Many pathologists and other physicians are accelerating their retirement plans as they become familiar with how MACRA, MIPS, and ADM will change the way the Medicare Program pays for physician professional services

Will Medicare’s make-over to how it pays physicians accelerate the retirement of more doctors—including pathologists? That’s the question many experts are asking as the nation’s physicians learn more about the rule to implement the Medicare Access and CHIP Reauthorization Act (MACRA), with its Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Model (APM) programs.

With the Center for Medicare and Medicaid Services (CMS) expected this fall to finalize changes in how physicians—including pathologists—get paid for Medicare services, it appears many physicians are considering retirement, rather than contend with Quality Payment Program (QPP) rules for a new value-based reimbursement system and other healthcare reforms.

The Physicians Foundation’s latest biennial survey, “2016 Survey of America’s Physicians: Practice Patterns and Perspectives,” indicated that 46.8% of physicians plan to “accelerate” their retirement plans due to changes taking place in healthcare. That number rises to 50% among doctors age 46 and older, and to 54.2% among physicians who own their own practices.

“Many physicians are dissatisfied with the current state of the medical practice environment and they are opting out of traditional patient care roles,” Walker Ray, MD, President of The Physicians Foundation, stated in a press release. “By retiring, taking non-clinical roles, or cutting back in various other ways, physicians are essentially voting with their feet and leaving the clinical workforce,” he conclude.

Walker Ray, MD, President of The Physicians Foundation, says many physicians are opting out of traditional patient care roles because of their dissatisfaction with the current state of the medical practice environment. His organization’s biennial survey indicated that 46% of physicians plan to “accelerate” their retirements, while many others are cutting back on patient care or seeking non-clinical roles. (Photo copyright: The Physicians Foundation.)

Walker Ray, MD, President of The Physicians Foundation, says many physicians are opting out of traditional patient care roles because of their dissatisfaction with the current state of the medical practice environment. His organization’s biennial survey indicated that 46% of physicians plan to “accelerate” their retirements, while many others are cutting back on patient care or seeking non-clinical roles. (Photo copyright: The Physicians Foundation.)

Even doctors who are not considering retirement are seeking to reduce time spent in traditional, full-time patient care. Only 52.2% of the 17,236 physicians surveyed said in the next one to three years they would continue practicing as they are, down from 56.4% in 2014. The remainder said they were:

• Considering working fewer hours (21.4%);

• Retiring (14.4%);

• Seeking a non-clinical job within healthcare (13.5%);

• Seeking a temporary position (11.5%);

• Working part-time (9.8%);

Switching to concierge medicine (9%); and

• Seeing fewer patients (7.5%).

54% of Physicians Rate Their Morale as Somewhat or Very Negative

Physicians’ level of dissatisfaction with their profession may increase in November when CMS is expected to release the final rules for the value-based reimbursement systems contained within MACRA, AKA the Quality Payment Program (QPP).

The QPP creates a permanent replacement for the Sustainable Growth Rate (SGR) reimbursement formula that formerly set prices for the Medicare physician fee schedule. Physicians can choose from two QPP reimbursement tracks:

1. The Merit-based Incentive Payment System (MIPS); or

2. Advanced Alternative Payment Models (APMs).

MIPS consolidates three earlier incentive pay programs:

1. The Physician Quality Reporting System (PQRS);

2. The Physician Value-based Payment Modifier; and

3. The Electronic Health Record.

MIPS will either pay physicians (including pathologists) an annual financial incentive, or penalized them, based on the physician’s compliance with MIPS.

Advanced APMs are a subset of APMs, which are a payment approach that gives added incentive payments to provide high-quality and cost-efficient care. Whereas APMs can apply to a specific clinical condition, a care episode, or a population, practices that are willing to assume some risk related to their patients’ outcomes can earn an additional 5% incentive payment through an Advanced APM.

However, CMS has predicted most Medicare Part B clinicians will be subject to MIPS.

QPP Will Impact Pathologists

According to a CMS QPP fact sheet, MACRA will begin on Jan. 1, 2017, and the data collected will affect Medicare reimbursements beginning in 2019. MACRA’s carrot-and-stick approach includes penalties for non-compliance and bonuses for successful participation that begin at 4%, but which could reach 9% by 2022.

Based on its analysis of the new payment system, the College of American Pathologists (CAP) estimates in its analysis of the new payment system that MIPS will have a $1.5 billion overall impact on the pathology specialty beginning in 2019.

Dan Golder, DDS, a Principal at Impact Advisors, a healthcare IT consultancy in Illinois, points out why Medicare’s latest move away from fee-for-service medicine may lead to more physicians rethinking their healthcare role.

