Is MACRA a Trojan Horse for Small Practices, Value-Based Care?

September 01, 2016 - While a final rule on MACRA implementation has yet to be issued, some providers are growing concerned that the value-based care models in the legislation could significantly burden small physician practices.

Providers in small practices will either go out of business or become part of a larger healthcare system in order to shoulder the financial requirements of succeeding under MACRA, according to a recent opinion piece in the Journal of American Physicians and Surgeons. The proposed MACRA implementation rules could also spell the end of Medicare participation for many providers in small practices.

“In reality, it is a replacement bill that is not a step toward freedom, but rather a Trojan horse,” wrote Kristin S. Held, MD, Director of the American Association of American Physicians and Surgeons.

“The MACRA rule states that its intent is to drive physician behavior, and the numbers published in the proposed rule support this,” added Held. “Apparently, CMS rulemakers mean to end small private practices and drive physicians to large groups.”

Held advises CMS to allow physician practices of 100 physicians or fewer to opt out of participation in MACRA value-based reimbursement models in exchange for no payment adjustment factor. By giving small practices an option to participation, CMS would “save money, resources, and error.”

The majority of small physician practices that also qualify as eligible clinicians under MACRA would face negative payment adjustments, the editorial stated. According to CMS data, 73 percent of eligible clinicians in practices with 10 to 24 physicians would receive a negative adjustment, while 60 percent of eligible clinicians in practices of 100 physicians or fewer would also see negative adjustments.

The reduced reimbursements are especially troubling, the editorial added, because most providers work in smaller practices. An American Medical Association study found that 60.7 percent of physicians worked in a practice with 10 or fewer physicians and average practice size remained relatively the same despite healthcare payment reforms between 2012 and 2014.

CMS recognized that MACRA may have a financial impact on smaller practices, but it reported that the lowest negative payment adjustments would only be four percent under MACRA, whereas providers faced negative adjustments of up to nine percent in Part B Medicare payments for failing to demonstrate meaningful use of certified EHR technology or reporting to the Physician Quality Reporting System.

However, Held reported that the maximum four percent decrease would only apply to the 2019 Medicare reimbursement rates based on provider performance in 2017. CMS intends to further penalize low-performing clinicians by up to nine percent in just 3.25 years.

CMS also stated that it will help smaller practices of 15 physicians or fewer to manage the transition to value-based reimbursement under MACRA by providing technical assistance. Held stated that the funding for assistance is more likely to go to intermediary groups, such as quality improvement organizations and regional health collaborations, rather than directly to providers.

“[The assistance] would be better spent directly on patient care than on expanding new classes of intermediaries to extend government reach into the physician’s office,” wrote Held. “This is a prime example of administrative waste, if not propaganda.”

Additionally, Held explained that proposed MACRA implementation rules would give the federal government too much authority over care delivery and distract providers from performing high-quality and personal care.

For example, the editorial stated that the resource use category in the Merit-Based Incentive Payment System (MIPS) would financially reward providers who spent the least resources on their patients. The proposed value-based reimbursement model would incentivize providers to spend as little money and resources on patients as possible to earn more resource use points towards higher payment adjustments.

The proposed Advanced Alternative Payment Model (APM) track would also create burdens on most eligible clinicians because they do not have the training or resources to manage the level of financial risk under the model, added Held. The reimbursement track would require physicians to “act as insurance companies.”

In addition, Held stated that MACRA would increase government control over care delivery because performance score rubrics under MIPS and Advance APMs would dictate what high-quality care is.

“Despite the fact that physicians spend their lives training and serving their patients to the very best of their abilities, it is assumed that they need a government scheme for communicating expectations and evaluating performance,” stated the editorial.

Held predicted that MACRA’s overwhelming government influence and burdens on small practices will lead to more practice consolidation. She also projected that more providers will “opt out of Medicare and commercial insurance to pursue successful practice models, providing an alternative for patients also.”

“But ultimately, private physicians cannot ethically comply with MACRA,” Held wrote. “Enabling such a dysfunctional system is unethical, if not inhumane. Without our complicity, their plans will fail. Doctors can care for patients without MACRA; MACRA can’t care for patients without doctors.”

Dig Deeper:

• Will MACRA Implementation Unfairly Affect Small Practices?

• What We Know About Value-Based Care Under MACRA, MIPS, APMs