As Healthcare Informatics Managing Editor Rajiv Leventhal reported in an article on Oct. 31, a survey by Medscape newly made public offers concerning insights into what practicing physicians in the U.S. know—and don’t know—about MACRA, the Medicare Access and CHIP Reauthorization Act of 2015. The fact that nearly nine in 10 practicing physicians responding to the survey said that they either have not heard of it at all (28.6 percent), or don’t know much about it (39.2 percent), with regard to the MACRA law, should be setting off alarm bells across patient care organizations.
Now, to be fair, the survey was executed throughout September, before the MACRA final rule was published on October 14. But still—this is a federal law whose provisions, particularly those under the MIPS (Merit-Based Incentive Payment System) program, are going to fundamentally change physicians’ relationship to the Medicare program, as truly pure fee-for-service payment will no longer exist, beginning on January 1 of next year, and as the Quality Payment System being put into place will affect all Medicare-participating physicians in the U.S.
Most of this survey’s respondents are practicing either in small groups (21.4 percent) or large groups (21.8 percent); 12.6 percent are solo practitioners; and most of the respondents are practicing either in academic hospitals (22.1 percent) or community hospitals (20.2 percent).
And, as Leventhal noted in his article, “While the government has afforded clinicians flexibilities that will allow them to pick their pace of participation for the first performance period starting in Jan. 2017, it does appear troubling that so few doctors know much about MACRA at this juncture. Similarly, a Deloitte Center for Health Solutions survey of 600 physicians from this summer revealed that 50 percent of non-pediatric physicians have never heard of MACRA and 32 percent only recognize the name ‘MACRA.’”
The Medscape survey, he noted, also asked Medicare doctors what their current payment arrangements were. Roughly 61 percent responded “fee-for-service, commercial;” some 49 percent said “fee-for-service, Medicare;” and 9.6 percent reported “bundled payment or episode of care.” Meanwhile, 28 percent of respondents disagree either completely or somewhat that they have sufficient infrastructure to support payer requirements.
So—this looks to be a kind of “perfect storm” situation, when it comes to an imminent policy and payment change that will dramatically affect physicians, one for which they’re broadly unprepared, and one in which data collection, analysis, and reporting will figure prominently in terms of their being successful under the new policy and payment parameters. And by “perfect storm,” I mean, a situation in which said doctors will be burning up the phone lines and rushing down hallways in order to get the attention—and help—of hospital and health system leaders, including CIOs, CMIOs, and other healthcare IT leaders.
Indeed, when one looks at specific requirements under MIPS, including the requirement for all practicing physicians to perform regular data security risk assessments—the conclusion is inescapable that practicing physicians are going to be knocking down CIOs’ and CMIOs’ doors for help, on the security risk assessment, as well as regarding so many other requirements.
What’s more, with senior officials at CMS (the federal Centers for Medicare and Medicaid Services) stating openly that they want to try to get as many physicians into alternative payment models (APMs) as soon as possible. And though CMS Acting Administrator Andy Slavitt did acknowledge in his Oct. 14 telephonic press conference that they realize that may take a few years, he also said this on that day: “In 2018, we expect approximately 20 percent of physicians to participate in an advanced APM and expect that to be on a significant growth trajectory. The Innovation Center and the ability that it has to move quickly and expand models we make advanced APMs available to most interested physicians over the next several years.”
And, Slavitt also said during that press conference, that "We’ve also received feedback to simplify how the scorekeeping, the rules, and the reporting work in what is known as the MIPS program, which is the program that will determine bonus payments in the core Medicare program, so that physicians can focus on patient care, not paperwork. We’ve made major steps, which will continue over the coming year, by cutting the number of measures in half, and simplifying how the program works.” In addition, he said, “We announced a major permanent effort yesterday to reduce physician burden. And, in 2017, we estimate that we will pay approximately $1 billion in bonuses for high-quality care to commissions in both advanced APMs and MIPs, in addition to positive payment adjustment of 0.5 percent, under MACRA.”
So the race is on now to prepare for MACRA and for MIPS and APMs, its two component programs. Here’s what is absolutely clear: CIOs, CMIOs, and other IT leaders and clinical informaticist leaders in hospitals, medical groups, and health systems, will be under unprecedented pressure to help physicians cope with this very large and very important set of requirements under federal law. And with practicing physicians still largely in the dark about what MACRA, MIPS and APMs are all about, the pressure will be that much more intensified on IT leaders to help them implement and optimize data and reporting systems. And yes, almost unbelievably, there are still practicing physicians who have not yet implemented electronic health records. Those doctors, if they are participating in Medicare, will be under almost unimaginable pressure to get their EHRs up and running as quickly as humanly possible, unless they’re planning to retire or otherwise leave medical practice—and yes, a few of those doctors will do so.
But it’s hard to believe that more than a very small percentage of practicing doctors will leave medical practice entirely over MACRA. Instead, they will be scrambling to prepare for the new law. Now, on the mildly positive side of things, the Medscape survey found that about half (51 percent) of respondents said they are already report PQRS (Physician Quality Reporting System) data to the CMS, and, of those who of those who do report, most (63.5 percent) report via an EHR-qualified registry. Of those who don’t report (96 respondents), most don’t report because they don’t know how (34 percent). So that was one mildly positive data point in an otherwise discouraging set of survey results.
But overall, the results of the Medscape survey should be deeply concerning—and yet also energizing—to CIOs and CMIOs and their teams, as well as to CMOs, VPMAs, and everyone else who will be helping practicing physicians to move forward under the new federal mandates. At the same time, CIOs and CMIOs can end up being real heroes in all of this. But they will need to learn the ins and outs of MACRA, MIPS, and in some cases, APMs, very, very quickly, in order to do so. And they will almost certainly need to either increase staffing, or find some other way (perhaps through externally engaged resources) to put themselves in a position to really be able to help doctors in the next two years, as this is going to be a very big lift for everyone—and time is absolutely of the essence here. I honestly can’t think of a situation comparable to this one in recent memory, in terms of its scope (affecting all Medicare-participating physicians), or the gulf between what is going to be required (robust outcomes reporting) and the resources in place now to fulfill those requirements. This is a big one—and is turning into a major moment for healthcare IT leaders.