Abstract
Background: Despite major efforts to transition to a new physician payment system under the Medicare Access and CHIP Reauthorization Act (MACRA), little is known about how well practices are prepared. This study aimed to understand how small and medium-sized primary care practices in the Heart of Virginia Healthcare (https://www.vahealthinnovation.org/hvh/) perceive their quality incentives under MACRA.
Methods: This study analyzed data from 16 focus-groups (70 participants), which yielded a range of physician, advanced practice clinician, office manager, and staff perspectives. Focus-groups were audio-recorded and transcribed, then imported into NVivo for coding and analysis of themes. A multidisciplinary research team reviewed the transcripts to maximize coding insights and to improve validity.
Results: The main findings from the focus-groups are: 1) MACRA awareness is relatively higher in independent practices, 2) steps taken toward MACRA differ by practice ownership, and 3) practices have mixed perceptions about the expected impact of MACRA. Two additional themes emerged from data: 1) practices that joined accountable care organizations are taking proactive approaches to MACRA, and 2) independent practices face ongoing challenges.
Conclusions: This study highlights a dilemma in which independent practices are proactively attempting to prepare for MACRA’s requirements, yet they continue to have major challenges. Practices are under extreme pressure to comply with reimbursement regulations, which may force some practices joining a health system or merging with another practice or completely closing the practices. Policy makers should assess the unintended consequences of payment reform policies on independent practices and provide support in transitioning to a new payment system.
- Accountable Care Organizations
- Focus-Groups
- Interdisciplinary Research
- Medicare
- Ownership
- Pay for Performance
- Primary Care
- Quality Improvement
- Virginia
Introduction
Health care payment reform in the United States is transitioning from a fee-for-service payment system to one that partially reimburses physicians based on quality indicators.1 This is a major shift that requires practices to use advanced functions of electronic health records (EHRs) and conduct complex quality measurement and data analysis.1 The new quality payment program (QPP) under the Medicare Access and CHIP Reauthorization Act (MACRA) aims to reward clinicians who provide better care rather than provide more services to Medicare beneficiaries. MACRA offers 2 choices to clinicians: 1) the merit-based incentive payment system (MIPS), which bases the composite performance score on quality, resource use, clinical practice improvement activities, and meaningful use of EHRs; or 2) the alternative payment model that rewards clinicians through a 5% lump-sum bonus payment based on the physician’s achievement of a threshold portion of their revenue or patients covered under a qualifying alternative payment model.1
Since the new payment program went into effect in January 2019, there has been limited research on MACRA preparations. In 2017, the American Medical Association surveyed 1000 physicians from different practice sizes, specialties, practice settings, and geographic locations to better understand physician preparation and knowledge of MACRA.2 The survey specifically focused on the decision makers who were involved in MACRA preparations. Results revealed 51% of physicians were somewhat knowledgeable about MACRA.2 A recent survey of 1431 primary care physicians across the United States found that more than half of the physicians believed MIPS could have unintended consequences and shift physicians’ focus away from patient care activities.3 Further, 60% of the respondents believed MACRA would reduce or have no effect on the value of care.3
Recent studies have also pointed to additional burdens MACRA would place on medical practices. The American Medical Association survey found that 90% of the respondents perceived MACRA requirements as burdensome.2 Respondents stated the time required for reporting quality measures was the most significant challenge. The study highlighted that physicians, especially those in small practices, needed more help preparing for MACRA.2 Other studies also emphasize the time and resource constraints of small practices4 and challenges in keeping physicians involved in quality improvement efforts in general.5
Multiple studies suggest small practices face major problems during transformation efforts such as lack of financial resources, evidence-based practice implementation, and time for reporting;6,7 challenges with adopting EHRs;8 and provider burnout.9⇓–11 One consequence is that small and independent practices are increasingly likely to join a health system, decrease the number of patients seen, or close the practice due to financial challenges.12 Physician-owned practices decreased from 76% in 1983 to 51% in 2014.13 More than two-thirds of primary care clinicians now work for health systems.14⇓–16
The Heart of Virginia Healthcare (HVH) collaborative was 1 of 7 regional efforts supported by the Agency for Healthcare Research and Quality.17 The HVH recruited 203 small and medium-sized primary care practices to participate in the initiative.14 The objective of the overall project was to transform small and medium-sized primary care practices while improving population heart health.17 This study aimed to understand how small and medium-sized primary care practices participating in the HVH reported on their perceived quality incentives under the Medicare Access and CHIP Reauthorization Act (MACRA).
