At the J.P. Morgan Healthcare Conference in San Francisco, Mr. Andrew Slavitt, acting administrator at the Centers for Medicare & Medicaid Services (CMS),announced on January 11th that “The meaningful use program as it has existed will now effectively be over, and replaced with something better”, and later clarified onTwitter that “In 2016, MU as it has existed– with MACRA– will now be effectively over and replaced with something better”. Meaningful Use is dead. Just like that. No apologies. No nothing. As someone who’s been lamenting the havoc wreaked by the program on both doctors and patients, I should be elated nevertheless. Well, I am not.
Let’s start with appearances. The J.P. Morgan Healthcare Conference is the “largest and most informative healthcare investment symposium in the industry which brings together global industry leaders, emerging fast-growth companies, innovative technology creators, globally minded service providers, and members of the investment community”. In other words the event is all about money for the millionaire and billionaire class. J.P. Morgan Chase itself is the largest financial institution in the country. It is the embodiment of Wall Street and its death grip on our collective neck. Was this conference really the best place to make such momentous announcement?
Besides, why would these extractors of wealth be interested in the fate of something as obscure as Meaningful Use? Shouldn’t they discuss more lucrative schemes, such as running all possible blood tests on one tiny blood droplet, or how the makers of Microsoft Office and the largest online retailer of everything are going to jointly solve for cancer? Shouldn’t they be analyzing trillion dollar addressable markets of genomic rainbows, and how mergers, acquisitions and inversions can help squeeze whatever is left in the turnips that are you and me?
Of course they should, and they did all that and much more. But changes to the Meaningful Use program are of strategic importance to all other rainbows, grails and unicorns. Why? Because Meaningful Use, other than funneling a respectable amount of billions of dollars into the health tech sector, is the enabler of data collection which fuels all other investment opportunities.
Furthermore, pretty much everything that could be sold to satisfy Meaningful Use, has been sold, so what’s next? As the Meaningful Use money making opportunities are ending, CMS is “moving to a new regime”. Interesting choice of words notwithstanding, the Meaningful Use successor consists of punishing doctors for nebulous “outcomes”, and of course all sorts of new technologies to better transfer all medical data into places where J.P. Morgan clientele can monetize them.
Let’s talk about substance. Meaningful Use has been created by an act of Congress, and enshrined for posterity in a subsequent act of Congress, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). It is not clear to me how a political appointee can invalidate acts of Congress at will, although this probably makes perfect sense in the rarefied circles convened by J.P. Morgan. If nothing else, the absolute confidence that Congress will oblige, and the President of the United States will sign whatever is put in front of him/her by the Wall Street lobby, is a perfect illustration of who is running this country and how it is done. A somewhat less politically disheartening explanation is that the demise of Meaningful Use has been greatly exaggerated in this announcement.
Meaningful Use, as we discussed in the past, is not just about onerous burdens on physicians. It is also about regulating design and production of medical software to serve the needs and wants of government and large corporations. From reading Mr. Slavitt’s remarks, I suspect that the latter effort is far from being over and may actually be greatly fortified under the “new regime”. If you design clever software, and mandate its purchase and daily use, there is very little utility in paying users to show their work, which is what Meaningful Use for physicians really meant. You do however want to keep those unwittingly exploited users calm and cooperative, which may explain why CMS wants to “get the hearts and minds of physicians back”.
Enter the American Medical Association (AMA). While across the ocean, the British Medical Association (BMA) is aggressively supporting its striking members in a nationwide struggle for the soul of medicine, the AMA is launching a “Silicon Valley integrated innovation company” to monetize its members in service to the new CMS regime. In a fortuitous coincidence, the creation of this new “stand-alone, for-profit entity”, Health2047, was announced in San Francisco on the same day the J.P. Morgan conference was convened. The goal of Health2047 is to leverage physicians’ expertise to “help forge new paths and bring commercial solutions to market faster”, and of course to make boatloads of money for investors, including the AMA.
Meaningful Use is dead. Long live something better! And what is that better something? It is paying physicians for outcomes. It is the use of evidence based medicine. It is interoperability and “user-centered” design. It is Accountable Care Organizations, value, patient centeredness, coordination and such. It is also the making of markets “by leveling the technology playing field for start-ups and new entrants”, because when Epic makes money, nobody on Wall Street or in Silicon Valley gets a piece of the action. It is about engagement and analytics and population health, calculations, penalties, incentives and lots of new technology things. It is “like the second generation iPhone”.
