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Hey everyone,
Rheo here with a quick article from "Physicians Practice" I figured I would share about MACRA and EHR requirements.

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MACRA Has EHR Requirements for Advanced Practitioners

At 962 pages, the proposed rule to implement the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) isn't quite as long as "War and Peace," which is 1,225 pages. Still, it's easy to miss what's important in this proposed rule.

For example, if your practice includes nurse practitioners and physician assistants, you'll need to consider whether to "test drive" the Advancing Care Information (ACI) category within the Merit-Based Incentive Payment System (MIPS) in 2017, says Tony Panjamapirom, senior consultant for research and insights at the Advisory Board.

Physicians Practice recently interviewed Panjamapirom to learn what this means for your practice.

Physicians Practice: MACRA's proposed rule involves a lot of reading. What's one thing that physician practices might have missed?

Tony Panjamapirom: In the past, Meaningful Use only applied to physicians. But as of Jan. 1, 2017, the MIPS program also includes some non-physicians, such as physician assistants and nurse practitioners and others. Practices need to start to think about whether these advanced practitioners will be able to meet the ACI requirements, which are the equivalent of the existing Meaningful Use.

If you have nurse practitioners and physician assistants seeing patients, these requirements might introduce new challenges. At least in the first year, these providers can opt in or out to meet the requirements in the ACI category in MIPS. In future years, CMS starts to transition these providers to the mandatory side.

Physicians Practice: What's your advice for practices as they start to bring advanced practitioners into the ACI fold?

TP: These providers weren't eligible to take part in Meaningful Use in the past, so they didn't need to pay attention to the requirements. The majority of advanced practitioners around the country have never seen Meaningful Use before. That's why, since 2017 is an optional year, it's a good thing for practices to use the year as a "test drive." This isn't going to make or break a practice's overall score or an individual provider's score because CMS will reweigh it.

Since it's an optional year, you might want to start training your advanced practitioners in the same way that you have done for your physicians for Meaningful Use purposes. Start tracking their performance on those measures that you're now tracking for your physicians. Look at how they perform and figure out what can be done to improve their performance.

Physicians Practice: Will the end result be greater interoperability?

TP: I think it will. The health information exchange objective that CMS has continued to adopt from Stage 2 and Stage 3 of Meaningful Use will drive toward interoperability among providers and data sharing. And CMS even makes it clear in the proposed rule, which says that the agency will do surveillance on data sharing to make sure that there's no information blocking.

Written by
June 14, 2016 | EHR, Healthcare Reform, Meaningful Use
By Aine Cryts

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That gives me a splitting headache.
How does all that colossal waste of time translate into better patient care?

I asked one of the expert billing consultants provided by the News York State Ophthalmologic Society whether a physician would be kicked out of Medicare if they refused to participate with MACRA? He said no. If a physician refuses to participate, he or she is only subject to the monetary reimbursement penalties. That is fine with me. I refuse to participate in this government mandated experiment to try to determine our level of competence and quality of care. The quality measures are irrelevant and the whole program is just a further attempt to control every aspect of the health care system.

I guess we will have to wait until November to see how bad the requirements are, but I'm guessing that one strategy might be to change from par to non-par status for Medicare. This would let a doc charge an extra 10% above the Medicare par rates, essentially negating the threatened 9% reduction. Of course the patients would need to handle their own billing, not a simple matter. But sometimes sharing the pain can wake people up.

John --
I agree with you in principle.
But years ago we were all "non-par" -- that was at a time when almost all insurance was "indemnity". In those remote times patients actually paid the doctor, and the insurance company indemnified the patient.

That system made sense, except for several problems
1. The insurance company couldn't control the doctors
2. If the insurance company didn't please the patient, we would have to intercede somehow anyway -- a sort of early version of "prior authorization", though in effect, it was "retroactive authorization", and even then it was pretty onerous.
3. Trying to collect Medicare deductibles, copays, and balance payments was a nightmare. All of the checks went to the patients, and a lot of them were too demented or otherwise damaged to figure out what the check was for. They just thought they got a government check, and they spent it. (Or their kids or caretakers did.)

I don't suppose that would be a problem in Sun City -- but it was in rural Oregon.

Might be time to dust off the resume or go sell cars. This industry has lost it's collective mind. Patient care is the furthest thing from anyone's focus anymore. Any accidental medicine that gets performed is a miracle.

I manage several practices in a billing company. We have a doc that just opted out of MCR and turned all of his loyal Medicare patients into cash patients because MCR were tax liening him. His practice took a nose dive and he can't get back in for 24 months (mandatory re-enrollment waiting period). He's also finding that because he's MCR now non-par he can't even prescribe them meds that are paid for on part D plans. Now the feds are taking his Tricare, CHAMPVA, etc. payments.
Expecting elderly patients to file their own MCR claims is crazy; even if you fill out the CMS-1500 form for them.

It sounds like your doctor dropped out of Medicare entirely, which CMS refers to as "Private Contract". This isn't the same as "Non-Par". A ?Non-Par? provider bills Medicare directly an amount called the Medicare ?Limiting
Charge?, set at 15% higher than the ?Non-Par Fee?, which itself is 5% less than the ?Par Fee?. Therefore it net gain is about 10% (less the still persistent "sequester").

