For instance, the Merit-based Incentive Payment System is based on metric for clinical outcomes, such as an HbA1C measurement for a diabetic patient. If a certain percentage of patients get that measurement, the doctor will receive a higher reimbursement. This model neglects patients with co-existing diseases…which has an impact on diabetes control. Some patients are sicker and will never get to the goals [set out by MIPS]. These patients require much more time and attention. And the doctor caring for them will probably be negatively adjusted based on the metrics reported. The extra time and care is not rewarded, but rather penalized.
If, for example, you have a healthy patient with diabetes, you don't need to spend as much time with them. They may just come in for refills. And they are likely to have better [metrics]. So, the doctor who does the less work here will get rewarded, just because they have healthier patients. And the doctor really spending quality time with patients trying to make them healthier loses money just based on a metric.
PP: Do you feel there is a way to pay for quality, which seems to be what MACRA is trying to accomplish?
Girgis: It's hard for small practices – hospitals and big systems have IT departments and a whole staff that's hired to carry this out. In private practice, we have to do that ourselves. It's costly and time consuming. It's hard for doctors to pay this the attention it needs. The regulations they are making, it's not helping.
If you look back at Meaningful Use's original goal, they didn't change it to make it better, they changed it because they weren't able to make it work. Systems need to interoperate with each other, but they don't do that. Meaningful Use had to go away because it couldn’t do what it supposed to do. We're not going to fix anything if we're spending billions more and trying to salvage what was not working to begin with.
PP: One of the things that should be noted is that it seems a lot of physicians aren't even aware of MIPS – do you find this to be the case and why?
Girgis: Most doctors aren't aware of what's coming. Doctors are so pressured, we don't have time to be reading up on this. The (MACRA) document, it's more than 900 pages. It's hard to know what's going on. I think doctors are getting used to getting beat up, so they don't care anymore.
PP: What would a 4 percent adjustment on Medicare payments do for some practices?
Girgis: Some practices have huge Medicare populations, so this could destroy them. If you look at reimbursements over the last decade, they've stayed the same but overhead costs are going through the roof. We're not getting reduced in our payments, but we are when you try to keep up with cost of living. This will reduce it even further. If this goes on … you'll see fewer doctors in private practice.
PP: On Twitter, you suggested opting out of Medicare, but for some practices, is that feasible? What if most of their patients are older?
Girgis: It's a big movement, taking insurance out of the picture, just having doctors and patients work together. In a larger sense, this won't solve the problem because patients won't have access to care. For me, I feel I need to serve those patients. That's why I'm [speaking out] against the system rather than walking away, but these are people with real problems, they need medical care.
PP: What message do you have to your fellow small practice physicians?
Girgis: One of the problems is doctors are so isolated and are not allowed to collectively bargain for our rights. This has put us in a lot of trouble. We need to come together, fixing things that need to be fixed, rather than stay in our own bubbles. We need to come together and find real solutions.