Internists in traditional small practices are worried about their futures. Flat reimbursement, combined with ever-increasing administrative tasks and high overhead costs, threatens the viability of even the best-run small practices. Having seen so many of their colleagues throw in the towel by selling out to hospitals, joining large employed systems, going concierge or direct primary care, or even quitting medicine, they question how much longer they can hold out.
While these pressures have been around for years, internists in small practices worry that the payment disruptions from the Medicare Access and CHIP Reauthorization Act (MACRA) will be the straw that breaks the camel's back.
As I wrote last month in this column, while such concerns are understandable, Congress intended for MACRA to reduce the burden of reporting on quality measures and provide more opportunities for positive updates, as compared to the existing Physician Quality Reporting System and Meaningful Use programs. ACP is committed to ensuring that this is what actually happens.
We know, though, that good intentions won't help small practices pay their bills and keep their doors open; what they need are concrete and specific improvements to reduce the time and money they spend on unnecessary and unproductive administrative tasks, allow them to spend more time with patients, and improve their bottom lines. And they are looking for someone to help them succeed.
In other words, we need to show ACP members in all practice sizes and types, but especially those in small independent ones, that we've got their backs. So, let me summarize 10 things ACP is doing to help small internal medicine practices do well under MACRA:
1. We have called on CMS to allow solo clinicians and groups of 2 to 9 eligible clinicians to be held harmless from any potential downward adjustments (cuts) under MACRA's Merit-Based Incentive Payment System (MIPS) until such time that a virtual group option is made available. The MACRA law requires CMS to establish and implement a process that allows practices of 10 or fewer eligible clinicians to elect to form a “virtual group” with at least 1 other similarly sized practice, so that they can combine forces to report quality data, giving them some of the economies of scale available to larger practices without requiring them to give up their independence. ACP believes that if the agency does not include such a virtual reporting option in the final rule to be released this fall, these small practices should be exempted from cuts in MIPS while being allowed to earn positive MIPS adjustments.
2. We have called for CMS to push back the start of the reporting period for MIPS to no earlier than July 1 of next year, rather than Jan. 1 as proposed. An additional 6 months to prepare will be especially helpful to small practices.
3. We have urged CMS to replace its overly complicated MIPS scoring system with a simpler alternative, developed by ACP, which will make it much easier for practices to proactively know what they can do to receive a positive MIPS score.
4. We have urged CMS to reduce the number of required MIPS quality measures and to completely revamp the “Advancing Care Information” reporting program (which will replace the current Meaningful Use program) to reduce the burden of reporting.
5. While we support CMS's proposal to give certified medical home practices the highest possible score for Clinical Practice Improvement Activities, 1 of the 4 MIPS performance categories, we have urged CMS to make it possible for practices to receive such certification without necessarily having to pay for accreditation. While we support medical home accreditation as an option, we believe that practices that are participating as medical homes in programs recognized by private insurers, their states, or Medicaid should also be “certified” by Medicare for the purposes of MIPS, whether accredited or not. Thousands of small practices across the nation are currently recognized as medical homes, and many more would receive favorable MIPS scoring if ACP's recommendation is accepted.
6. We have called on CMS to allow physicians to get appropriate credit for the many quality improvement activities that they are already doing when calculating their MIPS's Clinical Practice Improvement Activities score, with flexibility to choose what is most meaningful for their practices.
7. We have called on CMS to make better adjustments for differences in the complexity, health status, and socioeconomic characteristics of patients being seen in a particular practice. For smaller practices, a few complicated and sicker patients can throw off their entire performance and cost-of-care scores, unless there are appropriate risk adjustments.
8. We have called on CMS to make more options available for practices of all sizes to qualify as medical homes under the advanced Alternative Payment Model (APM) pathway created by MACRA, without having to take direct financial risk. For small practices in particular, acceptance of financial risk is a nonstarter. APMs are exempted from having to report under MIPS, and they will receive 5% Medicare bonus payments on their fee-for-service billings. Those that are participating in CMS's Comprehensive Primary Care Plus medical home initiative being launched next year in 14 regions will also be eligible to receive additional monthly risk-adjusted payments, ranging from an average of $15 to $27 per patient per month, for every Medicare patient they see.
9. We are working with CMS, EHR vendors, and standard-setting bodies to make electronic health records and clinical documentation more clinically relevant, less intrusive (with fewer unnecessary “clicks”), and less time-consuming for clinicians.
10. We have extensive resources available on MACRA, including a dedicated webpage that has videos, presentations, tips, FAQs, and much, much more to help practices be successful under MACRA. Later this year, we will be releasing a MACRA-specific online interactive tool to help ACP members and their practices determine whether they would do better under MIPS or as an APM, with resources to help them under either pathway.
Simplicity, flexibility, choice, and clinical relevance: This is ACP's MACRA mantra. If CMS listens, smaller practices can not only survive MACRA, they may even thrive under it.