Oh, It’s Just a Few Strings…by Pat Conrad MD


Last November a group of state and specialty organizations released a joint letter with the AMA to the Center for Medicare & Medicaid Services that recommended 10 principles to guide the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), the Medicare reform law that repealed the sustainable growth rate formula.

In particular, the recommendations deal with alternative payment models (APM) and the Merit-Based Incentive Payment System (MIPS), which are intended to promote improvements in the delivery of care for Medicare patients. The proposals include terms like “improve quality reporting…diversity…be equitable…provide stability and resources…patient-centered care…” The format is a parade of timidity, the rhetoric a chorus of banality, and has all the impact of a strongly worded U.N. reprimand. Read it for yourself here.

These proposals are the basis for the latest “AMA Wire” piece on better payment models, which makes for even more painfully tedious perusal. Apparently the MACRA legislation provided “incentives and resources” to develop APM’s, which means more tax money will go to consultants and a few lucky doctors who can cash these checks in lieu of seeing patients, to create more haze.

New payment models:

  1. Payment for a high-value service – “…if the physician commits to use these services to increase quality” (Hahaha, well of course)
  2. Warrantied payment for physician services – “… practice can be paid more to prevent problems and complications of treatment, rather than being paid more to treat problems after they have occurred … similar to what other industries do when they offer warranties on their products.” (But those other industries are making standardized products, not treating virtually infinite individual variations)
  3. Multi-physician bundled payment – “two or more physicians can share a single, “bundled” payment to enable them to work together … without concern about individual practice revenue.” (Which should work about as well as putting two hungry dogs into a burlap sack and throwing it in the river)
  4. Physician-facility procedure bundle – “…a physician could share in savings achieved in the cost of a hospitalization through more efficient scheduling of services, competitive purchasing…” (So a family doc owning an interest in a radiology center is immoral and illegal according to the Stark Law, but that same doc colluding with a hospital corporation would be merely “efficient”.)
  5. Condition-based payment for a physician’s services – “…rather than basing the payment on the type of treatment the physician uses, payment is based on the extent of the patient’s needs” (And how many codes and prior authorizations will be required to define that??)
  6. Episode payment for a procedure – “…physicians receive a single payment for an “episode of care,” …and could benefit financially if they can eliminate unnecessary spending.” (Again, how is ‘unnecessary’ defined, and by whom?)
  7. Condition-based payment for all services related to a condition – “physicians receive a single payment for all of the care needed to manage a particular health condition …would give the physician the flexibility to use completely different procedures or treatments if they will achieve better outcomes at lower cost.” (Sigh…more quality reporting).

This entire miasma is an acceptance of the status quo premise, that Medicare must be strengthened and improved, and that the government knows best. This premise so contrary to the fiscal realities tightening around all of us is being enabled by cowardly doctors who produce the sort of gobbledygook cited above that will be both cover and invitation to further exploitation by hospital corporations, Big Insurance, and CMS itself, while the AMA will congratulate itself again for having a seat at the table.

Until there is the acceptance of a radical reform of Medicare & Medicaid that realistically deals with the high cost of sustaining these dependent, ravenous populations, these non-ideas will keep pitting gullible docs against each other while effectively protecting the real profiteers.

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  4 comments for “Oh, It’s Just a Few Strings…by Pat Conrad MD

  1. Steve O'
    February 6, 2016 at 9:57 am

    It’s interesting how the Stark rules (see above) were part of the First Wave of criminalization and mistrust of the individual physician’ s presence in the community. Now, he/she is replaced by the gentle and altruistic Corporate Medicine Industry, billboards with luv-flowers on them and loving TV ads about babies and sunshine.
    Somehow, a rural doctor owning a hospital in the community (which happens in most countries across the world, BTW) was a criminal conflict of interest. Corporate replacement of such community-based facilities with urgent-cares and McPharmacy minute clinics was the more profitable solution to little primary hospitals. Never mind the screams of the rubes in the sticks. What do they know about quality care?
    Except for patient suffering, it works great. But suffering, by definition, must be due to a failure in delivery of quality service by human individuals. Get rid of the humans, and medicine can thrive.

  2. Seneca
    February 6, 2016 at 9:56 am

    Re: Condition based payment; ” …payment is based on the extent of the patients needs” sounds suspiciously like, “From each according to his ability and to each according to his needs.”

    AMA and AAFP swallow this BS because they want to sit at the table with the cool kids.

    Your final paragraph sums it up very well. Medicare is (and always has been) financially unsustainable. Since nobody wants to say “No” to beneficiaries or the medical industrial complex, we will get more of such “innovations” with absolutely no evidence to suggest that they will work.

    • Steve O'
      February 6, 2016 at 10:00 am

      A lot of medicine has risk, and the goal of 21st century medicine (and 20th century business) is to unload the risks back onto the suckers. Let the doctors and patients deal with the complexity of care, the vagaries of illness, the crumbs left behind! Pass a law that says all will be cured, and punish those who do not cure!

  3. Perry
    February 6, 2016 at 9:42 am

    Get those life jackets out folks, we’re gonna need them.

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