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The problem, she added, is that the criteria still need to be defined by the law, so it is hard to know if and when such proposals will be evaluated and approved. Meanwhile, all practices have the option of switching back to MIPS annually, but since the goal is to push physicians away from that model, as evidenced by the steeper penalties each year the law is in effect, this becomes less attractive an option.
Calls for calm
In some ways, according to Dr. Patel, this evolution in health care delivery should be seen as a good thing since “the fee-for-service model is not viable.”
And yet, an impact analysis from the CMS Office of the Actuary that was included with the proposed rule predicts that based on measurements to be taken in 2017, 87% of all solo practices will be negatively adjusted in 2019, the year MACRA goes into full effect. Nearly 70% of practices with between 2 and 9 physicians are predicted to be penalized, while about 60% of those with between 10 and 24 practices will be hit. Larger practices also are expected to be severely affected. For those with between 25 and 99 member physicians, nearly 45% will face negative adjustments and groups with 100 or more physicians will face a nearly 20% negative incursion, according to the analysis.
But before you sell your practice to the local hospital system or drop out of Medicare altogether, some analysts and officials advise against panic.
Robert B. Doherty, ACP senior vice president for governmental affairs and public policy, disputed the notion that the analysis is proof of the coming death of small practices. “I disagree with that. Essentially, the actuary was projecting using relatively low rates of participation [in the new value-based programs],” he said.
To that end, on May 11, acting CMS Administrator Andy Slavitt testified before the House Ways and Means Committee’s Subcommittee on Health that because those actuarial projections were based on data collected in 2014, they were not reflective of what he said was an uptick in quality measure reporting for 2015. Before the rule is finalized later this year, the actuarial tables would be updated to reflect the new data, he said.
That leaves plenty of time to advocate for feasible payment structures for practices of all sizes, Mr. Doherty said. “If we succeed in doing that, and I think there is some progress ... then I think there will be opportunities for smaller practices to get positive updates.”
Advocacy is not enough
Dr. Patel, a practicing internist in Washington, said that she agrees with this approach.
In addition to making constructive, written comments on the proposed rule, which closes on June 27, 2016, at 5 p.m. EDT, Dr. Patel said that taking steps to optimize available resources now, such as reporting quality measures, or using the chronic care management fee, are ways to ensure higher revenues in the future. “Think about ways to leverage your practice now in order to actually get on one of the advanced payment care models so you avoid being in that track that gets all that downward pressure,” she added.
Still, she said that advocacy may not be enough for some practices to stay solvent. “If the actuaries and CMS really believe that small practices are going to face these steep penalties and not be able to survive, then how we address that, such as through how we define alternative models that are broader [in scope] for practices to follow, has to actually be written by CMS into the final rule.”
No matter the type of ark you choose to build, particularly if yours is a small practice, you’ll have to create some kind of watertight vessel or else, said Dr. Patel, it is “going to be extremely hard to participate in the Medicare program.”
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