Will MACRA Implementation Unfairly Affect Small Practices?

MACRA implementation aims to transform care delivery, but it could have negative consequences for certain physician practices.

By Kyle Murphy, PhD on

The final rule for MACRA implementation — and with its provisions for both the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) — is many months away, but concerns about its impact on the healthcare industry are already growing.

The comment period for the proposed rule began back on May 9 and runs through early July and is likely to generate plenty debate about the merits and requirements of the Quality Payment Program.

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Massachusetts General Hospital's and Harvard Medical School's John Goodson, MD, foresees troubles ahead for small physician practices in particular if the proposed MACRA requirements go into effect as planned based on their inability to meet quality reporting requirements requiring collaboration with other providers and specialists.

In this one-on-one interview with EHRIntelligence.com, Goodson shares his opinions on the impact MACRA implementation will have on the healthcare industry as well as the rule's winners and losers.

EHRIntelligence.com: What impact do you envision MACRA implementation having on the industry?

John Goodson: Having watched the physician payment scene for some time, there is no question that MACRA is going to change the game. I tell folks that this is probably the biggest thing that has happened in three decades. It's bigger than SGR. It's bigger than meaningful use. And it's really bigger than anything since RBRVS — and that was 1992 when that finally got implemented.

I do see that CMS anticipates that everybody is going to be in the MIPS land. If you read the original discussion, the APMs sounded like they might be attractive. But if you look at the numbers they're talking about, it's going to be fraction — probably less than ten percent of the total — and that may be an overestimate. The shared financial risk you have to build in to meet the stipulated requirements for APMs are so gigantic that a lot of groups would not be able to pull that off and have enough specialty diversity. You've got to get the orthopedists, the cardiac surgeons, the anesthesiologists, and everybody to sign up. I just don't see that happening.

EHRIntelligence.com: As for the specific requirements of MACRA implementation, what stands out to you most?

JG: The bite on this thing is staggering and it really has all kinds of implications. The thing that really struck me as being most profound was that 2017 performance — and that's barely when people are actually going to know what this means — is going to affect 2019 reimbursement. My guess is that they are going to get a lot of pushback on that when the comments come in because that's just tomorrow. They are trying to move reporting from punching out the details that fill the columns to really showing the impact of healthcare. Yes, that makes sense if you're going to try to fulfill that value-based mantra, but the reporting requirements themselves could become so staggering that it would just weigh everybody down.

EHRIntelligence.com: Who stands to benefit from MACRA? Will there be clear winners and losers?

JG: There's an implication in there that everyone needs to be aggregated — I call this the attack of the aggregators. You really do worry about the little guy practices and how they are going to perceive this. I don't think it's gotten to them yet. And if you look at what's coming out of the professional societies, particularly family medicine, it's not quite clear that they see the alarm quite yet, but I promise you they will.

In large metropolitan areas, the aggregators have already won, like Boston, but there are a lot of metropolitan areas that are still not totally aggregated or matured as some would call it. If you go into a lot of rural or underserved areas, or even underserved areas in large cities, the big enterprises don't much care for or have much interest in going out there. These little guy practices could end up saying this is too much and want to get out. Getting out could mean getting out of Medicare. Then you're talking about a beneficiary issue that has real implications to Congressional districts.

Four, five, seven, nine is the way it progresses. The nine is within six years. That wakes people up. There is going to be a huge intimidation factor that could force people into enterprises or out of business. If you force people out of business, you're really talking about decreased access to healthcare. Now people are aware of this — they don't have good solutions, but they are aware of this potential.

EHRIntelligence.com: Will MACRA implementation ultimately prove to be good or bad for the healthcare industry?

JG: We're in uncharted territory here. The implementation of this is going to require an extraordinary amount of oversight and diligence. This is one of the few things that actually got through in 2015 and I do believe that there is a lot of interest on the part of Republican leadership that this thing not go off the tracks. They have a sense of stewardship if you will. Those of us in the field who really want to be sure that this doesn't an adverse negative effect on the practitioners needs to be aware that at the end of the day Congress is responsible for making sure that the laws are implemented in a way they intended them to and if there are serious changes that have to be made, then we need to figure out what they are.

This is very much like what happened with SGR. SGR started and there were legislative fixes that were required to re-fund it. Likewise, MACRA is going to take some fixes, particularly if it starts to have an adverse effect on these little guy practices.

Tagged Alternative Payment ModelsMACRAMerit Based Incentive Payment System

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