Methods
This article reports on the analysis of the focus-group data focused on MACRA, which was part of a broader objective of the HVH study between January and April 2018. The main goals of the HVH focus-groups were to collect data on the adoption of clinical guidelines, EHRs, assessment of the patients for aspirin use, blood pressure, cholesterol, and smoking cessation, clinical data extraction and reporting, evaluation of coaching support, and MACRA. Practices that enrolled in the HVH received face-to-face support from the coaches18 during the first 3 months of the intervention. The goal of the focus-group was to obtain group consensus from each practice on a range of topics involving practice transformation. The study was approved by the George Mason University Institutional Review Board in September 2017.
Study Design, Setting, and Sampling
Our key practice selection criteria included identifying practices with a minimum of 2 coach visits during the intervention period to better assess the perception of practice participants. We implemented a purposeful sampling, a maximum variation strategy, among practices participating in the HVH. We recruited practices for focus-groups19⇓⇓⇓–23 by stratifying the sample to obtain a maximum variation on practice ownership (independent practice, hospital-owned practice or federally qualified health center);11,14,24,25 practice size (2 to 5 providers, 6 to 10 providers, and 11 or more providers);11⇓⇓–14 practice single or multispecialty; practice designation as a patient-centered medical home;11,14,24,25 practice part of an accountable care organization (ACO);11⇓⇓–14,24 and whether the practice was located in a medically underserved area.11,14,24
A sample of 30 practices that met the selection criteria was targeted for focus-group recruitment. Our exclusion criteria were removing the practices with phone interview, insufficient discussions on MACRA, and Federally qualified health centers (FQHCs), which were exempt from the MACRA regulations. The final sample consisted of 16 focus-groups with a total of 70 participants, including physicians, advanced practice clinicians, practice managers, and other staff from the same practice.23,25⇓–27 Focus-groups were conducted onsite at the practice location. The average number of participants per focus-group was around 4, ranging from 1 to 10 individuals (Table 1). Each focus-group session lasted between 60 to 90 minutes and MACRA consisted of approximately 10% of the overall focus-group time. On completion of the focus-group, $150 was provided to each participant.
Characteristics of Primary Care Practice Sample, Heart of Virginia Healthcare, 2018 (n = 16)
Data Capture, Coding and Analysis
During the focus-groups, we asked questions about MACRA awareness, steps taken toward preparing for MACRA, and the impact of the new payment program on practices’ finance, workflow, and patient care (Figure 1). An experienced moderator facilitated the focus-groups and elicited responses from all participants. A written interview guide that included open-ended questions was provided (Appendix A). Focus-groups were audio-recorded and professionally transcribed, then imported into NVivo 12 qualitative data management software for coding and identifying themes. Data analysis included reviewing and coding transcripts by practice, then analyzing codes by cross-tabulating across attributes such as practice ownership, practice size, patient-centered medical home, ACO, etc.
Examples of the Heart of Virginia Healthcare (HVH) focus-group questions. Abbreviation: MACRA, Medicare Access and CHIP Reauthorization Act.
The 5 phases of coding consisted of reading and reviewing hardcopies of all transcripts, examining the transcript text and developing themes for the information, identifying the repeating patterns and connecting the themes, running cross-tabulation queries with different attributes, and developing a complete narrative of provider’s perspectives on MACRA from themes that resulted in a set of theoretical propositions.
We used researcher triangulation,28 which reflects that we purposefully included researchers from different disciplines for data analysis and external review to enhance the study’s validity and rigor. Three reviewers from different disciplines, Family Medicine, Health Administration and Policy, and Sociology, reviewed the transcripts and participated in discussions of the findings. Three researchers attended 8 focus-group sessions in-person which provided an opportunity to observe, listen, and interpret the findings.
