Tuesday, February 28, 2017

Blood, Guts, and MACRA




Sean MacStiofain said “most revolutions are caused… by the stupidity and brutality of governments.” Regulation without legitimacy, predictability and fairness always leads to backlash instead of compliance.  If something is not done to stop MACRA implementation, more physicians will opt-out of Medicare and Medicaid than is fathomable.  Once DRexit begins, there will be no turning back. 



The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is destructive to the physician patient relationship because it prevents physicians from prioritizing patient care.  MACRA supporters like to point out this legislation was passed with bipartisan support; in reality, it was passed simultaneously with repeal of the Sustainable Growth Rate Formula. The SGR was holding billions hostage and lawmakers had a gun to their head, leaving them no other choice. There is nothing bipartisan about that.



The Sustainable Growth Rate Formula was enacted through the Balanced Budget Act of 1997 and was designed by lawmakers to control Medicare expenditures. The SGR formula limited the annual increase in cost per Medicare beneficiary to the growth of the national economy.  Under the SGR formula, if overall physician costs exceeded target expenditures, a reduction in payments would be triggered.  Expenditures continued to climb, so Congress stepped in 17 times with short-term legislation (referred to as “doc fix”) to avert the payment reduction since 2002.



These patches kept increases in physician payments below inflation which ultimately resulted in a huge discrepancy between the actual level of Medicare physician-related spending and the target in the SGR formula. In 2015, if Congress did not act by March 31, payments to Medicare physicians would have been reduced by 21.2 percent.



Enter stage left, MACRA, known as the Permanent Doc Fix, which was passed concurrently with the Sustainable Growth Rate Formula repeal legislation.  This was the original repeal and replace.  MACRA established yet another new (and untested) method by which to pay doctors.  MACRA is the largest scale reform on the American health care system since the Affordable Care Act in 2010 and the jury is still out how great (or not) that system is working for the American people.   



Under MACRA, the Secretary of the Department of Health and Human Services was tasked with implementation of a Merit Based Incentive (MIP) program which consolidated three useless incentive programs into one big colossal unworkable program for eligible physicians everywhere. The legislation also allows for Advanced Alternative Payment Models (APM), which shockingly, are not actually saving money on care. 



Even better, MACRA related regulations also addressed incentives for use of health IT by physicians and other care providers.  Similar in scope to the Meaningful Use (aka Meaningless Abuse) Program except, now on steroids.  The Government Accountability Office in partnership with the DHHS have been assisting with the implementation of electronic health records (EHR) nationwide, while at the same time comparing and selecting programs for providers. 



So to recap, Congress has been working on a “doc fix” system in conjunction with every lobby possible on the planet EXCEPT that of Practicing Physicians since 1997.  They “repealed and replaced” SGR (first disaster) with the atrocity known as MACRA, which will end in a mass DRexit.  They are rapidly moving ahead with non-evidence based payment methods intended to decrease costs, yet are highly unlikely to be successful based on recent studies.  On top of all that, they are selecting computer systems for physicians which incentivize computer data entry while discouraging the placement of hands on patients.  Did I miss anything?



Recent studies show physicians spend twice as much time on technology than we do with patients.  Maybe with full MACRA implementation, we can be retrained as data entry clerks to treat conditions instead of people.  Imagine if we just called in prescriptions for hypertension, diabetes, or even started chemotherapy regimens without seeing patients at all?  MACRA pays us more for “doing less,” so now we can practice “drive-by medicine.”  I wonder if health outcomes will improve and mortality will be lower when compared with “drive-by shootings.”   



Controlling costs involves four major pillars of change to our healthcare system, about which I have been writing for some time.  Listening to a talk given recently by the executive director for the Association of Independent Doctors, Marni Jameson, helped focus the strategy.  The first cost control pillar is to educate patients and lawmakers as to how consolidations of hospitals and medical practices raise costs, reduce quality, decrease access, eliminate jobs, and result in unnecessary testing and procedures. The second pillar is to increase price transparency, so consumers can compare costs and choose the most affordable option. The third pillar is eliminating the onerous ‘facility fee’ to bring payments of hospital-employed doctors in line with the lower payments to independent doctors for the same care.  The final pillar is ensuring hospital profits are taxed equally across-the-board, regardless of whether they are non-profit or for profit institutions.



In the next four posts, I will cover these issues in more detail as each deserves its own separate discussion.  It will be an interesting mathematical exercise to calculate the forecasted cost savings of these four interventions alone.  If you are reading this post, you have skin in the healthcare game, whether as physicians, lawmakers, economists, hospital administrators, government, or IT experts alike.  As I have said before, we will ALL be patients eventually. 

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