MACRA: Proposed rule raises endless questions, concerns

Man putting money into white doctor's coat

Picture of Kent BottlesIn the last few months, the subject of the proposed rule for Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) has been a major topic of conversation among the physicians, hospital leaders, patients and policy wonks I interact with in my roles of teacher in the Jefferson University College of Population Health, keynote speaker, and healthcare consultant. I hereby report there is rampant confusion and conflict in the healthcare land about how to pay physicians.

Three good overviews of MACRA can be found in a recent Commonwealth Fund blog post, a Leavitt Partners white paper published before the proposed rule came out and a Health Affairs blog post on the proposed rule

Many in organized medicine applaud the legislation for getting rid of the Sustainable Growth Rate formula, encouraging the transition from fee-for-service to value-based payment systems and extending the Children’s Health Insurance Program, the Community Health Centers, National Health Service Corps. and the Teaching Health Center. They also point out that MACRA provides physicians with predictable income for the next several years. The American College of Physicians, which represents internists, is an example of a physician organization that has come out in support of MACRA.

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But the Association of American Physicians and Surgeons disagrees with the American College of Physicians and believes that MACRA harms both patients and physicians. This group of private practice physicians objects to physician scores being tied to resource use, the mandatory use of government certified electronic health records and the interference by Medicare with the free market. This organization is concerned that by Medicare’s own estimates, 87 percent of solo physicians will be penalized and 81 percent of doctors in large groups will earn bonuses under the new payment model.

Critics are skeptical that the Centers for Medicare & Medicaid Services can fairly and accurately measure the cost and quality provided by individual physicians. A Medicare Payment Advisory Commission (MedPAC) staffer has said that the MACRA system cannot distinguish 80 percent of physicians from one another on the basis of cost and quality, according to The Health Care Blog.

One of the few aspects where there is widespread agreement is that the law is very complex and difficult to understand. Having read the entire proposed rule twice, I must admit that I am still unsure about how it will all work out in the end. I am not alone. John Halamka, M.D., CIO of Boston's Beth Israel Deaconess Medical Center, writes in The Health Care Blog, “The 962 pages of MACRA are so overwhelming complex that no mere human will be able to understand them.”

Other concerns that I have heard expressed about the implementation of MACRA include:

  • The long delay between the performance period for individual physicians and when they will receive their reward payment lessens the impact of the incentive.
  • The narrow definition of an advanced payment model that will allow physicians to avoid the Merit-Based Incentive Payment System (MIPS) program will mean that most will have to participate in MIPS.
  • The desire of hospitals to avoid MIPS will result in hospitals participating in risk-bearing advanced payment models before they are ready.
  • The new payment methodology is “financial suicide” for small private practices, according to a report by Politico that quoted Farzad Mostashari, former National Coordinator for Health IT.
  • The attribution problem of deciding which provider a patient belongs to has not been adequately solved.
  • The risk adjustment problem of excluding factors outside of the doctor’s control has not been solved and may result in unfair individual ratings.
  • The requirements related to electronic medical record use for patient engagement are weak and require only “one unique patient” per year involvement.
  • Many physicians will retire or refuse to take Medicare patients in order to avoid the new rules.  

My biggest concern is that the physician groups and hospital leaders I deal with are not up to speed on the ramifications of MACRA. There is widespread confusion and anxiety among most physicians and that is a recipe for disaster. Many have addressed the above concerns in comments to the federal government, and we all can hope that the final rule will provide more clarity and detail to an incredibly complex law. 

Although I hope for the best, there are days when I cannot argue with Kip Sullivan, who writes: “Congress has essentially instructed CMS to build a new layer of undefined, unproven APMs on top of the existing layer of poorly defined and unproven ACOs and ‘homes,’ in other words, a second layer of sand castles over an existing layer of sand castles.”

Kent Bottles, M.D., is a lecturer at the Thomas Jefferson University School of Population Health and chief medical officer of PYA Analytics.

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