to differences in how practices are run.
“In a small practice, you might be doing it differently than the other folks in your hospital, and you may not have the ability to work together to do it the same way and get those better outcomes on paper,” Barber said.
MIPS penalties and bonuses are a zero sum game — there are winners and losers, McIntyre noted. CMS believes 87% of solo practitioners and 70% of small practices will be penalized under MACRA, while 81% of groups of 100 or more will receive bonuses. The government is using MACRA to drive the consolidation and employment of physicians.
Help for small practices
Working with specialty organizations, including the American Academy of Orthopaedic Surgeons (AAOS), CMS is identifying areas of improvement when it comes to transitioning small and private orthopedic practices to MACRA.
“We know from our experience and from analysis we have done since the rule that small practices can participate and perform as well as medium and large practices as long as they can report, and reducing the burden to report is a big deal for small practices, whether it is dollar investments or time,” Gronniger said. “Clinicians in small practices often do not have the same resources to dedicate to this, and we want to make reporting as easy as possible.”
The HHS recently announced that $100 million will be awarded during the next 5 years to help small practices successfully participate in the QPP. According to the HHS, the funding would provide hands-on training tailored to clinicians in individual or small group practices of 15 clinicians or fewer, especially clinicians who practice in rural areas, health professional shortage areas and medically underserved areas, through organizations that demonstrate their ability to strategically provide customized training.
“We are trying to provide flexibility for small and solo practices so they can continue to provide care for their patients and participate equally alongside larger practices, and we are focused on getting the program off to a strong start in the early parts of the program so people feel engaged and are able to grow and realize the promise of the program over time,” Gronniger said.
When it comes to the QPPs, CMS has listed several proposed flexible measures in the proposed rule under MIPS. Included in these flexibilities are low-volume exclusions, where clinicians or groups will be excluded from participating in MIPS if they have less than or equal to $10,000 in Medicare charges and less than or equal to 100 Medicare patients. However, according to Barber, even small orthopedic facilities may be able to go over those limits.
“One of the comments of the AAOS was that those limits should be raised because [$10,000] is nothing relative to charges in orthopedic surgery. We wanted to raise that to exempt more small practices from the rules, if possible,” Barber said.
Further flexibilities in MIPS include the flexibility in MIPS scoring based on applicable measures, group reporting, supplying multiple paths to success, burden reduction by the removal of unneeded measures and using a single reporting mechanism to submit information for quality, advanced care information and clinical practice improvement activities.
Iorio noted CMS recently made a proposal to open up the Bundled Payment for Care Improvement (BPCI) Initiative and the Comprehensive Care for Joint Replacement (CJR) to small practices and physician-directed bundles. However, despite allowing participating physicians the potential to qualify for the 5% bonus through the existing programs, physicians would still have to meet a share of practice revenue or a share of patients coming through the model, Gronniger noted.
“If a practice is participating, but only doing a small number of their practice through that model, then they probably would not quality for the 5% bonus, but the potential is there,” Gronniger said.
While the inclusion of BPCI and CJR programs as advanced APMs has been supported by orthopedists, according to Mark I. Froimson, MD, incoming president of the American Association of Hip and Knee Surgeons and executive vice president and chief clinical officer of Trinity Health, the sudden change has caused some orthopedists to become hesitant.
“The initial regulations appear to define the advanced APM fairly narrowly and for many orthopedic surgeons who have embraced the concept of APMs through programs like the BPCI or are subject to the CJR program, finding that the initial legislation has excluded those programs was disconcerting,” Froimson said. “More recently, Medicare in its proposed rule has indicated that it has opened the door for [the] possibility of inclusion of the CJR program and the physicians who are subject of CJR could find themselves in that arm of MACRA.”
He added, “The fact that the initial rollout of MACRA and the [changed] subsequent revisions also causes physicians to take pause because it is a changing landscape and a changing environment, and it has been a source of concern because as a small business, your average orthopedic practice needs to decide how it is going to invest its resources, and without a stable regulatory framework, it is difficult for a small business to know how to respond.”
Physician awareness survey
Recently, a survey performed by Deloitte Center for Health Solutions showed 50% of non-pediatric physicians said they had never heard of MACRA while 32% recognized the name, but were not familiar with the requirements. The survey further showed that among self-employed physicians and physicians in independently owned medical practices, 21% were somewhat familiar with the law compared with 9% of physicians employed by hospitals, health systems or medical groups.
According to Iorio, while there has been a lot of insurance discussion on the effects of MACRA, there has been little discussion on how MACRA will affect physician practices, which would explain the low-awareness rate in the Deloitte survey.
