The Trump administration has made clear its intentions to drastically reduce the size and intrusive nature of government. Let’s hope that extends to the Medicare Access and CHIP Reauthorization Act, otherwise known as MACRA, the heavy-handed new government “value-based payment” program for medical care, enacted in 2015, and set to rear its ugly head beginning this year. MACRA must die. MACRA is administrative overkill in an industry already overburdened by such things. And it makes little sense, and will make little difference, in our current dysfunctional health care environment.
For physicians, MACRA in practice is the Merit-based Incentive Payment System, or MIPS, a performance rating scale comprised of four categories: Quality Measures, Advancing Care Information, Performance Improvement Activities, and Cost. A physician’s annual MIPS score will be compared to the scores of other physicians to determine future Medicare pay increases or penalties. It is a system that only the most ardent bureaucrat could love, or would think effective.
To satisfy the MIPS Quality Measures rating, physicians must report data on six different measures. But the measures can be problematic for a number of reasons. One measure is “Diabetes: Hemoglobin A1c Poor Control (>9%),” which is the “percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0%.” This is a seemingly simple measure that assesses a physician’s performance on the most basic aspect of diabetes management. But in the current health care environment, where rising drug prices, high deductible insurance policies, and more and more restrictive medication formularies limit some patients’ access to even the most basic prescriptions, taking care of diabetes can be almost impossible. Many of my patients who use insulin now tell me they can no longer afford it! How can I be held responsible for “quality” when my patients can’t access the basic care they need?
Physicians taking care of lower income, uninsured, or under-insured patients may be penalized in such a system. In addition, practices that include many older patients and certain ethnic populations, whose diabetes is often more difficult to treat, may be unfairly penalized. Of course, such a system also holds physicians accountable for their patients’ lifestyle choices, over which they have little control.
The second MIPS rating category, Advancing Care Information, is just the government’s wildly unpopular electronic health record (EHR) “Meaningful Use” program with a new name! Meaningful Use, which started in 2011, forced a generation of physicians to purchase and use what often turned out to be exceedingly expensive and unusable EHR software programs. Many of those physicians now work late into the evening just to keep up with basic documentation using their unwieldy EHRs. Meaningful Use placed demands on EHR software that many programs were simply unable to meet. Until there are truly usable EHR programs, easily affordable, available to all physicians, “Advancing Care Information,” or the same program by any other name, will continue to be a pointless burden.
The third MIPS category is “Improvement Activities.” Practices can select from 92 such activities (most practices will need to perform four activities per year, though practices with fifteen or fewer clinicians can do just two). I know I am beginning to sound just a bit negative here. But I have what I think is a reasonable question? Will practices that are already struggling to be paid in a system that makes it damn near impossible, and that are already reeling from the huge administrative burdens created by Obamacare, HIPAA, medical homes, and accountable care organizations, and to boot, are still trying to actually see and take care of patients every day (let’s not forget that), really going to put much into or get much out of one more program like this? We’re crying, “Uncle!” There needs to be true administrative simplification before another such program is piled onto the current mess.
The first such “improvement” activity listed on the CMS MACRA website suggests that we improve access to medical services by investing in a new position like a diabetes educator. What a great idea! Let’s just say, as an example, that I earn $100,000 from Medicare patients in a year, and through the MACRA program, earn the top incentive available (in 2024), a nine percent increase. All else being equal, my pay would rise to $109,000. If I hired a diabetes educator, that would cost the practice somewhere in the $75,000 range (the internet told me that). So I would be out $66,000 per year! Thanks, MACRA!
The final MIPS category is cost. Doctors whose care is relatively inexpensive across a number of “episodes of care” score favorably, and those who generate higher expenditures will be downgraded. This can be problematic in any number of ways. Unless CMS is very explicit about what care is reasonable and appropriate during these “episodes,” and unless I have clear information about the costs of the tests and treatments that I order (I usually don’t), and I have choices about such things (like being able to send a patient to a lower-cost facility), then there is very little that I can reasonably do to limit the expense of my care. Without such things, the very clear incentive is just to withhold care (which may end up being necessary care, unfortunately).
So, MACRA encourages me to prescribe more medicine and order more tests in an effort to improve quality scores, but will penalize me if those tests or medicines cost too much, in a health care system that often doesn’t cover such things anyway, and to use a computer system that slows me down, making it harder to pay the new staff I had to hire. In other words, MACRA must die.