MACRA. Good for some. Bad for others.
Although my first two posts basically focused on the pros and the benefits that MACRA should be bringing to medicine. It’s also important to understand that no law, bill, or policy is bassed with 100% satisfaction from everybody. It’s all about the opportunity cost and understanding that the benefits of implementing something like this will come with its costs… it’s just important how much the lawmakers took into account certain parties and groups, and you would think that for something that would greatly impact healthcare and medicine, that they took into account the healthcare providers right? Ehhh. We’ll see.
Of course, not every medical personnel or provider is affected by MACRA if they don’t take medicare, but MACRA brings about significant change in how those that do take Medicare will be conducting business and providing care. Granted, medicine can be stubborn and resistant to change, that much is clear with the rough and slow transition into EHRs, but also with how Medicare reimbursements and collections have been going. A close family friend of mine runs his own private practice for family medicine, he mentioned at how one little technical error in filling out his reimbursements led to a stophold on his reimbursements for a number of months while he worked it out with the appropriate persons. He told me that it was already difficult enough as it is now and he feels that MACRA will just be another migraine-inducing bill that lawmakers without an understanding of medicine pushed onto them. Just looking at a nearly thousand-page document, healthcare and medicine has become a complex business that is no longer governed, led, and maintained my medical professionals, instead it’s all about the red-tape bureaucracy that continues to strongarm medicine into doing whatever it wants.
Quite frankly, I’m not sure if any ordinary provider would be able to dissect and enderstand the bureaucratese that is littered throughout page after page and even understand the nuances within the minute details. Something that is constantly pounded into your head when you’re in any policy-making or management class, is that any new change or report should be written in a way that is easily understood. But unfortunately, in the ring of politics, MACRA was written in a way that is designed to trip up people and it makes it overly complex and burdensome for many. Something else that definitely looks like will cause problems is that the implementation is unreasonably fast. Meaningful Use and its stages faced a ton of backlash and was delayed months and even years for implementation. The fact that Meaningful Use Stage 3 was supposed to be implemented in 2018, yet the new requirements in MACRA are trying to be implemented in 2017, January of this year definitely does not seem reasonable. Granted, the 2017 year is meant to be collecting data for payments that will start in 2019, it really only gave the healthcare organizations give or take a few months off of a year to revamp and reimplement their entire workflow and practice. And quite frankly most doctors would be unaware of the upcoming changes and the specifics behind it.
Lastly, my family friend runs a small solo practice with im as the primary physician, a physician’s assistant (PA) and a gamut of nurses and administrative assistants. Talking to him, he mentions that the new regulations are going to hit him hard and with the current metrics and values that he works with, he’ll be hit with negative adjustments. In fact, CMS projected that 87% of solo practices will face a negative financial adjustment, to a total of $300 million lost. Additionally, practices with 2-9 eligible doctors, which comprise 70% of practices will face a negative adjustment as well with $279 million lost. Statistic Source MACRA, and by extension MIPS implementation will all depend on the extent that practices and caregivers are already participating in the current value-based programs and reporting like PQRS and MU, the practices that have avoided this will face a much steeper learning curve. Fortunately, 2017 is the first transition year so those who weren’t participating should definitely take this time and go through the policies and compare it to their current practices to see what needs to be implemented, improved, or removed to be up to standard with MACRA. Something else to consider and a great way to implement Health IT and data analytics is in regards to collecting and reporting data, because payments won’t start until 2019, it’ll be too late to fix any mistakes and errors made in the practices now. As a result, there could be a great niche area that helps to analyze reported data to help generate insight for these practices and how to improve!
Because he’s not associated with a larger healthcare organization or university group, most of the data that he collects usually isn’t relevant to his direct care of patients. The statistical reporting demands doesn’t seem necessary because it may not provide much for patient insight, quality of care, and growth of his practice, but most of it won’t be used and as a result, most of the checklist items in MIPS may not be applicable. As a result, even the small solo practices that survived through the ACA and Obamacare may take another hit which may encourage assimilation or purchase into the larger healthcare organizations and university groups.
Changes masquerading as meaningful have only increased physician
. We should pay physicians for time spent engaging patients in conversation, instead of rewarding them for checking boxes on a computer screen. Unfortunately, reimbursement for “valuable” dialogue is difficult to quantify within the physician-patient framework. Link Source
One of the most significant impacts from MACRA are the points that must be supported by IT. Especially in smaller practices, not all of them will be using EHR that are certified in the most recent attestation programs from CMS. It transforms how they can deliver care. Meainingful use of health IT and implementation of the EHR has been a long road and these changes with MACRA will make this an uphill battle that must be overcome. But even then, most practices have already taken a pretty significant hit with purchasing an EHR, but the fact that the following features that must be supported (but not all) can hurt even more: Source
- Electronic prescriptions
- Protecting patient health information, including the use of security risk analysis
- Provide patients with electronic access and educate patients about program usage
- Coordinate care through patient engagement, including secure messaging, view-download-transmit of summary care information, and patient-generated health data
- Exchange of health information, such as patient care records, and reconciliation of clinical information
- Reporting of immunizations to public health organizations and clinical data registries
Unfortunately, this means that these features must be supported fully for compliance, and with the amount of reporting that must be done. This can be easily be checked through audits. If it wasn’t clear before, the areas under of MIPS are umbrella terms and within each of the categories are a plethora of metrics and activities that practices can pick and choose to fulfill depending on how much they’re looking to receive in their payments. Each activity and metric is weighted differently depending on what it is mandating and takes into account the difficulties in implementing something like that. As a result, there should be a mix of easy and challenging metrics fulfilled that fall in line with a thought-out plan that will help improve the practice. What I mean is that it is easier to fulfill these activities, if they would be activities that were going to be fulfilled in the first place or if they were directions that the practice was intending to pursue as a result. Make these activities fit the scope of the practice, and not change the scope of the practice to fit the activities.
As pessimistic as it may seem, I’m not too sure that MACRA will be implemented well and make much of a positive impact in medicine. It’s scary because I hope to enter the medical workforce in a couple of years (make that like a decade) but if lawmakers continue to think that adding more and more pages of laws and policies to medicine will revolutionize medicine with a new era, they’re sorely mistaken. I’m not going to say it will fail, but by adding more and more red-tape bureaucratic measures, it takes away from the overall capability to attend to a patient’s needs.