After collectively sinking billions of dollars in Certified EHR Technology over the last five years, hospitals and doctors will now be expected to foot the bill for new software and computer products to support the lifestyles of a new generation of Silicon Valley entrepreneurs and the insatiable greed of the old generation of Silicon Valley investors. Why? Because the next app is sure to fix health care in America. It’s always the next one. There is always “something better” you can buy. Planned obsolescence, which is fueling the obscene fortunes of Silicon Valley and destroying life everywhere else, has finally arrived to the $3 trillion health care sector. It took a bit longer than the folks at J.P. Morgan expected, I’m sure, but we’re in business now. Let the good times roll…..
This all boils down to 1 thing: money, as stated above. However, what has not been discussed is why. Our great FFS system, in place for 40+ years (which all docs have benefited from), has managed to consume approaching 18% of GNP (see http://www.oecd.org/unitedstates/Briefing-Note-UNITED-STATES-2014.pdf). Other industrialized countries are around 12%. Our healthcare system is an incredible drag on our economic output, and if it continues to grow, will bankrupt us. If our healthcare spend was more reasonable, none of this would be happening. So the government wants to reduce the spend, and how do we do it? They come up with quality and outcomes. Sounds good in theory, but will probably not work, because too many vested interests will work against it. It’s hard to take money away from people once they get used to earning it. So once we go through this great experiment, we will then probably move on to single payer. I predict this will all happen in 7 – 10 years.
I basically agree with what you write, except one thing: FFS is not the culprit here. Those “other industrialized countries” have FFS as well (Germany is practically all FFS). It’s the money grab unleashed by allowing corporations to run the table.
Splitting hairs, but FFS allows the money grab. And we (the whole medical-industrial complex) certainly take advantage of it. Germans, I guess, have a much higher sense of moral restraint. Every country needs its own system, but FFS cannot last here — too many vultures.
Interesting point…. I know this is a bit off subject, but what are your thoughts on direct primary care (DPC)?
Here is a serious question: fee for service works for lawyers, dentists, accountants, lasik docs, plastic surgeons (whether they bill you by the hour or they charge a fixed fee for a bundle …like a Will, or house design etc….it is ffs).
So why would it not work for medical care (like Direct Primary Care as suggested by Margalit below)?
In response to both above, my thought is that DPC is a good idea. It provides more money for primary care physicians, and therefore more time with the patient. This can help avoid unnecessary downstream costs like visits to the OR and specialist visits that are not needed. It also allows for the patient to have a care coordinator. All this should help save money. One great thing about this is that no one can argue about costs avoided. There is a big difference between not going to the OR, and trying to reduce a payment for a procedure. I believe that Qliance in Seattle has shown that they can save some money. I would argue that DPC as I understand it is not FFS, but really capitation. As I understand DPC, it is a fixed payment every month for as much time you need with your primary care doctor. From DPCare.org: Elimination of Fee-For-Service: DPC eliminates undesired fee-for-service(FFS) incentives in primary care.
Good point. I am in agreement with any system in which the doc or other provider is free to set his/her price for bundled or un-bundled services and offer them to patients who are free to choose to take it or leave it.
But I invite your thoughts on why fee for service works for the other professions, but you think it is not suitable for medical services (although I argue it IS working for lasik and plastic surgery).
My definition of DPC would be when the physician is selling nothing but their own professional advice. This makes the physician a pure agent of the patient with no economic conflict of interest to employers or partners. We expect this kind of agency from our lawyers and accountants. Shouldn’t we expect the same of some of our physicians?
Payment for DPC is easier to analyze in the context of agency. There’s no obvious reason to capitate these payments, but a small retainer or minimum payment could make sense. I would certainly expect a complex chronic disease patient to pay more for DPC than one who is mostly healthy. It might also make sense for DPC to be paid-for outside of insurance. This would allow the physician to advise the patient on best choice of insurance plan as well as best choice of service providers.
The tragedy of primary care though is that professional advice includes prescriptions, tests and referrals. Since money is the main interest of all other participants, this creates an inherent conflict between their money (not the doctor’s and often not the patient’s money either), and the integrity of that professional advice.
The reason I am so hellbent on preserving independent practice is that I’d rather have a quarter million private professionals make billions of ad-hoc decisions based on their ethics (I’ll take my chances because I believe people are basically good), than have a handful of conflicted commercial corporations, or government payers, make those decisions in bulk based on their interests.
