Concerns About Small, Rural Providers May Delay Start of MACRA

CMS Acting Administrator Andy Slavitt said yesterday that implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) may be pushed back from January 1, 2017, to give small and rural doctors more time to prepare.

Slavitt, speaking before the Senate Finance Committee, there are fears that many physicians will not be ready to meet new Medicare requirements. CMS is weighing everything from a 1-year delay to obtaining data from registries to limit paperwork for smaller practices.

“We’re putting in an awful lot of change,” Slavitt said, according to an account from the American Association of Family Physicians (AAFP). “Too much change on top of an already burdened physician practice is not where we should be going.

Physicians’ groups including the AAFP have called for CMS to delay MACRA, which will not have final rules until November under the current schedule. They say giving physicians only 2 months to prepare to for a fundamentally different way of billing for Medicare will overwhelm some practices, causing more to be acquired by hospitals or shut altogether.

HHS has eyed primary and rural care access with concern for some time. In October 2015, HHS Secretary Sylvia Mathews Burwell awarded $240 million for scholarships and loan repayments to support doctors and medical students working in underserved parts of the country. Last week, CMS said the proposed 2017 Physician Fee Schedule will put another $900 million into primary care, mental health, and care coordination.

But MACRA is another matter entirely. Physicians groups, and some members of Congress, say many small practices that are lifelines for rural or underserved areas lack the manpower and expertise to add more paperwork and still focus on patients. Groups like the National Quality Forum have found that rural practices need different measures and incentives to take part in the movement toward value-based care. And a study in Health Affairs in January found wide variation in how well rural providers are adapting to health information technology requirements.

AAFP has asked to delay MACRA’s start date until January 1, 2018, and use 2017 as a preparation year. Senators yesterday asked CMS to why MACRA should proceed before rural providers are allowed to form “virtual groups” for reporting.

Slavitt said yesterday that rules for virtual groups will require significant physician input. “It’s just a whole new way of reporting,” he said, according to The Hill.

CMS may also rework a “low-volume threshold” that would allow some providers to escape MACRA rules because they don’t see enough Medicare patients. Right now, the limit is $10,000 a year in charges and fewer than 100 patients, which would exempt about 10% of physicians. Groups like the American Medical Association say the dollar amount should be raised to $30,000, which would exempt about 30% of physicians.

The possible delay comes amid concerns that there aren’t enough doctors and nurse practitioners to meet demand created by the Affordable Care Act (ACA), now that Medicaid has expanded in 31 states. Patients newly covered under the law may not have seen a doctor regularly for years, and studies have shown those covered by expansion have more health problems and higher costs than patients who already had insurance.

Health care spending that had dipped significantly in 2010-2014 appears to be rising again as these new patients join the system, according to a CMS statement released yesterday. National health care spending growth for 2015 is expected to be 5.5%, compared with 5.3% in 2014, with final numbers due later this year.

While this growth rate is below the 8% levels seen before 2008, spending is still expected to outstrip the gross domestic product by 1.3% a year through 2025, CMS said.