No small feat: Rural practices brace for MACRA

Dr. Jean Antonucci's practice in Farmington, Maine, is just one small outfit that could suffer under the burden of MACRA.

For small practices like those run by Jean Antonucci in Farmington, Maine, succeeding under new MACRA regulations will all boil down to the details. Unfortunately with MACRA, there are just so many she is just one of the many small practitioners dreading the rollout. That's not surprising given the 4,000-plus comments the Centers for Medicare and Medicaid Services received on the law.

"I don't gain anything positive from this that is not financial, and the financial gain is so tiny for the enormous complexity and reporting burden. It's not simple and it's not useful," Antonucci said.

Despite promises from CMS that the rule actually streamlines reporting and allows doctors more time with patients, many physicians say it is far too complicated. And with a third of her patients on Medicare, Antonucci doesn't believe she'll see much return on the investments she will have to make.

Antonucci is basically a one-woman show, handling both patients and all the administrative and reporting work for her practice. She has even outsourced billing, and gets help five hours a week when a medical assistant comes in to help with clerical work, patient follow-ups and care coordination tasks.

As the rule approaches its January implementation date, many small practices are worried about how they will be able handle the changes, even though CMS in September softened its requirements by giving doctors the option to "pick their pace" when it comes to MACRA quality reporting. The proposed rule has been out for months, but CMS only expects to finalize it in November. That's causing a lot of worry for doctors who think a two-month turnaround between the final rule and the Jan. 1 rollout is just too short.

She's read the MACRA legislation cover to cover and submitted her comments to CMS, but not knowing for sure what the final rule is going to entail is daunting.

Workload pressures

The American Academy of Family Physicians has backed the law, saying they believe MACRA simplifies the quality reporting process for physicians, offers a variety of options to submit quality data and includes the Comprehensive Primary Care Plus program as an advanced payment model acceptable under the law. They are also pleased to see the the medical home model in the proposed rule.

But the AAFP still calls MACRA overly complex and burdensome and has asked CMS to issue an interim final rule in November and allow a comment period.

Robert Wergin, AAFP immediate past board chair and a family physician with Milford Family Practice Center in Milford, Nebraska, a rural community in Seward County with a population of roughly 2,000, said he is hearing similar concerns from big practices too, since gaining a real understanding of the rules and then deciding what quality measure to pick and report on, which he says can largely depend on location and patient mix, is a major endeavor.

MACRA's workload stings for doctors already suffering from change fatigue due to electronic health record regulations and other mandated clerical tasks.

According to a study by the American Medical Association and Dartmouth-Hitchcock published in early September in the Annals of Internal Medicine, during the office day, physicians spend 27 percent of their time with patients and 49.2 percent of their time on EHR and clerical activities. Outside of office hours, physicians spend another one to two hours of personal time each night on data entry demands.

"This study reveals what many physicians are feeling – data entry and administrative tasks are cutting into the doctor-patient time that is central to medicine and a primary reason many of us became physicians," said AMA Immediate Past President Steven Stack, MD. "Unfortunately, these demands are not being reconciled with patient priorities and clinical workflow. Clerical tasks and poorly-designed EHRs have physicians suffering from a growing sense that they are neglecting their patients as they try to keep up with an overload of type-and-click tasks."

That's especially difficult for small practices, which often lack the staff and resources of larger groups.

Lee Gross, MD, a primary care physician in a CMS-designated underserved area for primary care in southern Sarasota County, Florida, said his staff includes two physicians and one nurse practitioner. He lists his group as the last independently owned primary care practice in the region.

In 2010, Gross wanted to find a way to remain independent so he started operating under a membership model where he does not take any insurance for patients under the age of 65. Instead, he charges a membership fee for his younger patients. For those over 65, he only accepts Medicare. He said his membership fee patients number around 500 in addition to a few thousand Medicare patients.

