On today's Wall Street Journal opinion page, several letters describe potential consequences for both doctors and their patients as CMS writes the rules for the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA)- "The Creature from the Black Lagoon." This complex piece of legistlation (962 pages) affects more than 800,000 physicians and their millions of medicare and medicaid patients. As I suggested in a recent blog, MACRA is about much more than reimbursement. The program drives a continuing restructuring of the American health care system and a new generation of technology to support it. CMS emphasizes the potential positives:
- Reimbursement based on value, not volume
- IT/EMR focused on performance, not process
- Comprehensive health care integrating multiple providers
However, "the devil is in the details." As the rules for implementation are being written, many physicians and health care organizations are voicing serious concerns. Just this week, the AMA and 36 medical societies wrote to the Office of the National Coordinatior for Health Information Technology and the acting administrator of CMS expressing concern that the metrics used to define interoperability of EMRs in the new law must focus on clinical value to patients rather than just the quantity of information exchanged. Current rules for "meaningful use" of the EMR are widely viewed as requiring documentation of clinically irrelevant information rather than true patient outcomes.
Similarly, the CMS proposal on implementation of MACRA outlines a complex Merit-based Incentive Payment System (MIPS) comprised of four weighted metrics including quality, EMR use, clinical practice improvement, and cost. The MIPS score is intended to rank physicians with financial incentives of 4-9% reimbursement increments for the winners and a similar magnitude negative hit for the losers. Many solo physicians and smaller group practices are concerned they will get the short end of the stick as they are less likely to have the robust data reporting capability of the larger groups. CMS itself projects 87% of solo practices will face negative adjustments of reimbursement in 2019 totaling 300 million dollars. If these figures are even remotely in the ballpark, it's likely we'll see a continued reduction in solo or small group practices.
MACRA's potential consequences for harried, burnt-out physicians coping with a blizzard of documentation requirements using dated, unfriendly EMR technology are highlighted in the WSJ letters. Dr. Ackerman notes that some physicians will pursue early retirement or opt out of medicare. He laments that the health care system is losing a cohort of experienced physicians just as the demand for care is increasing. Dr. Dunham describes his decision to pursue a form of concierge medicine several years ago in reponse to the increasing bureaucracy of Medicare. Both authors highlight the critical blindspot in previous "meaningful use" rules and the risk ahead for MACRA - failure to focus on what really matters: quality of patient care.
As the rules for MACRA are written, we are again at a critical juncture in US health care. There are RISKS for both physicians and our patients:
- loss of autonomy
- burdensome documentation - "meaningless use"
- reduced compensation
- burnout, premature retirement
- more standardized, less "customized" care
- decreased access to medical care, particularly in rural or under served areas
Is MACRA really "The Creature from the Black Lagoon?" Maybe, but I'm still optimistic physicians and patients can play a role in shaping the rules and the program going forward. Evidence-informed, value based care is the future direction of U.S. medicine and MACRA will be a principal driver. As the rules are finalized, physicians and patients need to work to ensure that the primary goal is improvement in the quality of patient care by focusing on key, nonnegotiable requirements:
- Preserve physician autonomy to exercise clinical judgment in individual patients and deviate from standardized care when appropriate
- implement vetted clinical practice guidelines in clinical workflows to eliminate unnecessary variation in care but expect and measure deviation for continuous quality improvement
- Cutting edge IT to streamline clinically relevant data capture while improving patient/physician interaction. Cut the clicks!!!
- Measure carefully selected patient-centered quality outcomes which can be influenced by the caregiver
Time is short.