The Inbox: Physician Deliberations on MACRA

May 30, 2016

In our recurring blog "Inbox" we share comments from physicians and practice administrators telling us what keeps them awake at night.

Editor's note: We work hard to write about issues that will help physicians run their practices in a manner that is both prosperous and efficient, while still delivering quality patient care. And we are delighted when our readers let us know what they are thinking. This month we are excerpting two articles that were written in response to the release of CMS' final rule on the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which received a lot of response from our readership. The articles have been edited for space and are followed by comments made by readers at PhysiciansPractice.com.

A Conversation on MACRA with a Family Physician

KrisEmily McCrory is a family medicine physician who teaches and practices at Ellis Medicine, a 438-bed teaching health system in upstate New York. … McCrory recently attended the AAFP's 2016 Annual Chapter Leader Forum in Kansas City, Mo., where AAFP president Wanda Filer gave a brief response to CMS' recently released proposed rule on [MACRA].

Physicians Practice: What was the AAFP's initial reaction to the proposed rule?

KrisEmily McCrory: I think that the thought process that has been set up by Wanda Filer, acting on behalf of the AAFP, is that there is great opportunity here to really take some challenging things that came out of meaningful use and things that were related to the previous legislation and make it more flexible and possible for doctors to provide quality care, without feeling like they are overburdened with checking a bunch of check boxes. That being said, because it is not completely finalized yet, it is still just an opportunity. We don't know in the long run that it will really do what they are hoping it's going to do. The Academy is really putting forward a very optimistic face right now, but I can tell you just based on comments (there's a lot of comments on the AAFP website) … family physicians are very concerned about MACRA, the requirements, what they may or may not be, how they are getting paid.

Reader Responses:

Jordan says: I feel bad for my father, he is 73 and still practicing. He has the lowest admission rate at the hospital and is getting burned out trying to keep up with idiotic requirements that have zero to do with quality care. All of these people making rules have no understanding of the practice of medicine and the AMA and other lobby organizations for doctors are just as much to blame. It's so sad that large groups and hospitals get so much favor. And real metrics like admission rates, keeping your patients healthy into their 90s, etc. are ignored in favor of data, data, data. Data is useless without real good doctors to interpret and act and educate patients. … Government shouldn't be in the business of telling doctors what to do, Doctors are doctors; they know what to do.

Dana writes: As a physician who started a private practice only one year ago, I'm becoming more and more concerned about the increasing federal legislation that dictates care. I feel as if government is trying to force me, as it has my predecessors, to join large group such as ACO's. These have already been proven ineffective, almost as ineffectual as the expensive EHR that now bogs down my practice and takes part of my daily profits from billing for its use. But like this I have little choice. In fact, I notice that government reimbursement pays little heed to growing physician expenses such as high student loan debt, malpractice insurance, and god forbid a lawsuit. We are expected to do more with less to keep government happy, all while giving patients less. Less time with the patient, and now less workup in order to avoid a payment penalty. …

Paul comments: This is just another nail in the coffin of independent solo/small group primary care. Have EHRs and meaningful use helped make me practice better - minimally. Try telling an 85 year old they need to sign up on the internet for a patient portal, so they can send me secure messages! MACRA is just another smoke and mirrors attempt by the government to make it appear they are improving healthcare. Want to improve healthcare - mandate to insurers to stay out of my office and stop telling me how to practice medicine and to cover tests when I deem them needed and cover prescriptions when I think it's in the best interest of the patient to have them prescribed. Stop the endless "request for diagnosis validation - that only benefits the insurers yet my staff and I do all the work. This bean counting, check the box exercise is likely to force more solo and small practices out of business - let the masses have their assembly line medicine I am working longer and harder with sicker patients and getting paid less and less - trust me - if patients didn't feel I was giving them quality service - they would go elsewhere.

Small Practice Doc Speaks Out Against MACRA

The proposed rule is less than a week old but Linda Girgis, a family medicine physician in South River, N.J., is not too pleased with the Medicare Access and Summary CHIP Reauthorization Act of 2015 (MACRA). If CMS' own projections are accurate, in two-and-a-half years, she'll be joined in her dissent by many other small practice docs across the country. By next year, MACRA will change the way physicians are reimbursed for Medicare, combining and configuring the Physician Quality Reporting System (PQRS), the Value Modifier Program, and the Medicare Electronic Health Record (EHR) Incentive Program (Meaningful Use).