Results
Study Population
The final sample included 16 small and medium-sized primary care practices with 70 participants. Practice sample consisted of 8 independent practices, and 8 hospital-owned and health system affiliated practices. Table 1 outlines the characteristics of the focus-group sample.
Themes Emerged from the Focus-Groups
A total of 3 themes emerged from the focus-group discussions that included 1) MACRA awareness; 2) steps taken toward compliance; and 3) the impact of MACRA on practices’ finance, workflow, and patient care.
1) MACRA Awareness
Participants from practices reported differing levels of MACRA awareness, which varied based on practice ownership (Table 2). Participants in independent practices had a higher level of awareness and knowledge on MACRA, whereas we observed less awareness and lack of knowledge of the participants in hospital-owned practices. Independent practice participants either discussed the recognition of due dates for MACRA reporting or the advanced payment model itself. A participant statement from an independent practice to a question, “Are you aware of MACRA?” included:
MACRA Awareness and Analytic Themes by Practice Ownership, Heart of Virginia Healthcare, 2018 (n = 16)
[I7]: “Well, we’re done with this year. You know, [the] deadline [for MACRA reporting] is passed. We did score the maximum number of points [for MACRA] that we could score this year.”
Hospital-owned or health system-affiliated practices had relatively lower awareness for MACRA. The practice participants either did not know much about MACRA or found it confusing (Table 2). In response to the question, “Are you aware of MACRA?” many physicians and staff in hospital-owned practices made similar statements such as:
[H2]: “I must admit, I am not as knowledgeable as I probably should be [about MACRA]. I have not delved all that much into the stuff [related processes] about MIPS and MACRA.”
2) Steps Taken toward MACRA Compliance
Preparation for MACRA also varied by practice ownership (Table 3). Independent practices were focused on improving the capacity of their EHR systems to meet MACRA reporting. Practices mentioned building additional features into their EHRs such as integrating an “alert system” or “pop-ups” to meet the requirements. One independent practice participant responded to the question “How do you get ready for MACRA?” with the statement:
Steps Taken toward MACRA, Variation by Practice Ownership, Heart of Virginia Healthcare, 2018 (n=16)
[I6]: “We are building templates in our electronic medical records (EMR) that captures all the tick marks [for MACRA that] you have got to meet for meaningful use. So, we are working on that right now.”
In contrast to independent practices, hospital-owned and health system-affiliated practices were dependent on corporate guidance for MACRA preparations. Practices were not involved directly in the decision making around MACRA; rather the corporate or larger health entity would inform the practice what and when to do things (Table 3). For example, one of the participant statements from a health system included:
[H7]: “They [corporate] will tell us what to do, and we will do it. ‘Yes, sir.’ [We will try] to the best of our ability [to comply with MACRA requirements]”.
3) Impact of MACRA on Practices’ Finance, Workflow, and Patient Care
There were mixed perceptions regarding the impact of the QPP on practices’ finance, workflow, and patient care under MACRA (Table 4). Some practice participants were unsure about the impact, while others discussed the negative influences of the program on their practice such as needing to hire a new person and spending extra time to extract data. Regardless of the practice ownership, the participants had mixed perceptions on the impact of MACRA on practices’ finance, workflow, and patient care and responded to the question: “How will the quality payment program (QPP) affect your practice overall?”
Impact of the Quality Payment Program (QPP) on Practices' Finance, Workflow, and Patient Care - Heart of Virginia Healthcare, 2018 (n = 16)
Hospital-Owned Practice: “Too Soon to Tell”
Independent practice [I7]: “Sure. I didn’t have [administrative staff] 10 years ago. Or at least [administrative staff] wasn’t doing this job 10 years ago.”
In addition to participant responses to our impact questions, we heard grunts and sighs, and saw several participants roll their eyes or make other moves to show their dissatisfaction with participating in MACRA.
