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MACRA: Reinventing the Structure of the Practice of Medicine

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MACRA Will Reinvent the Way the Practice of Medicine is Organized

An Interview with Dr. Miles Snowden, Chief Medical Officer, TeamHealth

HSTM: Dr. Snowden, some have said MACRA and the new quality payment program will result in sweeping changes not only in physician reimbursement but also in how physicians practice. What are your observations about this?

Snowden: I think the marketplace as a whole has dramatically underestimated the impact of MACRA to the practice of medicine going forward. While there has been a great deal of focus on MACRA, it has not been seen as the catalyst for a dramatic change in the organization of physicians to practice medicine, so I’m going to give you some context around that. Today, based on the most recent available data, some 47% of physicians still practice in groups of five or fewer physicians. A group of that size will find it essentially impossible to be able to aggregate data, report results, and improve upon quality performance status sufficient to avoid very large penalties under the MIPS and MACRA program.

So, if you think about half of the 880,000 physicians in the United States today being in groups of insufficient size to survive this change, you can begin to understand that this is not just about an additional burden of reporting. This is a fundamental change in how physicians organize themselves. It’s also interesting to look at the demographics of those physicians in the groups of five or fewer. They are much older on average than the physicians that constitute the larger group practices. You have half of the country’s nearly one million physicians in very small groups, and they are older approaching retirement. You have half younger and large groups. The larger groups will most likely be somewhat successful in the program; the smaller groups will be the peer group contributing the funds (through penalties) that will allow those in larger groups to receive incentives. As you can imagine, if you have half of the population creating a pool of money to be given to the other half of the population, there’s going to be a push to move from one side to the other side of that situation.

HSTM: How would you say the changes that MACRA will cause compare to other changes you’ve seen over time in the practice of medicine?

Snowden: I don’t recall any circumstance where a program has had the potential for a swing of up to 9% either favorable or unfavorable to the baseline. That is a make or break level of change. I don’t believe that it is possible economically for a physician to sustain a practice in the face of consistent penalty payments under MIPS.

That then takes us to an additional consideration. In essence, the program will drive all physicians to seek the shelter of a better performing group in the program. So, I believe the program has a limited lifespan of a decade or less because eventually, you will be assessing serious penalties on individuals who are actually performing at a very high level. The program may not be limited by regulation and rule but limited by the practical application of always measuring a group of individuals on a scale that’s rapidly rising as a whole.

This has been an e-book excerpt. To read the full interview, click here to download the e-book.


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