Physicians Practice: You have not been shy in your criticisms of MACRA, what are your biggest problems with the proposal?

Linda Girgis: It's penalizing small practices and solo doctors. It was supposed to be based on quality initiatives, and [CMS] has already revealed how many bonuses they're going to give, how many negative adjustments. I thought this was supposed to be about quality, but it's obviously about balancing their budget rather than improving quality healthcare.

PP: Is any of it salvageable in your eyes?

Girgis: I think [CMS] is going about it the wrong way. I think patients need quality medication, but they are serving their political agendas, rather than have it be about clinical outcomes. They said they are making it patient-centric, but that's not true. They have it so people are focused on the data, rather than the patients. The metrics [look at patients as data points]… there are patients who are sick with multiple diseases [that won't be looked at positively in terms of data analysis] but you can improve their health. Under this incentive system, you get penalized for spending a lot of time with those patients who are never going to get better.

Reader Responses:

Bradley writes: The only way for doctors to have real power and influence is to unite and form a union. This is the only way that doctors can impact the rules and regulations that affect their financial future and the way they care for patients. Individual doctors have zero power, zero voice in influencing those that make regulatory decisions. In the inevitable future when we do have a single payer, universal healthcare system, a unionized physician entity will be the only way to powerfully represent physician interests. … Multibillion dollar insurance companies are, of course, interested in one thing, their profits. They maximize this by paying physicians as little as possible for their professional medical care and by denying care to patients. They deny care through ever increasing monthly premiums which employers then pass on a portion to the employee, they deny care by yearly increasing the deductibles so patients simply don't go to the doctor until problems are advanced, and they deny care by denying diagnostic tests, and newer, more effective medications. …

Dominick says: The time has come to disenroll from Medicare. Many physicians do not understand that the patient can submit the claims with form 1490S or physicians can submit this form on behalf of the patient. The patient receives the check and forwards you payment.

Benefits of disenrolling:

1) You are no longer subject to Medicare guidelines, mandates, and edicts.
2) The office staff overhead goes down significantly
3) You are back in a contractual legal arena. You have six years to collect from your patient, not one.
4) You can send your patient to collections and sue them in court for payment if necessary and get a judgment.
4) The threat of audits go away.
5) Payment reduction goes away.
6) MACRA goes away.
7) You will see increased reimbursement.

Will your patients go away? Probably not. The Medicare generation is still used to paying for medical care. The majority will forward payment to you. The few that don't you can send to collections just like your other patients. It is time to take back this profession. Patients have a right to the standard of care wherever they may seek to be treated. They do not have a right to free care.

Samuel A. Nigro, MD, writes: The enemy of healthcare (and practically everything else) is bureaucracy. Healthcare is neither the purpose nor the function of the health insurance industry (. Contemporary medical care is no longer part of "the American way." The art of medicine is an absolute contradiction to reporting to a central committee. Physicians must hang together, or as the aphorism ends, we will all hang separately (and a case can be made that we have already been hung out to dry). Indeed, the divide and conquer carve-up of medicine by the health insurance industry is against the common good and an autopsy for the medical profession. To practice "separately" is to hang! In fact, the health insurance industry must deal with all physicians [in total], especially without special contracts which make physicians fight each other. Medicine must become a profession again: distinct, virtuous, self-defined, self-contained, self-defending ... and without pathological parasites depending on all we do. The basic problem is that people who cannot practice medicine are making the rules. Medical care is considered appropriate and payable only if a third party thinks it understands and agrees with what took place, regardless of patient improvement or satisfaction ("Does the patient feel better and is getting better?"). … Medicine cannot be a profession as long as the doctor's relationship with a patient is determined by insurance companies, lawyers, or politicians. …

Have you thought about how your practice will meet the new quality metrics under MACRA? Tell us what you think; join the conversation at bit.ly/talk-on-MACRA and bit.ly/doc-speaks-out.