TMA Tries to Lift New Medicare Burden From Small Practices

Patients in some Texas communities may not know their doctor is under immense pressure to adapt to a new law that will determine how they provide care and get paid. According to Texas Medicine magazine, the new government requirement is putting a strain on smaller medical practices — and over time, could force some doctors to retire or surrender their small medical practice. That could reduce patients’ access to doctors’ care

Congress passed the new law, the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA, primarily to replace Medicare’s controversial Sustainable Growth Rate (SGR) formula. Physicians argued the SGR payment formula was flawed because it ignored the cost to care for Medicare patients. Congress passed emergency funding patches each year for a decade to avoid cutting physicians’ pay significantly for caring for America’s seniors and people with disabilities. The SGR forced doctors out of Medicare, leaving patients uncertain over whether their doctor would be there to care for them. MACRA ended that uncertainty.

However, Texas Medical Association (TMA) President Don R. Read, MD, said MACRA is “not what Congress ordered.” It forces doctors to deal with a new set of bureaucratic hassles and payment hurdles. The new law incorporated existing government programs intended to measure physicians’ health care quality — programs doctors also saw as problematic. “When MACRA legislation was enacted, TMA had no reason to expect CMS [Centers for Medicare & Medicaid Services, which oversees Medicare] would propose to continue flawed concepts from the current quality programs along with plans to diminish a physician’s worth down to a complex point system. More disappointing is to learn that CMS proposes to design a program that is stacked against solo physicians and small group practices in its first year of implementation,” said Dr. Read. 

MACRA’s two payment options for physicians came with new quality-reporting requirements. Doctors are forced to invest in computer software to capture and report data, and in training to comply by Jan. 1, 2017 — too little time to prepare, in physicians’ minds.

The government’s draft MACRA rule forecast that nearly all smaller physician practices would struggle to adapt. It estimated in the first year MACRA would cut Medicare payments for almost nine in 10 solo doctors, almost three-quarters of small practices (two to nine eligible clinicians), and 59 percent of practices with 10 to 24 eligible physicians.

“In Texas, more than 60 percent of patient care physicians are in very small practices of one to three physicians,” TMA wrote CMS in response to the MACRA forecast. “MACRA is very likely to levy penalties on most of them, pushing some or all of them over time to retire, or join large groups or hospitals.”

Some doctors, like Dallas cardiologist Rick Snyder, MD, (a member of TMA’s Board of Trustees) insist even his large and sophisticated practice can’t make it under Medicare’s proposed new pay-for-quality rule. “We pride ourselves on being cutting-edge on regulatory compliance, [but] there’s no way in the world we are going to be ready Jan. 1. Our goal is just not to lose money.”

So in its letter to CMS, TMA recommended the government delay the deadline to start collecting physicians’ data six months, until July 2017, to give doctors more time to prepare. In response to TMA’s letter and a top CMS officer’s meeting with Drs. Read, Snyder and other TMA leaders, federal officials say they will temporarily exempt physicians from penalties if they simply choose one of three reporting options in 2017. Practices struggling to adopt the changes can avoid pay cuts in 2019 by at least attempting to report some data in 2017.

Immediate crisis averted perhaps, but TMA and physician leaders say significant amounts of work remain to make the new law tenable for physicians and the patients in their care.

U.S. Rep. Michael Burgess, MD (R-Lewisville), the primary House author of the MACRA bill and a TMA-member obstetrician-gynecologist, says it’s up to organizations like TMA to show physicians how to be successful in the post-SGR world. “My hope is, people will look at 2019, see the risk of a ding, and realize with a little bit of work they can get a payment bump up. So instead of a ding, you get a bump. How’s that? That would be good,” Rep. Burgess said.

Dr. Read said TMA will continue to offer CMS and Congress recommendations to improve MACRA and protect physicians and their patients. “We strongly believe Congress did not intend many of the adverse consequences that will be the result of the new payment formula. We are hopeful that CMS will use its considerable discretion to act in every way possible to minimize the adverse impact.”

TMA is the largest state medical society in the nation, representing more than 49,000 physician and medical student members. It is located in Austin and has 110 component county medical societies around the state. TMA’s key objective since 1853 is to improve the health of all Texans.

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