Some standalone DPCs where the D is indeed a D, are fantastic. Others, that are essentially primary care corporations, seem to be defeating the purpose.
I agree re preserving independent practice….but I don’t see the inclusion of testing, referrals and prescriptions as a tragedy…..and per Adrian Gropper’s comment: while I trust my real estate attorney, estate lawyer, litigation lawyer (once)…I am careful what I ask them to do and I watch their billable hours…(.I don’t think they are free of the wish to maximize the $ I spend on their services)….but all of that is the way of the world.
Also, I don’t share your attitude toward corporate providers of service….as long as they are competing with other providers….whether other corporations, Chapter S group practices, or independent docs.
I think we are in agreement that we will be better off if we can pry the hands of the government bureaucrats, oligarchic insurance bureaucrats, almost monopolistic suppliers (think Epic), and think tank social engineers who want to micromanage what patients and doctors can and can’t do.
I agree with Dr. Gropper. It has been shown that when physicians have a financial interest in tests, prescriptions, etc. they recommend more of it, and make more money. This is exactly part of the problem with our system. Are these tests necessary? who knows? But if there is no financial interest, then there is no conflict, and presumable only necessary tests/procedures will be ordered. In fact, the reverse can be argued — if a doc does not order a test, then there are more dollars available for necessary services. As a patient, I would want and expect that from a physician. However, I disagree with Dr. Gropper about FFS. If a physician provides services on an FFS basis, if he has spare capacity (i.e. not a full panel) then he will also tend to want to fill his panel and see more patients, perhaps even when not necessary. If he is paid on capitation then no such incentive exists. Obviously FFS does not work in complicated situation that he mentions above unless the complicated situations can be statistically modeled and taken into account across a panel of patients. Medicine is unusual in that the customer (patient) is not really in the position to know how much of it (medical services) he/she needs. So they need to trust the service provider (physician). The patient wants to minimize their spend. Therefore setting up a system that does this (as opposed to just leaving it up to professional judgement and hoping it works out) is much better.
I think patients should be able to choose their poison….fee for service or capitation.
Capitation doesn’t eliminate the conflict of interest….in fact it may make it worse. If the doc does not order the test, the cat scan etc…..he (or his employer) make more money. Even if the entity is a non profit it does not solve the problem: fancier dining rooms, executive bonuses….even private jets to ferry around the “non profit” executives (yes, I know a specific non profit where this happened).
For me….I will take fee for service any time….I don’t want to be in a position of wondering what the motivation is for my doc not ordering a test….and I welcome the freedom to tell my doc I am going to skip the colonoscopy (as long as he explains the statistics/risks).
Just to be clear here, most primary care physicians have no financial incentives to ordering expensive tests such as MRIs, CTs, etc., nor do they receive any kickbacks for prescriptions or labs.(IF they do, they are in big big trouble with Uncle Sam).
The only financial benefit may be seeing the patient more often, or as you say more patients in a day than would be normal. However, if patients are put out by wait times or the doctor not spending enough time with them, they will go elsewhere anyway.
FFS is not the problem. Third party payer is (due to tax favoritism towards employer sponsored health care)
If someone thinks that single payer works (assuming a meeting of the minds as to what single payer is) then they should tell us how to fix Medicare which is essentially a single payer system.
If someone thinks capitation removes bad incentives then he should think again. Capitation is loaded with incentives not to treat leading to denial of necessary care. Unlike FFS the paper trail can be non existent so that the results of the bad incentives of capitation can remain hidden.
It’s worth noting that the death of MU likely will have very different impact on the physician vs. hospital sides.
Yes, it’s likely that some (many?) of the physician MU requirements will be folded into forthcoming MACRA regs. We don’t know which ones yet, so both vendors and physicians are likely to stay in a holding pattern for now.
But…hospitals don’t a MACRA staring them in the face. As an example, perhaps this will improve the current “my mom has 9 patient portals” scenario. Hospitals no longer will be required to get 10% of their patients to receive EHR data…perhaps some decide to dump or vastly reconfigure their patient portals.
This is a GREAT point Vince. I didn’t think about that. Obviously, hospital payments for employed docs will be affected, but what will happen to all other payments? Will they maintain MU (or some minimal version of it) for hospitals only, at least until the money runs out? Or will they come up with a mixture of things similar to MIPS for hospital payments? I am having a hard time imagining that hospitals will be off the hook (so to speak) considering the incredible amounts of data they generate…. What are your thoughts?
