Monday, June 27, 2016

CMS + MIPS/APM = Death of the Private Practice Physician.




Small, independent private practices are closing, increasing numbers of physicians are retiring early, and fewer medical school graduates are choosing primary care.  The old-fashioned practice my father and I have built is a dying entity.  Parents say coming to see us for an appointment feels more like a visit with a friend than a medical encounter.  I am fighting for the survival of primary care practices.  MACRA proposed reimbursement will decimate rural care as we know it.  

Seven days ago, I attended an “informational listening session” for rural physicians, sponsored by the Center for Medicare and Medicaid Services (CMS) to learn more about the new MACRA proposal known as MIPS/APM (Merit-Based Incentive Payment System/Alternative Payment Model.)  This plan will penalize 7 out of 10 small 1-2 physician practices in this country.  Why? Because we will be overwhelmed complying with statistical reporting demands that do nothing to enhance the quality of care, instead of spending precious time seeing patients. 

I inquired as to how CMS proposes to ease our burden of data reporting.  “I am not sure, but leave a website comment and someone might consider your needs.”  Not likely.  A family practice physician described how technical mistakes at the claims clearinghouse froze her Medicare payments for 8 months.  “Thank God my father died and left me a small inheritance,” she said.  Otherwise her solo practice would have gone bankrupt.  Is this the future of medical care in this country?  Over 50% of her patients are on Medicare.  If we allow this MACRA atrocity to go into effect, who will be left to care for the sick, disabled, and elderly?

MIPS will base reimbursement on four categories:  Quality, Resource use, Clinical practice improvement, and meaningful technology use; the details of which have not yet been finalized.  The four meeting facilitators answered 9 out of the 10 questions (including mine) with the following statement:  “I don’t know.  I can email you.”  Can someone please hire me to do their job?  Or maybe hire a group of monkeys from the zoo?  Healthcare would be on stronger footing either way.

We should pay physicians for time spent engaging patients in conversation, instead of rewarding them for checking boxes on a computer screen.  Unfortunately, reimbursement for “valuable” dialogue is difficult to quantify within the physician-patient framework.  Physicians were trained to care and comfort people, not chase blood pressure numbers and pain scale scores.  Changes masquerading as meaningful have only increased physician workload.  We are widgets in the ever expanding assembly line.  Do you think the MIPS will give us more time to practice medicine?  If you believe it will, then I have a bridge to sell you.    



CMS coordinators are traveling around the country armed with useless knowledge, assembling groups of health care providers under the guise of providing “information”, and selling them snake oil.  It is ridiculous CMS will determine what constitutes provision of high quality care; they could not recognize value if it were right under their nose.  

I get it.  You do not want to pay me for work saving lives.  You want to pay me for crunching numbers that hypothetically constitute the illusion of high quality health care.  Which numbers exactly?  The CMS coordinator responded, “I don’t know, but here is my card for us to communicate further”.  This might come as a surprise, but I want to communicate with my patients more, not a coordinator hired by CMS who peddles false hope. 

Why have physicians given CMS dominion over medical care delivery in this country?  They are essentially in charge of a relationship they are incapable of comprehending.   The system is incentivizing incorrectly.  Remember what EMR’s have done for the quality of care? Not much, but physicians sure know what it did to our workload.  Where are the anticipated benefits of technology for patient care, physician work-life balance, and improved efficiency?   These benefits have not materialized.

CMS believes they are just not compiling the correct statistics; practicing physicians know technology requirements have only served to further undermine the physician-patient relationship.  Investment in the physician-patient relationship and direct physician to physician communication are two methods that could pay huge health dividends for future generations.  However, the return on investment is not glitzy enough for those controlling the health care machine. 

Neither my father nor I have admitted a single patient to the hospital for asthma or dehydration in more than 15 years, we see sick patients the same day, and our families are rarely seen in the ER except for true emergencies.  Before you think we cherry pick patients, understand 45-50% of ours are on Medicaid.  I know these families just as well as any who walk through our door. 

If I am paid for my time spent talking to patients, teaching them how to use their inhaler regularly, and helping avoid hospital admission, it is far cheaper than cost of a 3 day hospital stay.  But CMS misses the forest for the trees.  They believe saving on the office visit altogether is better overall.  Do you honestly believe value-based payments will benefit physicians and patients?   I can still sell you that bridge...

Undoubtedly, value-based care will result in lower reimbursement to physicians and death to private practices in rural towns where access is already less than optimal.  MIPS will do little to enhance patients’ lives or physicians’ livelihoods.  I can guarantee it will boost the bottom line for capitalists in control.

There are 826,000 physicians in this country.  We must refuse to tolerate a reimbursement scheme until its parameters help us provide better quality health care to the human beings we serve.  Our collective future wellness is at stake.  Is the statistical framework and useless data collection necessary in high quality health care or are thriving patients and contented physicians more essential?  Do not settle for more robots and fewer humans.  We will all be patients someday. 

























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