I think I speak for most physicians when I say that we did not choose to go into medicine to shape health care policy. Medicine is a calling, and I treated it as such. I immersed myself with taking care of patients, and keeping up with the ever changing knowledge landscape that is medicine. I left the policy making to the folks I voted for the last 8 years. These were the adults, the intellectuals – they would take care of the task of taking out the bad elements of our healthcare system and leaving the good. I truly believed. I eagerly began the ehr/meaningful use saga believing this would result in better care for patients.
It took me two years to realize the meaninglessness of meaningful use. I still can’t believe how long it took me to realize that creating a workflow in my office to print out and deliver clinical summaries to patients didn’t do anything other than fill the trashbin. I still held out hope. I thought – this was a first draft, improvements would come. What came instead were positively giddy announcements of the success of the meaningful use roll out. The administration was actually doubling down. There was no acknowledgment for the mess that had been created – onward and forward on the same road we must continue to march. Except the road would no longer be paved and we would be walking uphill.
I watched as reimbursements were cut to physician practices, while hospital reimbursements were left alone. Independent practices collapsed only to reemerge in a hospital employed model. The landscape was changing seismically – and yet I saw no evidence that patients were safer, or that this new model was more cost efficient.
It is in this setting that MACRA arrives. MACRA is the newest iteration of tying reimbursement to value instead of volume. An admirable goal that is spelled out in a 962 page document. It is filled with paragraphs like these:
This seems a daunting task for any practice to wrap their arms around. This can’t possibly be deemed practical for small practices to implement. Unfortunately this is exactly what the head of CMS – Andy Slavitt – is counting on.
Mr. Slavitt and his team actually believe that bad practices will be penalized and good practices will be rewarded. In reality, practices with the resources to report on outcomes will be rewarded, and the small practices that don’t have teams to upcode risk, and check off and submit metrics as part of registries will be penalized. The jobs that proliferate now are jobs working for large systems that demand we spend 12 minutes with every patient during the day, and do notes at night after the kids go to bed in a billing software that masquerades as an electronic medical record. If you are in primary care you are doing all this for a salary that is less than a nurse anesthetist with north of $200,000 of school debt. Is it really hyperbole to say this is anything but a war on the individual practitioner? Is it wrong for physicians to be angry?
Some are disappointed by this response. Apparently it is OUR system that was screwed up, and WE need to fix it. Yes, the same physician furiously treading water in piranha infested waters is apparently in charge of fixing the healthcare system as well. This is akin to expecting the sons of liberty that dumped tea into the Boston Harbor to also put out a white paper on funding the East India Tea Company. There is a place for anger here – we must not as a profession sit by any longer while bureaucrats that know nothing about health care delivery tell us how to deliver health care. Put MACRA where it belongs – in the Boston Harbor.
Anish Koka is a cardiologist based in Philadelphia.