“Meaningful use is first-grade arithmetic, and MIPS and MACRA are college-level calculus. It’s very, very complex,” Golder said in Modern Healthcare, referring to MIPS.

“There are over 200 quality measures folks have to review and pick from. There are over 90 ‘clinical practice improvement activities,’ which are another part of MIPS. The complexity of MIPS is going to be very difficult for physicians to stomach. They’re going to be really challenged to read and understand the rules and to perform at a high enough level,” he added.

Physicians May Be Unaware of the Impact MACRA Will Have On Them

The Physicians Foundation survey found that while 43% of physicians are being paid using value-based models, the vast majority of doctors are unaware of the game-changing rules for value-based reimbursement under MACRA. Only 20% of physicians surveyed stated they were familiar with MACRA’s new pay formulas. Meanwhile, 56% said they were “somewhat unfamiliar” or “very unfamiliar” with the new payment system.

“Doctors have been on a slow boil over a variety of issues for years,” Mark Smith, President of consulting firm Merritt Hawkins, told Forbes. Merritt Hawkins conducted The Physicians Foundation survey. “Implementing value-based care and adjusting to MACRA on the fly has turned up the heat a few more degrees. The result is more than hard feelings,” he concluded.

However, despite the fears raised by MACRA and MIPS implementation, not everyone opposes the upcoming changes.

Damian P. Alagia III, MD, Chief Physician Executive/Chief Medical Officer at KentuckyOne Health in Louisville, Ky., acknowledges the program “looks pretty onerous,” but he points out the “bottom line is physicians will continue to be compensated for seeing patients, diagnosing, treating them, and following up with them to determine the effectiveness of treatment.”

“None of our traditional interactions will change,” he stated in Inside KentuckyOne, an online news site for KentuckyOne Health’s physicians and employees. “What will change, however, is the added expectation that as part of the increased focus on quality—or the transition from ‘volume to value’—we will be expected to more effectively document the quality-related work we do. We will be ‘scored’ across the following four categories: Quality, Cost/Resource Use, Clinical Practice Improvement, and Advancing Care Information.”

Donald Crane, President and CEO of California Association of Physician Groups (CAPG), which represents more than 250 accountable physician group practices, also predicts the final outcome of the Medicare reforms will be positive. “MACRA is going to force considerable change—all of it in the right direction,” Crane told Modern Healthcare. “It’ll be tough, but it’s what the doctor ordered and what we want. And over a number of years, we’ll successfully do it.”

The changes from implementation of the MACRA law may prove beneficial in the long run, but pathologists who are paid under Medicare’s physician fee schedule will be affected as the financial incentives and penalties of MIPS and APM become reality. The financial stakes are substantial for the anatomic pathology profession.

“Survey after survey indicates that most physicians don’t know about MACRA. Even fewer understand the law which triggers a major change in how Medicare will pay for physician professional services,” stated Robert L. Michel, Editor-in-Chief of The Dark Report. “A huge amount of money is at stake. The College of American Pathologists estimates that the MIPS program will have a $1.5 billion overall impact on the pathology specialty beginning in 2019.”

Dark Daily recently conducted a special webinar tailored to the needs of pathologists, their practice managers, and their business advisors. The webinar presentation, and transcript of this webinar can be purchased here. (Or copy and paste this link into your browser: https://ddaily.wpengine.com/audio-conferences/webinar-everything-you-need-to-know-about-macra-82516.)

—Andrea Downing Peck

Related Information:

The Physicians Foundation: 2016 Survey of America’s Physicians

Survey of 17,236 Physicians: Half of US Doctors Plan to Retire, Cut-Back or Seek Non-Clinical Roles

Notice of Proposed Rule: Quality Payment Program

The Quality Payment Program

How Medicare’s New Physician Payment Systems Under MACRA Will Affect Pathologists

More Doctors to Retire as MACRA and Value-Based Pay Hit

Few Docs Ready for Risk under MACRA

With MACRA Looming, Doctors Can’t Afford Waiting to Plumb Its Intricacies

MACRA’s Impact on Our Practice

CMS Unveils New Advanced Alternative Payment Models for 2018

PRESS RELEASE: Most Pathologists Unware of New Federal MACRA Law Accelerating Medicare’s Transition Away from Fee-for-Service Payment: Upcoming Webinar to Prepare Pathologists for MIPS and New Medicare Payment Models

Are You Ready for MACRA? What You Need to Know, What Your Pathology Lab Must Do to Protect Pathologist Income