“CMS [and] the government [are] concentrated on providing insurance for patients under MACRA and the [Affordable Care Act] ACA, but [those organizations] have not talked about the implications of eliminating the SGR, implicating MACRA and innovating with the physicians for how it is going to affect their practices,” Iorio said.
Gronniger noted CMS is performing outreach and listening to physicians on what they do not know about MACRA so they can help prepare them for the future.
“We have done hundreds of listening sessions across the country and talked to tens of thousands of clinicians already,” Gronniger said. “We are working closely with specialty societies to both engage their memberships, [to get] input and to listen to areas of high priority based on the proposed rule going to the final rule.”
He added, while there has been historically low reporting from physicians, CMS has “seen a significant increase over time in participation in the physician quality-reporting system.”
“Even though there are some people who may not have heard of the words MACRA or QPP, there is a general awareness of these types of programs and we will have the opportunity to do some more specific education once we have a finalized set of policies and can tailor materials and messages to people who need it,” Gronniger said.
Along with low physician awareness, the survey noted most physicians did not support some of the requirements under MACRA, with 74% of physicians who believe performance reporting is burdensome and 79% who do not support tying compensation to quality. However, McIntyre stated since MACRA was established with bipartisan support, it is legislation that is not going away.
“MACRA was a bipartisan law,” McIntyre said. “It had support of the Republicans and Democrats, so this is the way Washington, D.C. wants things to go.”
Staying educated
While Barber recommends orthopedists wait until the final ruling for QPPs to be published later this year before moving forward with implementation, he noted orthopedists can at least begin understanding and meeting meaningful use in their practices.
“The easiest thing they can do is meet meaningful use as quickly as they possibly can because that is going to be a minimum standard,” Barber said. “Secondly, they can start understanding the changes and what is going to be measured so they can make sure that by Jan. 1, 2017, they understand how their own behavior will influence the outcomes that are measured so they can modify that behavior as necessary to get the best outcomes.”
According to McIntyre, it is important for orthopedists to study and understand their marketplace because there are different pathways depending on the location of the practice. Froimson noted most physicians become disinterested in this legislation because they do not feel the requirements correlate with better patient care. Orthopedists should educate themselves on what they can do to align themselves with the regulations while also contributing to better patient care.
“What we advise to our physicians is try to identify those areas within the requirements that do feel like they give you an opportunity to improve your practice,” he said.
If orthopedists do not feel like they can keep up with the information being provided by the CMS, Iorio noted they should contact AAOS or their subspecialty organization for guidance.
“[Orthopedists] have to pay attention and stay involved because a lot of this is being defined right now, and the more they comment and have input [in], the less likely they are to be surprised by what is coming down the pipe in the future,” Iorio said. “It is going to start in the next couple of years, and they need to understand how it is going to affect their practice, so [they need to] pay attention.” – by Casey Tingle
Editor’s note
Visit Healio.com/Orthopedics for regular updates about MACRA.
- Reference:
- Are physicians ready for MACRA and its changes? Perspectives from the Deloitte Center for Health Solutions 2016 Survey of US Physicians. Available at: http://www2.deloitte.com/us/en/pages/life-sciences-and-health-care/articles/macra.html. Accessed Aug. 30, 2016.
- HHS announces major initiative to help small practices prepare for the Quality Payment Program. Available at: http://www.hhs.gov/about/news/2016/06/20/hhs-announces-major-initiative-help-small-practices-prepare-quality-payment-program.html#. Accessed Aug. 31, 2016.
- Medicare Access and CHIP Reauthorization Act of 2015: Flexibilities and support for small practices. Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Small-Practices-Fact-Sheet.pdf. Accessed Aug. 22, 2016.
- Medicare Access and CHIP Reauthorization Act of 2015: Quality Payment Program. Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/NPRM-QPP-Fact-Sheet.pdf. Accessed Aug. 22, 2016.
- For more information:
- Thomas C. Barber, MD, can be reached at 3600 Broadway, Oakland, CA 94611; email: thomas.c.barber@kp.org.
- Mark I. Froimson, MD, can be reached at 20555 Victor Pkwy., Livonia, MI 48152; email: hoernerb@trinity-health.org.
- Tim Gronniger can be reached at the Hubert H. Humphrey Building, 200 Independence Ave. S.W., Washington, D.C. 20201; email: press@cms.hhs.gov.
- Richard Iorio, MD, can be reached at 333 East 38th St., 4th Fl., New York, NY 10016; email: richard.iorio@nyumc.org.
- Louis F. McIntyre, MD, can be reached at 755 North Broadway, Sleepy Hollow, NY 10591; email: lfm@woapc.com.
Disclosures: Barber, Froimson, Gronniger, Iorio and McIntyre report no relevant financial disclosures.
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, “As an orthopedist in a small practice, do you feel prepared for and educated on MACRA? Why or why not?”