On May 6, just nine days after HHS released a proposed rule to guide implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), the AAFP provided about 300 family physicians and chapter executives an audience with two high-ranking CMS officials to discuss the law that will greatly influence how physicians are paid.
Attendees speak with CMS Deputy Chief of Staff Tim Gronniger after a town hall meeting that focused on the Medicare Access and CHIP Reauthorization Act. About 300 family physicians and chapter executives attended the May 6 session during the AAFP's Annual Chapter Leader Forum in Kansas City, Mo.
CMS Acting Administrator Andy Slavitt participated in the town hall meeting during the Academy's Annual Chapter Leader Forum via conference call, and Deputy Chief of Staff Tim Gronniger attended the event here. An AAFP staffer introduced Slavitt and Gronniger as "our friends from CMS," drawing laughter from a smattering of audience members.
Gronniger said he gets it.
"I hope that through this process we'll be recognized as, if not friends, warm acquaintances who are open to listening," he said.
Listening is key, Slavitt said, in a process that allows physicians and other members of the public to comment through June 27.
"Our marching orders are to get out of Washington and spend time with physicians on the front line," Slavitt said.
He acknowledged that MACRA comes at a time of "record low physician morale" because of issues related to reimbursement, regulations and administrative burdens.
- CMS Acting Administrator Andy Slavitt and Deputy Chief of Staff Tim Gronniger participated in a May 6 town hall meeting that focused on the Medicare Access and CHIP Reauthorization Act (MACRA) during the Academy's Annual Chapter Leader Forum in Kansas City, Mo.
- Slavitt said the MACRA rule-making process offers an opportunity to reduce administrative burden and improve payment for physicians.
- He encouraged physicians to offer feedback on a proposed rule to implement MACRA that was released in April. The public comment period runs through June 27.
Slavitt said the regulations are well intended but "when stacked on top of each other, they contribute to distraction from what physicians want most, which is to see patients.
"We need to give physicians back more time, more simplicity and payment that makes more sense. We, as a country, don't generally pay physicians the way they want to be paid for the care they give. We have an opportunity to change that."
Slavitt said the agency's goals during the rule-making process include ensuring that CMS' actions are patient-centered. He also said regulations should be "practice-driven" and flexible. That, he said, includes allowing physicians to customize performance measures that are right for their practice. Finally, he said, the agency recognizes the need to simplify, including reducing measures that aren't needed.
Gronniger said CMS supports the core measures set recently introduced by Core Quality Measures Collaborative, which includes the AAFP. Those measures are an option in MACRA's Merit-based Incentive Payment System (MIPS).
Slavitt encouraged physicians to provide feedback on the 962-page proposed rule.
"Your comments will be vital to let us know what we're seeing and what we're not seeing," he said. "This is an enormous opportunity for progress, but if we don't implement well and carefully with the patient in mind, there's also opportunity to hurt the Medicare program."
Gronniger provided a broad overview of MACRA,(www.cms.gov) including details about the two payment pathways -- MIPS and the alternative payment models (APMs) -- before engaging in a lengthy question-and-answer session that drew a long line of attendees to the microphone.
Laurel Dallmeyer, M.D., of Canandaigua, N.Y., said three of the four physicians in her small private practice left to work in other settings, and the clinic's nurse practitioners left to work with subspecialists.
"When a nurse practitioner gets $300 for spending five minutes with a cardiology patient and I get $80 for half an hour, something is deeply flawed," said Dallmeyer, who added that without changes family physicians will "vote with their feet" and leave the specialty.
Gronniger agreed, saying the agency is looking at overvalued codes. He also said CMS is working to create options that would recognize the importance of primary care and allow family physicians to "continue to operate independent of a hospital or any other facility."
Family physicians line up to ask questions about the Medicare Access and CHIP Reauthorization Act during a town hall meeting with CMS staff. Acting Administrator Andy Slavitt and Deputy Chief of Staff Tim Gronniger participated in the May 6 event.
Kimberly Becher, M.D., of Clendenin, W.Va., expressed concern that some elements of MACRA are based on flawed elements of the existing fee-for-service payment system.
"Why are you even listening to the RUC?" Becher asked, referring to the AMA/Specialty Society Relative Value Scale Update Committee that makes recommendations to CMS on the relative values of CPT codes.
"I've been listening to the AAFP about the RUC for at least eight years," Gronniger responded, alluding to the Academy's efforts to push back against subspecialty bias on the committee.
Gronniger reiterated that CMS is looking at overvalued codes and attempting to "return money to the pot." That, he said, included the creation of a chronic care management fee last year. He said CMS is looking at ways to reduce documentation requirements so more primary care physicians can benefit from that revenue stream.
The comments about overpayment led to a pointed question from Lloyd Van Winkle, M.D., of Castroville, Texas.
"We've heard you say you are looking at areas where you are overpaying, but we've never heard you say you're looking for areas where you are underpaying," he observed. "The solution you're looking for is in this room. What are you doing about underpayment? You are losing the base that is the source of your success."
Gronniger replied that CMS is looking at underpayment, as well. He later said CMS is "obsessed" with making things work for primary care and added that the agency is looking at additional changes to the Medicare physician fee schedule to support primary care.
As expected in a listening session related to a rule that isn't finalized, Gronniger couldn't always offer concrete answers. For example, AAFP Board Chair Robert Wergin, M.D., a small practice physician from Milford, Neb., said he would need to transform his practice by 2017 to participate in an APM. He said he and many other practices may need more time before MACRA's performance year starts.
Gronniger said CMS was looking at that possibility but that it would be "tricky" because of the law's many moving parts.
Payment based on 2017 performance isn't scheduled to kick in until 2019. That's too long for some primary care practices that already are struggling, said Anna McMaster, M.D., of Liberty Center, Ohio. McMaster said her small community lost three primary care physicians in the past year because of payment issues.
"There's a gap between now and 2019," Gronniger said. "It's something we're looking at to see if there is anything we can do."
Gronniger acknowledged many shortcomings in the current system but pushed back on a suggestion that they were solely CMS problems.
"It's a U.S. health care system problem," he said. "Our health care system is the most expensive in the world, and it's not performing the way it should."
Reform, he said, will require partnership.
"I believe the people in this room are at the center of that reform effort," he said.
On the same day as the session with Slavitt and Gronniger, the AAFP rolled out an extensive set of resources designed to help members prepare for MACRA.
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