MACRA's Quality Payment Program for Small Practices

The Centers for Medicare and Medicaid Services (CMS) is reaching out to small practices to ensure their success under MACRA, while also backing away from earlier estimates that most solo practitioners or clinicians in groups of 24 or less would likely incur penalties in 2019 under the new payment system.

MACRA Help for Small Practices

On June 20, the Department of Health and Human Services announced that it will award $20 million each year over the next five years for training and education for Medicare clinicians in individual or small group practices of 15 clinicians or fewer. Specifically, the $100 million will be distributed to organizations that can help small practices in historically under-resourced areas, including rural areas, health professional shortage areas, and medically underserved areas, to successfully participate in the new Quality Payment Program (QPP).

“Doctors and health care providers in small and rural practices are critical to our goal of building a health care system that works for everyone,” said HHS Secretary Sylvia Mathews Burwell in a press release announcing the program. “Supporting local health care providers with the resources and information necessary for them to provide quality care is a top priority for this administration.”

While the number of solo and small practices is shrinking — between 1983 and 2014, the percentage of physicians practicing alone fell from 41 percent to 17 percent, and the percentage of physicians in practices with 25 or more doctors grew fourfold (5 percent to 20 percent) — small practices are still common. As many as 4 of 10 physicians practice in groups of fewer than five physicians.

Proposed Estimates Are Wrong

Meanwhile, acting CMS Administrator Andy Slavitt has been trying to convince the healthcare community that the estimates that most small practices would incur a penalty included in the proposed plan to implement the QPP are wrong.

“I don’t think that table represents the reality,” Slavitt told apprehensive members of Congress in May. In fact, he contends that the new system allows small practices to prosper along with large ones if they report performance data to CMS.

The “table” Slavitt referred to is Table 64, in which most of the 46 percent of eligible providers who would receive a pay cut in 2017 were clinicians in practices of 24 or fewer members — as many as 87 percent. Of the majority of the 761,000 eligible clinicians who would earn a bonus in 2019 based on their performance in 2017 (54 percent), 80 percent of the clinicians were in groups of 100 or more members.

According to Slavitt, the dire estimates for small practices resulted from the 2014 PQRS data used in the proposed rule. In 2014, a large number of solo and small-group practices failed to successfully report PQRS data.

“This is just a proposal,” he added. “We’re hoping people can give us further ideas on how to reduce the administrative reporting burden.”

Built-In Flexibility for Small Practices

In a fact sheet detailing the flexibility and support built into the MACRA proposed rule for physician practices of 15 or fewer providers, CMS shows how the program is designed to accommodate small practices. For instance,

Practices with low Medicare volume — defined as $10,000 or less in Medicare charges and 100 or less Medicare patients — are excluded from the Merit-based Incentive Payment System (MIPS) payment adjustment.
Practices without sufficient measures or applicable activities in a MIPS performance category will have that category excluded from the overall MIPS score, which determines the payment adjustment a practice receives.
Individual physicians have the option to combine and report as a “virtual group” under MIPS.
Practices can submit a single report for the MIPS Quality, Advancing Care Information and Clinical Practice Improvement Activities, and they do not need to report in the cost performance category.
Under the Advanced Alternative Payment Model (APM), special rules apply to small or rural practices, or those in healthcare professional shortage areas, for medical home alternative payment models.
APM rules would include unique financial risk standards for medical homes with 50 or fewer physicians.

Small Practices Are Uncertain

However, in a recent BlackBook Research study, of physician groups with five or fewer clinicians, 67 percent of the 1,300 groups surveyed believe their independence will end with MACRA. BlackBook also found that 89 percent of solo practitioners said they will respond to the new guidelines by minimizing their Medicare volume to avoid filing quality, clinical practice improvement, or cost performance reports to CMS.

For those planning to participate, however, in order to access the needed reporting and revenue cycle tools, 78 percent of independent primary care physicians expect to join a bigger group or integrated delivery network before 2019. As well, in practices with 10 or fewer practitioners, 63 percent are unsure which health information technology and products they need, and 55 percent plan to hold off on technology shifts or purchases until they determined if they will acquired by larger practices or IDNs.