Great question. While I’m not aware of other regulatory structures that might “adopt” MU for hospitals, who knows what the feds might jigger up. Congress seems unable to agree on just about anything, so new legislation doesn’t seem likely. Probably safer to bet on Powerball, though.
Missed the Powerball window, so I’ll bet on inertia, i.e. they keep a skinny MU3 for hospitals for a few years….and incorporate the same in MIPS but call it something else because the name is now toxic….
While I agree with Margalit on most things….including EHR and Meaningful use…..the rant blaming the financiers is a too popular short cut that reflects an almost universal naive understanding of economics. The real culprits are legislative mandates: once they are created (at the behest of “experts” and legions of social engineers who think they know best…..who never trust that docs and patients can ever figure out the right thing to do)….and politicians who have no interest in the unintended consequences that always follow their mandates. Once mandates are created will the finance industry help those who seek to get their piece of the trillions of dollars mandated?….yes. But they are not the main villains in this ongoing train wreck of medical system reform.
Hi Paul. I think we need to take one more step back in tracing the problem. How are those legislative mandates created? Usually they originate from industry lobbying. And then another step back, why are industry lobbyists afforded such preference in setting legislative agendas? Usually because every politician is compelled to fund raise continuously. And who is funding these politicians (and lobbyists too)? Some funds come directly from financiers, while others funds come from industries supported/funded/profited from by said financiers. Any way you want to look at it, the buck now stops on Wall Street… in my view, of course 🙂
Margalit….I believe the right to petition the government is a fundamental principle of western democracy that derives from England (the Magna Carta ???don’t hold me to that specific one). Does that often lead to bad things? Sure. But mess with that principle and worse things will happen.
The right (indeed the duty) to petition the government is great. I do object to the ability to legally bribe the government though.
Hyperbole aside, Margalit’s post points out the contest between not-for-profit-in-name-only incumbents on one side and private-equity-funded-innovators on the other. Each side is now poised in an epic (sic) tug-of-war over $3T worth of turnips.
The regulators and politicians refereeing this contest will do so by scoring “outcomes” and penalizing “data blocking”. I still have hope that somewhere along the way our focus and data practices shift from profit to patient and medicine will, once again, be an open, non-rivalrous good.
Why Adrian? Why are you still hopeful? What signs am I missing?
You’re missing the impact of technology. Today’s EHR and MU technology dates to the 1970s. HITECH became law in 2009. That’s the same year that Bitcoin open source software was first released. In 7 years and a bit more than $1B of private equity financing we have a secure and stable technology with global reach, unhampered by regulation, and freely accessible to almost anyone in the world.
Health IT will follow the same trajectory as soon as the patients and doctors realize that it’s just another aspect of medicine and build the open source software they need in a patient-centered way that treats the institutional legacies as relics.
The recent Guidance on patient right of access http://www.healthit.gov/buzz-blog/privacy-and-security-of-ehrs/your-rights-to-access-and-transmit-your-health-information/ is a major step forward. Combined with current work on API standards, it can immediately shift the center of gravity away from the institution and back to the patient-physician relationship (as one of the commenters below asked about DPC). See http://bit.ly/HEARTfromHIPAA for a very rushed analysis of how HIPAA can now drive the data blocking-related standards.
Let’s hope the Feds and Congress stay serious about data blocking. 21st Century Cures is making its way through DC and it could either accelerate or delay patient-centered and privacy-preserving technology a bit. But, as with Bitcoin now being adopted by major banks and ad-blockers teaching people that they can control technology if they own it, the result may be inevitable.
I think I understand now. I am not certain that the comparison to Bitcoin is valid, at least as far as privacy is concerned, but for the first time I understand your argument, and see how it may be possible. Thank you for taking the time to explain.
When a program is “killed” by the government and going to be replaced with something
“better’ watch out.
The article really informative and nicely executed on the topic.
Only missed the reference to how “data blocking” won’t be tolerated. Of course, since we don’t have a usable definition for data blocking – we’ll just use the standard Government issued one. Data Blocking is like porn – we’ll know it when we see it.
Yes. Just delete your browsing history after each exhaustive session 🙂
“the next app is sure to fix health care in America. It’s always the next one. There is always “something better” you can buy.”
Free Beer Tomorrow.
Count me in….