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    Physicians Should Just Say ‘No’ to MACRA

    I can't recall the exact moment I crossed over from believer in today's version of the healthcare quality movement to skeptic. Perhaps it was when the office trash would fill with clinical summaries the staff dutifully handed out to patients to satisfy a “meaningless use” measure. Or maybe it was trying to convince a 75-year-old Mrs. Davis that we would really appreciate it if she logged on to our electronic health record (EHR) using the patient portal. To do what, she asked? I stared back at her blankly.

    The election of Donald Trump and his subsequent choice of a former orthopedic physician, Tom Price, MD, has raised hopes among the independent physician community that relief may be coming from meaningless regulations that flow liberally from Washington, D.C. At the moment, there is no better embodiment of untenable regulations that have little to do with patient care than the Medicare Access and CHIP Reauthorization Act (MACRA).


    Related: Guide to understanding MACRA


    For those still blissfully unaware—and there are many—MACRA is a program seeking to transition the physician community to payment based on performance and value. This is a worthy goal, and one that I supported at its inception and for many years after. To put it mildly, the implementation leaves much to be desired. And the insistence to stay the course despite evidence and anecdotes to the contrary has forever cured me of the idea that the future of healthcare could ever safely lie in the hands of well-intentioned bureaucrats.

    The passage of MACRA means that starting this year, physicians will be asked to participate in a new model. The practicalities of this for physicians are either complying with the Merit-based Incentive Payment System (MIPS) or ensuring enough of your patients are enrolled in an advanced alternative payment model (APM).

    Most clinicians won't qualify for advanced APMs because they won't have enough qualifying patients. I still can't figure out which of my patients belong to the local accountable care organization (ACO), and even if I did there are only a few ACOs in the country that meet the criteria for advanced APMs (Only ACOs in a two-sided risk model qualify for advanced APMs). While there are other models for advanced APMs, the majority of clinicians seeking to play this game will be forced to use MIPS to “win.”

    MIPS involves reporting on quality measures, completing improvement activities or doing meaningful use-like measures with your EHR to come up with a composite score.

    There is nothing simple about any of this. Measures are converted to points based on performance relative to other clinicians reporting measures, total points are compared to total possible points and a Quality Performance Score is generated.


    Hot topic: Is DPC a viable way to MACRA-proof your practice?


    High performers are rewarded, and those that fail to report will accrue reimbursement penalties as great as 9%.

    Societies jumping onboard

    The hue and cry from physicians that resulted from the proposed version of the MACRA rule, especially from small physician groups, resulted in a pullback with regards to the immediate reporting burden. The on-ramp to the eventual utopia that is MIPS/MACRA was essentially made less steep, but make no mistake: the final destination remains unchanged.

    Physicians, forever anxious about income, and certainly forever anxious for approval from superiors, will no doubt try to jump through these hoops. Reimbursement penalties will start to accrue in 2019 and at this point are slated to be at maximum 9% to those physicians who don't choose to jump through these regulatory hoops. Medical professional societies seem to be content to “help” physicians through this process, rather than provide resistance.

    Next: My advice to physicians 

    Anish Koka
    Anish Koka is a cardiologist in private practice in Philadelphia trying not to read the writing on the wall. Follow him on twitter ...


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    • UBM User
      Irrespective of the "quality" of care provided (and that definition is definitely built on shifting sands), the simple financial truth is that for most small groups and solo MDs, the cost necessary to comply with MACRA/MIPS will meet or exceed any extra reimbursement. Dr. Koka is absolutely right--we should vote with non-participation. Unfortunately, the great majority of physicians who are employed by someone else may have no choice.
    • kl1325@------.com
      Both the article and the first comment are absolutely correct. Spending time documenting that you have done what you said you did is ludicrous. The reporting aside, it is impossible to quantify "quality". No matter how many vaccinations you give, mammograms you request or colonoscopies you suggest, it is still the responsibility of the patient to accept or reject the recommendation. Is your quality of care worse if the patient refuses to have lab work, x-rays or any supplementary exam done? I have no doubt whatsoever that the care is good. These absurd recommendations, coming from people who do not actually practice medicine, never take into account patient responsibiltiy. I hope that with a physician at the top, we will see more logic coming out as it regards reimbursement.
    • DavidLouisKeller@------.com
      I agree 100% with Dr. Koka: all doctors must adopt the mantra "No MACRA". Here is a mathematical proof that MACRA will fail in its primary mission, which is to reduce the cost of Medicare in the wake of the collapse of the "sustainable growth rate" (SGR). To prove that MACRA will actually increase the cost of Medicare, consider the following: 1) MACRA mandates payment of bonuses for non-clinical work, such as reporting data to CMS, which requires a lot of time, effort and expense from doctors, but which does absolutely nothing to benefit patients directly, nor to provide them any medical care whatsoever. As an example, I cite the gathering of statistics proving that you, as a doctor, are vaccinating a large enough percentage of your patients. As opposed to actually vaccinating them, a crucial distinction. 2) Money spent by CMS to reward doctors who submit their statistics dutifully must be subtracted from the pool of money available to pay for medical services which patients actually need and benefit from, such as hernia repairs, cataract extractions, skin biopsies, angioplasties, chemotherapy, pacemaker implantations, and so on. You know, the diagnosis and treatment of illnesses. The stuff we learned how to do in medical school, when we should have been studying MIP's and ACO's, and APM's - where the real money is. 3) However, the only excuse for the existence of the medical profession is that we do diagnose and treat illnesses. But, under MACRA, there will be less money for patient care because money that has been awarded for reporting statistics is no longer available to pay for hernia repairs, angioplasties, etc. QED. The above is a very simple concept which should be obvious to anyone, especially if they have a Harvard MBA. Yet, the geniuses who run CMS seem to think that they can spend the precious dollars in the Medicare trust fund twice - once to pay for meaningless quality bonuses, and again to provide the actual clinical care that patients need. We doctors must get the attention of our Congressional representatives and demand that all 2400 pages of MACRA be repealed. And we must enlist our Medicare patients to do so, as well.
    • Anonymous
      I'm not sure I completely agree with your post. The money for the MACRA bonuses comes from the money saved by the MACRA penalties, in other words the "bad" doctors pay for the "good" doctors. Theoretically then it will not cost Medicare anything, although it may well hurt physician productivity. Now whether the "bad" doctors are actually worse than the "good" doctors is another story. Many of the docs in the "bad" group are probably doing just as good of a job practicing medicine but not reporting due to financial/staffing factors.

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