Tuesday, June 7th, 2016
MACRA Won’t Work, and Here’s Why
What is the Basic MACRA Idea?
Submitted by Richard L. Reece, MD
The basic idea behind MACRA (the Medicare and CHIP Reauthorization Act of 2015) is to drive physicians who use fee-for-service (FFS) into coordinated care models in which physicians assume the risk of caring for Medicare patients using a fixed budget. CMS is also hell-bent for rewarding and punished physicians in Physician Group Practices (PGP) for providing Evidence –Based-Medicine (EBM), also known as Value-Based Medicine (VBM) for Medicare patients who belong to PGPs.\ http://www.wsj.com/articles/macra-the-quiet-health-care-takeover-1464734029 MACRA and VBM will not work, and here is why:
A MACRA-scopic View of Federal Acronyms reveals the federal government’s acronym fetish
Recall that this began in earnest in 1933 when Franklin Delano Roosevelt (FDR) unleashed a series of government programs designed to help lift America out of the Great Depression, such as;
–Emergency Banking Act (EBA)
–Economy Act (EA)
–Civilian Conservation Corps (CCC)
–Federal Emergency Relief Act (FERA)
–Agricultural Adjustment Act (AAA)
–Emergency Farm Mortgage Act (EFMA)
–Tennessee Valley Authority (TVA)
–Truth-in Securities Act (TISA)
–Home Owners’ Loan Act (HOLA)
–National Industrial Recovery Act (NIRA)
–Glass-Steagall Banking Act (GSBA)
–Farm Credit Act (FCA)
And now there are 4,298 Federal Acronyms!
At last count, the federal government has 4,298 acronyms for God- knows-how-many federal agencies (GKHMFA).
And CMS has its share of them
At Centers for Medicare and Medicaid (CMS) acronym-making is an art form. Among other health care acronyms are these – Patient Protection and Affordable Care Act (PPACA), Centers for Medicare and Medicaid Innovation (CMSMI), Patient-Centered Medical Home (PCMH), Accountable Care Organization (ACO), Alternative Payment Model (APM), Merit-Based Incentive Payment System (MIPS), Pay-for-Performance (P4P), Fee-for-Service (FFS), and that jaw-breaking acronym MACRA (Medicare Access and CHIP Reauthorization Act of 2015).
Back to the point: MACRA won’t’ work, because of three fundamental problems:
One, Medicare patients do not “belong to” or are they “owned” by physicians or a PGP. Medicare Patients are free to go to any physician whom they like or prefer, even if that physician is outside a PGP or is not a Medicare “provider.”
Two, in short physicians who treat Medicare patients are not by law “attributable “ to a specific PGP. This is the Attribution Problem (AP).
Three, It is impossible to measure physician risk (costs) or performance for a given patient when patients seek care from multiple physicians and clinics outside the PGP — in emergency rooms, urgent care centers, concierge practices, or retail clinics. The average Medicare patient with chronic disease seeks or shops for care from 6 different physicians, often a cadre of specialists, who may not be in a PGP or ACO. This is called the RAP (Risk Adjustment Problem).
MACRA is essentially Unworkable
Creating programs and acronyms to herd physicians into APMs (Alternative Payment Models (APMs) to facilitate reward or punishment for physicians to control health care costs is an exercise in political and bureaucratic futility. It may appear to be politically correct (PC) given the very real problem of mounting Medicare costs, but it will not work. And it may not be ethical for doctors. MACRA turns off physicians who actually treat patients because its bureaucratic morass will raise cost and reduce doctor productivity (quality) when how physicians enter clinical data into an EHR or track where patients go outside the physician’s office and/or sphere of influence will directly affect their pay — paid more for doing less patient care.
As Kip Sullivan, a Minnesota health care analyst , after reading the 962 page MACRA document, explained in “Sloppy Risk Adjustment and Attributable Guaranteed MACRA Won’t Work” (June 5, in The Health Care Blog): http://thehealthcareblog.com/blog/2016/06/05/sloppy-risk-adjustment-and-attribution-guarantee-macra-wont-work/ :
“CMS’s inability to determine accurately which patients ‘belong’ to which doctors (the attribution problem), and CMS’s inability to adjust costs and quality scores which are outside physician control (the risk adjustment problem) are a lethal one-two punch to the fantasy that CNS or anybody else can measure the ‘value’ of the vast majority of physicians accurately.”