Commenting on MACRA


Received this from a reader.  See his letter and request at the bottom:

Dear Doug:

CMS will allow comments on the upcoming MACRA/MIPS program through June 27. Although I doubt comments from US physicians will in any way alter the ultimate outcome, it couldn’t hurt if those of us who oppose such hogwash make our wishes known–hopefully in large numbers.  Although the Quality Measures Development Plan comes in at 56 pages (without references), commenters are limited to 5000 characters. Below is my comment, for what it is worth.

Dear Sir or Madam:

I am writing to comment on the upcoming MACRA/MIPS program which is to be initiated by CMS in 2017. Last week, I attended an informational seminar by CMS’s Dr. Barbara Connors, who encouraged the physicians present to comment. Dr. Connors was both well spoken and well informed, but the overwhelming consensus of the over 100 community physicians in the room was that they had to either limit their exposure to Medicare patients or exit the program altogether. Our small community has already “lost” three physicians to concierge care and at least four others to premature retirement; it seems likely more will follow.

We physicians understand that Medicare funding is in trouble and that continuing the current system is economically unsustainable. The general public seems markedly less aware of this problem. Dr. Connors started her presentation with a statement to the effect that fee for service medicine is the problem that has gotten us where we are. That single statement alienated most practicing physicians in the room. Everyone knows that you can bend the rules of economics, but you cannot break them. Paying people for their work is necessary such that they continue to perform the work. How Medicare got in economic trouble was their attempt to offer an all-you-can consume healthcare benefit with little out of pocket cost to the consumer. The economic day of reckoning currently experienced by CMS was predicted by many prescient souls in 1965.

Mr. Slavitt has already stated publicly that the current EMR requirements with MU penalties have largely lost the hearts and minds of American physicians. The multiple layers of bureaucratic chores proposed in the MACRA/MIPS plan seem even worse. The physicians in this country took a huge hit with EMR’s that really did not benefit them and now CMS wants to double or triple down on their bet using doctors labor and capital.

So what alternative suggestions would I make? None that are easy, but here goes:

Continue to concentrate on inpatient costs. That is where the money is!
Severely limit administrative costs at hospitals which participate in Medicare. Cap hospital administrators’ salary at $250K if they want to continue to get CMS dollars. Paying CEOs of hospitals millions is a national disgrace. These are quasi public institutions which get the majority of their funding from tax dollars and often get tax exempt status. Federal agencies have frequently used the power of the purse to achieve goals—see colleges and universities, state highway departments, and any company subject to OSHA or EPA rules. Such a mandate would obviously be extremely unpopular with CMS’s hospital businessmen colleagues, but would be well within the agency’s authority.
Mandate or develop a universal computer platform for EMR in the next five years. We all know CMS did not want to pick winners and losers from IT providers, but the bonanza it has developed for rent seeking medical IT firms is unprecedented. Five years will give the existing systems enough time to age out. Intraoperability seems to be one of the genuine benefits of electronic records and the decision to launch this very large project on multiple platforms is another example of poor planning which necessitates billions more in IT consultant fees.

Work toward putting some reasonable patient financial responsibility into all levels of health care. The former 80/20 cost sharing split was a good one and would do a great deal to limit utilization. The staggering amount spent on end of life care by families on elderly relatives with almost no expectation of survival would be massively curtailed if some of the money from the estate was being spent on their continued inpatient services. The conversation would go from, “Let’s fight the good fight” to, “She has lived a good life and now it’s time to let go” if there were some financial liability for ongoing care. Those with Medicaid secondary insurance would have some exemption from this with the States deciding how they want to apportion the Medicaid dollars. Even a 95/5 split on the inpatient end would likely result in less demand for expensive inpatient services.

Do everything you can to keep primary care doctors in business. If you think that what you are doing now is working, you are sadly mistaken. The data seems pretty clear that primary services delivered in the office setting is magnitudes of order less costly than hospital services. When I look at ER fees I realize that if I keep one person out of the ER, that pays my entire salary for several days. A same day COPD visit that avoids hospitalization probably saves what I make in a month or more. Facility fees lavished on hospital owned practices should be severely curtailed and redistributed to all doctors who see Medicare patients. The current projected requirements for MACRA and MIPS will be particularly hard on small practices; the proposed small practice exemption for those with less than 100 Medicare patients or less than $10,000 per year in billing would apply to practices which would be better described as microscopic than small. Since most of these are on their way out anyway, why not exempt existing small practices from what is an onerous unfunded mandate? Driving these practices out of existence will disrupt a large number of frail elderly Medicare beneficiaries lives which will result in more ER and inpatient utilization—hardly a cost effective move. Small groups provide cost efficient care and CMS should explore exempting those with less than five physicians. There is some thought that NPs and PAs will assume a great deal of the primary care in the US and that is undoubtedly true, but when it comes to caring for sick, elderly Medicare patients, most PAs and NPs have neither the training nor the desire to do that kind of work. There are already studies documenting increased specialist, ER, and imaging utilization with extenders. It would be unwise to think that they can do the job of caring for seriously ill people as cost effectively as physicians.

Limit your data collection and make it truly “meaningful”; that is, not in the perverted sense of the essentially unworkable MU program. CMS has, admittedly of necessity, launched some huge multi-billion dollar programs with little evidence of efficacy. The fact that half of the organizations dropped out of the Pioneer ACO project would indicate to most that this model should be re-evaluated. Physician quality is notoriously difficult to measure and many of the metrics proposed are questionable at best. I would suggest that the CMS powers read Dr. Groopman’s article on Medical Taylorism (N Engl J Med 2016; 374:106-108). If CMS insists on pushing through with MACRA, they should go back to the drawing board and reduce its complexity by at least 75%. The 56 page Quality Measures Development Plan is a good example of Orwellian government overkill. Delay this implementation and simplify, simplify, simplify! If CMS concentrates on end of life care alone, that could save billions and actually result in better quality of life for Medicare beneficiaries. The staggering reporting burden placed on physicians will place an undue burden on them with little objective data that it will save any money.

Use more candor in your public relations outreach. No one believes it when a CMS representative says things like, “…fee for service is the problem” and “…computers don’t interfere with patient visits.” These two statements were made by Dr. Connors and I doubt even she believes them. Starting to educate the general public about the economic catastrophe that awaits Medicare may help avoid the expected outcry as services are curtailed. Rationing is a dirty word in the US, but we are already clandestinely rationing health care. Why not put it out in the open? Ultimately, every rational person understands that there are not unlimited funds, even for government programs.


J. Lee Krantz, M.D.
Thurmont, MD

The online comment may be posted at:”>

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If you would consider placing a comment on your blog about this issue, I would hope that there will be more comments such that CMS can appreciate the breadth and depth of opposition to these programs among practicing physicians. Unfortunately, when I checked this morning, there were only 322 comments.

Many thanks,

Lee Krantz

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