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Putting the Penalties and Rewards of MACRA and MIPS into Perspective

· Despite what you have been led to believe, participation in MACRA and MIPS is not mandatory. In fact, participating is not in your best interest

· The financial penalties for non-participation are either non-existent or insignificant

· There is little evidence that participation in MACRA / MIPS contributes to improved patient care

· The time expended in complying with MACRA / MIPS contributes to physician burnout and increased overhead

MACRA and MIPS. Ever heard of them?

Medicare Access and CHIP Reauthorization Act (MACRA) is a program sponsored by Centers for Medicare and Medicaid Services (CMS) that is designed to “repeal the Sustainable Growth Rate formula, change the way Medicare rewards clinicians for value over volume, streamline multiple quality programs under the new Merit Based Incentive Payment System (MIPS), and give bonus payments for participation in eligible alternative payment models (APMs). [1]

If you search for MACRA and MIPS on the web, you’ll discover that practically everything published about them addresses the meaning, intent, penalties, rewards and necessity of compliance. Articles that explore the burdens and costs of participation are virtually nonexistent, and the promulgation of these programs has been done in such a way as to impart a sense of inevitability to them, as though participation is compulsory.

It is not.

Are there costs to participation? CaduRx believes that there are. Are there reasons to not participate? We think so.

The operational mechanics of these programs are so complex that it is nigh impossible to calculate reimbursement from Medicare and Medicaid. The programs are, by law, revenue neutral; that is, they must fund themselves, so rewards for compliance can only be derived by financially penalizing the non-compliant: no external monies may be applied. Since nobody knows what percentage of the physician population is participating at any given time, there is no way to calculate rewards until two years after participation and performance levels have been tabulated! MACRA and MIPS render standard fiscal controls and financial projections untenable for physicians’ offices. The maximum penalty that can be levied against providers is 9%, but that penalty takes effect incrementally and won’t be in full force until 2022.

Even if it were possible to calculate reimbursement real-time, the metrics are so complex that most medium to small clinics don’t have the resources to engage. CMS payment schemas for MIPS are incredibly complex, involving separately weighted categories with clinic performance measured against benchmarks that are presented in terms of deciles and percentages with variations, bonus points and submission methods. Suffice to say that it requires a well-educated full-time employee to track, implement and manage these programs in a medium- to small-sized clinic. It is estimated that the average physician spends 785.2 hours annually simply tracking and reporting quality measures.[2] That’s the equivalent of about two-thousand level three office visits (99203, 99213). And there is little consensus on the value of these quality measures. The Government Accountability Office concluded in a 2016 study that: “Although hundreds of quality measures have been developed, relatively few are measures that payers, providers, and other stakeholders agree to adopt, because few are viewed as leading to meaningful improvements in quality.”[3]

The net effect of these government programs has been the decimation of independent physicians running smaller practices; a “consolidation of stakeholders,” as it has been euphemistically termed.[4] Small practices simply don’t have the resources to compete, so independent physicians have gone from being autonomous professionals who own their own practices to micro-managed employees in big hospitals or integrated care groups. Numerous important studies confirm that physician dissatisfaction and burnout is at an all-time high.

But what are the consequences of not participating?

CMS itself recognizes the inherently onerous burden of documentation and has exempted physicians who generate less than $90,000 / year in Medicare and Medicaid earnings from participating. So if you make under $90,000 / year from Medicaid and Medicare, you will not be penalized for not participating.

But suppose you make over $90,000. Remember that CMS bases its compliance on your ENTIRE patient population, but it can only manipulate its own reimbursement. As currently configured, the most you can be penalized is 9% of your total CMS reimbursement (starting in 2022). CaduRx believes that if you focus more time on patients and less time on collecting data for CMS, most physicians can easily compensate for a 9% penalty.

For example, if you make $100,000 / year from CMS, you would only need to have one additional level 3 office visit (avg. ~$80 commercial payer) every other day to offset the penalties. If you make $150,000 / year from CMS, you would need three additional level 3 office visits per week to offset the penalties. If you make $200,000 / year from CMS, you could offset the penalties with one additional level 3 office visit per day. In fact, we believe you will be able to see multiple additional patients per day and provide them with better care by rejecting the onerous time burdens imposed by MACRA.

CaduRx believes that medicine belongs to doctors, not administrators and bureaucrats. We believe that data is good only insofar as it assists physicians in making health care decisions, and that physicians are the best arbiters of determining which data is germane for which patient.

CaduRx believes that Electronic Health Records should be designed for physician use, not for government data collection. Accordingly, we are in the process of optimizing our EHR for physicians. We do not require (or even suggest) that physicians comply with Meaningful Use, MACRA or MIPS. We believe that a physician’s responsibility is toward patients, not bureaucrats or administrators. We are streamlining our system to work for doctors. CaduRx doesn’t micromanage you, nor does it make you collect bucket loads of extraneous data. It won’t help you play the MACRA game, but it WILL help you care for your patients. And after all, isn’t that what it’s all about?


[2] “As MACRA Implementation Proceeds, Changes Are Needed,” John O’Shea, Health Affairs, April 21, 2017

[3] HEALTH CARE QUALITY: HHS Should Set Priorities and Comprehensively Plan Its Efforts to Better Align Health Quality Measures, United States Government Accountability Office Report to Congressional Committees, October, 2016

[4] MACRA: Quality Incentives, Provider Considerations, and the Path Forward, Leavitt Partners, December 21, 2015

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