Many healthcare providers have been waiting for the end of meaningful use with baited breath. After all, the end of MU promised to lessen the burden of compliance requirements, and usher in more realistic reporting guidelines.

But the Centers for Medicare and Medicaid Services’ (CMS) thousand-page proposed rule for the Medicare Access & CHIP Reauthorization Act of 2015, or MACRA, isn’t quite the fix physicians were hoping for.

While it’s clear that the CMS had “good intentions” when it crafted the proposed ruling, many industry experts feel the agency still missed the mark. If the ruling passes as it is, small practices could potentially be its biggest victim.

What Will be the Implications for Small Practices?

Before getting into some of the specific implications, it’s worth mentioning that small practices should assume they’ll go through the MIPS path and not its alternative, the advanced payment models (APMs). CMS currently estimates that only 4% of solo practices will qualify for APM status, and even then, they will need to report MIPS data.

Also some consultants, such as Ingrid Lund, PhD, practice manager for research and insights at The Advisory Board Company, are encouraging small practices to hold off for several months before adopting an APM model, such as an accountable care organization, or from participating in the Comprehensive Primary Care Plus program, for the sole reason of APM track qualification. As Lund puts it, “It is too late and this is too dramatic a change.”

Soloists Will Incur Penalties, Though No One is Sure How Many

Strong concerns have been voiced over Table 64 that was included in CMS’ 962-paged implementation rule. The table shows that as many as 87% of soloists may incur penalties in 2019.

Since receiving numerous complaints, CMS has backed off their initial estimates from Table 64. “I don’t think that table represents the reality,” acting CMS Administrator Andy Slavitt, told the concerned members of Congress in a recent hearing. Slavitt maintains that small practices can prosper just as much as larger ones in the new system, so long as they report performance data.

To read the full report, visit CMS’s Small Practice Fact Sheet.

Reporting That Data Won’t Be Easy

Robert A. Berenson, MD, a fellow at the Urban Institute in Washington, D.C. and one of the country’s best-known health policy experts, feels that physicians don’t have the sophisticated IT systems that will be required to collect and report MIPS data. “The obligations required to submit the data mean they will have to pay someone to do it for them. And we already know that small practices are just getting by and accept much lower payment levels from insurers than large practices do.”

Further complicating things, is the new penalty structure, where MIPS, PQRS, Meaningful Use, and the value-based modifier will be combined. Instead of getting hit with the current 2% penalty for not reporting on PQRS, soloists could potentially be hit with a 9% penalty starting in 2019.

Berenson is concerned that many small practices will not be able to stay afloat with this new penalty structure. “I believe the MACRA legislation indicates that physicians unwilling to accept the yet unproved value-based payment approaches will take a real hit, and when you combine that hit with all the other trends in the market, then you see all these factors pressuring small practices.”

There is No Opt-Out

Unlike other reporting initiatives, MACRA does not offer the option for providers to opt-out of reporting by paying a penalty. This means that any physician who accepts Medicare patients must comply.

Small Practices May Become Overwhelmed

As happened with meaningful use, many small practices may take one look at the list of MACRA requirements and feel completely overwhelmed, causing them to throw in the towel and decide to stop accepting Medicare patients or require cash-only. This would ultimately be a loss for both, patients who would need to find another doctor, and the practice itself, which would potentially take a revenue hit.

On the other side of the spectrum, there are those who recommend that physicians should stay away from the panic button. They believe MACRA to be better than what physicians currently have to put up with; PQRS, Meaningful Use, and Value- Modifier programs because:

• By combining reporting of quality data into one program instead of the three separate ones, MACRA can substantially ease the burden of reporting. There are reductions in measures to be reported under the Advancing Care Information Act (Meaningful Use).  In addition, MACRA adds a new category for reporting on Clinical Practice Improvement Activities, with approximately 90 flexible options for physicians to get credit for, many of which, they are already making in their practices
• MACRA allows physicians to earn positive payment adjustments while the current PQRS and Meaningful Use programs only allow physicians to avoid penalties (no positive adjustments allowed).
• MACRA’s maximum potential penalties for failing to successfully report quality and cost data, for the next four years, are less than under the current reporting programs.Under the current PQRS, Meaningful Use and Value-modifier programs, physicians in 2017 could get a maximum downward adjustment of up to 8%: -2% from PQRS, -2% from Meaningful Use, -2% from the Value Modifier Program (for physicians in groups of 2-7) or -4% (for groups of 8 or more). Under MACRA, the maximum downward adjustment a physician could get in 2019 (which CMS is proposing will be based on data submitted in 2017) is -4%, -5% in 2020, and -7% in 2021.

Read: Relax it’s Only MACRA

How to Prepare for MACRA

While there is still time before MACRA officially goes into effect, every physician should begin to become familiar with the programs, and start preparing for the changes ahead.

With this in mind, here are some things you can do to prepare for MACRA and lessen its impact on your practice:

Learn the basics.

Visit the CMS website to learn as much as you can about the different programs. You may also want to check out CMS’s FAQ about the programs here, and their handy timeline here.

Participate in the comment period. 

Consultants are advising smaller practices to participate in the comment period, which will continue through June 26. Through this dialogue, the CMS will hopefully gain a different perspective on their current proposal and make changes to the penalty system, setting up small practices for success.

Make sure you’re up to speed with current initiatives.

Numerous elements of the Merit-Based Incentive Programs (MIPS) will be derived from existing programs, so make sure to assess where your practice currently is with the Physician Quality Reporting System (PQRS), EHR Meaningful Use and the value-based modifier.

Understand how you are currently being rated.

You should review your practice’s Quality and Resource Use Reports (QRURs) for the 2014 calendar year, as well as the first part of 2015. The QRUR will help you understand how you are currently being rated on both cost and quality.

Deliberate and decide quality measures to report on.

The biggest challenge for a majority of small practices will simply be, deciding which quality measures make the most sense to report on? Physicians should examine which quality measures will be the easiest to collect within their current workflow.

Become familiar with the clinical practice improvement activities.

The clinical practice improvement activities, is a new program that will count toward your MIPS score in addition to PQRS, meaningful use, and value-based modifier. While CMS has remained rather hush-hush about the specifics, it’s clear that these activities are meant to improve population management, enhance care coordination, implement new processes to expand access to practices, improve patient safety and engage Medicare beneficiaries.

Involve your staff.

The transition to MACRA should be a group effort, so get your staff involved. As a group, brainstorm ways you can improve patient communication, and whether outside resources may need to be added to help you provide even better care. Keep in mind the CMS Physician Compare will allow your patients to compare you in ways they hadn’t been able to before.

Wear a new hat.

If you want to keep your doors open, you’re going to have to get used to wearing a new hat: one of a number cruncher. Get in the habit of running your numbers on MIPS or APMs to understand what makes the most sense for your practice.

Buddy up to your payers.

Strengthen your relationship with your payers by asking what matters most to them in terms of quality and outcomes? It’s also a good idea to ask if you can join one of their pilots for cost-saving programs?

Stay on top of current information.

The proposed rule that implements MACRA is expected soon, and you can be sure that in the wake of its arrival, more information and changes will come down the pike. CureMD realizes our physician customers have little time to devote to reading up on the latest healthcare initiatives. That’s why we are committed to providing you with updates and resources, that will help you make the MACRA transition smoothly. Be sure to check back here often for the latest information.

To learn how to prepare your practice for quality programs watch CureMD webinar

The Bumpy Road Ahead : Challenges facing physician practices in 2016.