Themes Emerged from the Data
ACO Involvement
The first is that regardless of the practice ownership, being part of an ACO was a major differentiator of MACRA awareness and steps taken toward MACRA (Table 5). Participation in an ACO provided an advantage for reporting quality measures. A participant statement from ACO practices included:
MACRA Awareness and Steps Taken with MACRA by the Accountable Care Organization Practices - Heart of Virginia Healthcare, 2018 (n = 16)
[H4]: “[When preparing for MACRA], I think the ACO has given us an opportunity to really grow across party lines, so to speak, and see what everybody else is doing.”
[I3]: “We are a Track I ACO, so we will be reporting as MIPS, and then we have to report separately advancing care initiatives. So, last year we reported through the ACO because that was their first reporting year. We will be reporting again through the ACO.”
Challenges with MACRA
The second finding was that independent practices experienced relatively more challenges preparing for MACRA than the hospital-owned practices (Table 6). Among the challenges included the noncompatibility of existing EHR system with quality measures required under MACRA (Table 6). A statement from a physician at one independent practice stressed the difficulties with EHR systems about the quality reporting:
Challenges with MACRA Preparations - Heart of Virginia Healthcare, 2018 (n =16)
[I7a]: “They [TCPI: Transforming Clinical Practice Initiative] don’t do all the measures, but they do a portion of the [MACRA] measures in getting you on track. It keeps you on track with our EHR, that program does make us upgrade and do things that are painful. So that is where the pain portion is, [which] is with the EHR.”
Independent practice participants also perceived that they had limited resources, such as human resources and capital when dealing with MACRA (Table 6). A participant statement from an independent practice included:
[I7b]: “We wear multiple hats here in our independent practice. We have to be very creative in how we [do things], and [be] resourceful with our employees. So, having resources that are knowledgeable and reputable, that could benefit. You know, it was me going through these steps and preparing for MIPS.”
Another major concern for independent practices was spending extra hours on tracking and documenting the quality measures (Table 6). Providers had to see fewer patients because the responsibility for MACRA reporting fell on the providers. Physicians in independent practices expressed similar sentiments as the following:
[I2] “One to three hours every night, and I do spend one to three hours [on] MACRA.”
[17a] “So, is there a cost? Absolutely there is a cost. And do docs see less patients? The answer is yes.” [I2] “Yes, because you can see 100 patients a day. It’s going back and charting on what their issue is. Because, you can see the patients, you can take care of them but there is so much documentation that they’re going to require until we see a revamping of that, of the whole system.”
More resources were available to hospital-owned practices for MACRA preparations compared with independent practices. None of the hospital-owned practices mentioned challenges for MACRA preparations; in fact, some spoke of receiving additional support (Table 6). For example, one of the hospital-owned practice participants stated:
[H4]: “Well, we’re, also have [third party organization]. Have you heard of [third party organization]? We have an outside consultant that’s helping run this whole deal. So yes, so [parent health system] hired them to.”
Finally, we expected to see the impact of some of the attributes such as patient-centered medical home recognition, practice size (number of providers), and Medicare patient population (payment mix), but the analysis did not produce critical findings.
Discussion
This qualitative study explored how small to medium-sized primary care practices participating in the HVH reported their perceived quality incentives under MACRA. To our knowledge, this study is the first analyzes focus-group data to understand how primary care practices perceive quality incentives under MACRA. Our study’s findings are relevant because the new payment reform is still in transition from volume-based to a value-based model that requires practices to transform and adopt to quickly changing situations. Our study highlights the importance of supporting independent practices and assessing the unintended consequences of policy changes on small practices.