But the switch to a direct medicine model didn't help much when it came to regulatory burdens. The meaningful use program was a struggle, he said, and he only expects it to get worse when MACRA hits. He said he already spends about half his time on administrative work and has no more resources to throw at maintaining compliance and reporting, let alone getting to know almost 1,000 pages of new rules. His biggest concern overall is who's responsible for compliance.

"It's just mind blowing how many resources we spend on just compliance," Gross said. "We don't have a compliance officer. Who in my practice is responsible for reviewing the legislation and making sure they are doing things right?" Gross said.

Wergin also pointed to staffing and infrastructure as one of his biggest issues. With so much time devoted to reporting, there is no time to branch out into the community to establish population health practices that could be rewarding under MACRA, he said.

He suggested finding help, even temporarily, in the form of a payment coach to help ease the transition and develop structures needed to make sure things are done accurately. A healthcare coach could help with patient engagement and getting patients to follow-up and take care of their conditions, all things that affect quality.

[Also: CMS offers flexibility on MACRA, gives doctors ways to avoid payment adjustments]

But that's not an option for Antonucci, which means all of that reporting directly limits her ability to deliver care.

"I could probably see five more patients a day if I had less of the bureaucratic work that is obscuring me," she said. "And with the shortage of primary care, five patients a day is huge."

Tech hurdles

Experts predict most providers will participate in MACRA on the Merit-Based Incentive Program rather than participate in an advanced payment model like an accountable care act. That means one of the four major areas practices will be evaluated on their utilization of certified EHRs. For small practices, just making sure their systems are updated and in compliance with that requirement may be a challenge, especially financially, since updates can cost tens of thousands of dollars.

Gross, Antonucci and Wergin all expect that their EHR systems will need upgrades. And aside from their own challenges with those modifications, that also means every software vendor in the country has to implement those reporting requirements into their software, push out those updates to every practice, and then service them. All of that will have to be done in the short turnaround following the release of the final rule.

But the technology problems go beyond EHRs. MACRA rules require providers to ensure free access to their medical record database for CMS and ask them to attest that they aren't blocking access with the Office of the National Coordinator for Health Information Technology to their database.

Wergin also said interoperability is going to become a bigger issue for him, since the critical access hospital that is the central facility for their system, but is also 20 miles away, uses the Meditech EHR while his practice uses Allscripts. The two systems don't communicate, so he often has to call the hospital office to have records faxed to him and then scans them into his system. It's not an ideal solution since his computer can't pinpoint data in a PDF file. Fixing that system would be a major undertaking, especially for a remote Nebraska practice like his.

[Also: Enter MACRA: CMS chief Andy Slavitt says new law lets doctors be doctors]

"We work around it. But if we're going to meet the real potential of an EHR that is integrated and has interoperability, then the vendors need to make that happen," he said.

Antonucci accepts that the tech hurdles will be high, but without help she'll just have to manage, she said.

"My computer reports quality measures very awkwardly and poorly, but I bet I can figure out how to make it happen."

Good intentions

Despite CMS itself estimating that 87 percent of solo practices and 70 percent of small practices will face a penalty in the first year, both Antonucci and Wergin see potential in MACRA if it is simplified and adjustments are made.

Wergin and the AAFP are pushing for a faster implementation of virtual groups, which would connect remote practices to neighboring larger ones to seek guidance and help where needed.

But Gross sees MACRA as the ultimate demise of his work with Medicare patients. He said he has no expectations of being able to comply, especially as it is laid out now. His practice is already making less money than 15 years ago when his practice was new. Eventually, he expects to be a membership-only outfit, and the thousands of Medicare patients he cares for now, will have to go elsewhere in their already underserved community.

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"I just don't see us spending more resources on it. We will probably opt out before we do that," he said. "We've basically set 2019 as our opt-out date before the penalties kick in. Once we can't afford to take care of the Medicare patients anymore, I think we're done."

Twitter: @BethJSanborn