The problem is that Medicare pays the patient directly for 80% the ?NonPar Fee?. The patient is then responsible for passing on the Medicare payment to the provider, plus pay for the 20% co-insurance (covered by a secondary policy if the patient purchased such coverage).

Although the patient doesn't have to file the CMS-1500, they have to troubleshoot the opaque CMS EOBs. And of course pay the doctor. But we all do this to collect our Medicare deductible at the start of the year anyway, so you should have some insight on which patients will be collection problems. Our practice has been very strict on terminating Medicare patients who default at 90 days. Usually some family member emerges to straighten things out (not surprising, since there are other financial needs for these patients).

As MACRA turns up the heat, simultaneous with the Baby-Boomer peak, I expect that finding a Medicare-par provider will be challenging, so getting dropped by your doctor for delinquent payment will be risky. I think it's important for patients to realize that when CMS threatens our financial viability, it hurts the customer as well.

I would certainly go Non-Par if I thought it would work. There were serious problems in the late 70's and early 80's when that was actually the only choice, and the complexities have become far greater.
I don't know anything about conditions in Florida -- but in rural Oregon, it turns out to be
a lot less difficult to go "Par".
Getting people to understand the Medicare system takes an awful lot of staff time -- I don't think that in our case at least that we would come out ahead.

If you can stand the humidity, this area of Florida is a good place to add new patients, as long as you like retirees. We get around 60 new patient calls for the two of us per month, most of whom we can't absorb. Some of the callers tell us we are their 4th or 5th office they've called with no one taking new Medicare. Many of the FPs are either no new Medicare or have gone non-par. A bigger part of our clientele is Medicare, so making a non-par decision is more risky. But so is getting creamed by MACRA.

The solution seems to just be volume.
I haven't figured out how to do it yet, but in principle, if you hold people to ONE PROBLEM per visit you can't probably survive.

Diabetes today
Heart failure tomorrow.
Arthritis next Thursday.
Hypertension in a week or so.
Fatigue next month.
Insomnia later.
Freeze off a few keratoses in two months.
Etc.

I make the mistake of just sort of lumping it all into one visit because I feel sorry for the old folks who have trouble getting to the doctor.

But I'm beginning to feel less and less sorry.

There still may be hope yet... at least for 2017:

NEIL VERSEL reported that CMS says ?pick your pace? in 2017 MACRA payment program

In the face of much criticism over the proposed timeline for implementing Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) rules, federal officials have decided to offer flexibility, at least for 2017.

The Centers for Medicare and Medicaid Services said late Thursday afternoon that it would offer four options for physicians to participate in the outcomes-focused initiative next year. Dubbed the Quality Payment Program, this MACRA provision is intended to replace the widely reviled Medicare Sustainable Growth Rate formula and merge several existing reporting programs under one umbrella.

?In recognition of the wide diversity of physician practices, we intend for the Quality Payment Program to allow physicians to pick their pace of participation for the first performance period that begins Jan. 1, 2017,? acting CMS Administrator Andy Slavitt wrote in a blog post.

The four options are:

Submit some data to the Quality Payment Program as a ?test.? According to Slavitt, ?This first option is designed to ensure that your system is working and that you are prepared for broader participation in 2018 and 2019 as you learn more.?
Participate for some of the year and earn a prorated payment. ? For example, if you submit information for part of the calendar year for quality measures, how your practice uses technology, and what improvement activities your practice is undertaking, you could qualify for a small positive payment adjustment,? Slavitt said.
Go all out and participate for all of 2017. ?We?ve seen physician practices of all sizes successfully submit a full year?s quality data, and expect many will be ready to do so,? Slavitt said.
Choose a Medicare Advanced Alternative Payment Model. This program, along with the Merit-based Incentive Payment System (MIPS) are new ideas from the MACRA plan that consolidate the Physician Quality Reporting System, Meaningful Use and the Medicare value-based payment modifier.
Initial responses to this decision to offer flexibility were filled with cautious optimism.

?I think it?s welcome news for the small-practice physician,? said John Squire, president and COO of Boston-based electronic health records vendor Amazing Charts. ?Anything that eases the burden is good, but it?s just for 2017.?

Squire noted that Slavitt did not offer many details, and that there is no guarantee this leniency will continue into 2018 and beyond.

Dr. John Goodson, staff internist at Massachusetts General Hospital and associate professor at Harvard Medical School, said that CMS left two major issues unaddressed: attribution and risk adjustment.

In other words, what year will the reporting be attributed to, and will CMS take into account the patient mix, since high-risk patients have a lower chance at positive outcomes?

?How can you expect to do anything prospectively if you are going to be judged retrospectively?? Goodson wondered.

Still, he likes the direction CMS is heading. ?I think it gives people some breathing room,? Goodson said.

Goodson also said that value-based payment is here to stay, at least when it comes to Medicare. ?The real message here is that you have to have your data in order,? he said.

Slavitt said CMS would release the final rule no later than Nov. 1.