Our study findings revealed that respondents in independent practices were more involved in the MACRA processes and faced relatively more challenges with MACRA preparations in contrast with the hospital-owned practices. The independent practice physicians are more likely to be involved in the processes because they are responsible for implementing these types of changes in regulations. In contrast, our study findings of hospital-owned and health system-affiliated practices were more distanced and bureaucratic with respect to MACRA may reflect that the corporate entity has centralized resources devoted to dealing with MACRA. The finding also indicates the influence of autonomy in the independent practices and bureaucracy in hospital-owned systems. Our findings suggest there might be a link between the challenges independent practices face––time constraints, limited resources, the capability of EHRs for data extraction and reporting6⇓–8,14,24––and a tendency of joining a health system or merging with another practice or completely closing the practice.12⇓⇓⇓–16,29 MACRA preparations could be burdensome2,4,5 for small to medium-sized independent practices, which may need additional support and technical assistance to comply with MACRA requirements. The findings suggest that for independent practices, MACRA is simply another administrative burden for which they cannot get relief, in contrast to system owned and operated practices. This likely results in more hours spent on compliance, a greater risk of burnout, having to reduce the number of patients served, and feeling forced to trade independence and autonomy for the potential security and support that comes from being employed by a health system. Well-intentioned efforts to improve the quality of primary care should take into account the potential for unintended consequences.
We also found practices that were part of an ACO are more proactive with reporting quality measures and taking steps toward MACRA for quality improvement. 24 Our study suggests being part of an ACO may provide an advantage and add value to small practices with respect to quality improvement efforts, which enables the practice to receive support for health information technology (IT), data analysis, and quality reporting. 30 Further, regardless of the ownership, our study demonstrates practices’ mixed perceptions toward the impact of the QPP on financial stability, workflow, and patient care. Considering the QPP is still in progress, it is too early for the practices to measure the real impact of the payment program on their practices.
Our study has several limitations. First, it might be possible that small practices already doing well may have been more likely to participate in the study. This has a potential to create sampling bias as well as positive study findings. Second, the main goals of the focus-groups were broader than this study. Due to a limited time spent on MACRA during focus-groups, it was not possible to obtain a detailed perspective of physicians on MACRA preparations by MIPS domains or by ACO types. Third, the physicians were the process owners and the implementers in independent practices. Therefore, those individuals might have known more about the process than physicians and staff interviewed from hospital-owned practices. Future studies should explore the main reasons for this variance. Fourth, the study findings are limited to the perspectives of respondents within the practices. We did not have the opportunity to analyze corporate perspectives within health systems. Fifth, our focus group participants consisted of individuals from different professional roles in which the hierarchy within the group may have affected discussions. Finally, the study was based on 16 primary care practices in Virginia willing to participate in focus-group, but results may not generalize to other geographic areas or practices.
Appendix. MODERATOR FOCUS-GROUP DISCUSSION GUIDE
Quality Payment Program (QPP) (Brief) (10 Minutes)
We are almost done, but I want to take this opportunity to get some information from you on your practice’s readiness for the requirements and regulations of MACRA (The Medicare Access and CHIP Reauthorization Act of 2015) and what the Centers for Medicare and Medicaid Services is calling the Quality Payment Program or QPP.
A. Preparing for the Quality Payment Program.
Describe what steps your practice has taken to prepare for MACRA/QPP.
Can you tell us whether the clinicians at this practice feel committed to the steps you described in preparation for MACRA/QPP? What about your practice manager? Your IT staff?
Do the clinicians at your practice believe these steps can be accomplished in time to meet the MACRA/QPP deadlines?
What is left for your practice to do? When do you expect your practice will be ready?
B. How do you think the Quality Payment Program will affect your practice overall?
Do you expect it to have a financial impact on your practice? Discuss.
Do you expect it to have any impact on your workflow? Discuss.
Do you expect it to have any impact on patient care? Discuss.
C. Do you have anything to add regarding the MACRA/Quality Payment Program?
Notes
This article was externally peer reviewed.
Conflict of interest: TGS, DGG, and AEC report no conflicts of interest. AJK was the key investigator of the overall project funded by the Agency for Healthcare Research and Quality.
Funding: This research was funded by the Agency for Healthcare Research and Quality (R18HS023913, PI Kuzel).
To see this article online, please go to: http://jabfm.org/content/33/6/942.full.
- Received for publication April 11, 2020.
- Revision received June 26, 2020.
- Accepted for publication July 10, 2020.
