MACRA Comment: CMS + MIPS/APM = Death of the Private Practice Physician

flying cadeuciiSmall, independent private practices are closing, increasing numbers of physicians are retiring early, and fewer medical school graduates are choosing primary care.  The old-fashioned practice my father and I have built is a dying entity.  Parents say coming to see us for an appointment feels more like a visit with a friend than a medical encounter.  I am fighting for the subsistence of rural primary care practices.  Most will not survive MACRA proposed changes to the reimbursement structure. 

Seven days ago, I attended an “informational listening session,” sponsored by the Center for Medicare and Medicaid Services (CMS) for rural physicians to learn more about the new MACRA proposal known as MIPS/APM (Merit-Based Incentive Payment System/Alternative Payment Model.)  This new plan will penalize 7 out of 10 small practices with 1-2 physicians in this country.  Why? Because they will be overwhelmed complying with fruitless statistical reporting demands that do nothing to enhance the quality of care, instead of spending precious time seeing patients. 

Raising my hand, I inquired as to how CMS proposes to ease our burden of data reporting.  “I am not sure, but leave a comment on the website and maybe someone will address your needs.”  Not likely.  A family practice physician described how technical mistakes from the claims clearinghouse caused her Medicare payments to be frozen for 8 months.  “Thank God my father died and left me a small inheritance,” she said.  Otherwise her solo practice would have gone bankrupt.  Is this the collective future of rural care in this country?  Over 50% of her patients are on Medicare.  If we allow this atrocity proposed by CMS to go into effect, who will be left to care for the sick, disabled, and elderly?

The Merit-based Incentive Payment System (MIPS) will base reimbursement on four categories:  Quality, Resource use, Clinical practice improvement, and meaningful use of EHR technology.  The details for determining these factors have not been finalized.  The four individuals facilitating this meeting answered 9 out of the 10 questions (including mine) with the following statement:  “I don’t know.  I can communicate with you over email.”  Can someone please hire me to do their job?  Or maybe hire a group of monkeys from the zoo? Healthcare would be on stronger footing either way.

How about we pay physicians for time spent engaging our patients in substantial conversation, instead of rewarding them for checking boxes on a computer screen like robots?  Unfortunately, reimbursement for dialogue is difficult because its value cannot be quantified within the physician-patient framework.  Physicians were trained to care and comfort people, not to chase blood pressure numbers and pain scale scores.  

CMS coordinators are traveling around the country armed with empty knowledge, assembling groups of befuddled health care providers under the guise of providing “information”, and selling them snake oil.  It is ridiculous to task CMS with determining what constitutes provision of high quality medicine; they could not recognize value if it were right under their nose. 

I get it.  You do not want to pay me for the work I do saving lives.  You want to pay me for crunching numbers that supposedly constitute provision of high quality care.  Which numbers exactly?  “Can you provide an example?” I asked.  “I don’t know, but here is my card for us to communicate” he quipped.  This might come as a surprise but I want to communicate with my patients more, not a coordinator hired by CMS who peddles false hope. 

Why have physicians given CMS dominion over medical care delivery in this country?  They are essentially in charge of a relationship they are incapable of comprehending.   It is so clear the system is incentivizing incorrectly.  Remember what EMR’s have done for the quality of care? Not much, but physicians sure know what it did to our workload.  Where are the anticipated benefits of technology for patient care, physician work-life balance, and improved efficiency?   These hypothetical benefits have not materialized.

CMS believes they are just not compiling the correct statistics; practicing physicians know technology requirements have only served to further undermine the physician-patient relationship.  Investment in the physician-patient relationship and direct physician to physician communication are two methods that could pay huge health dividends for future generations.  However, the return on investment (ROI) is not glitzy enough for those controlling the health care machine. 

There are countless easy, cost-effective ways to improve care quality; unfortunately most of us on the front lines are too busy taking care of actual patients.  Neither my father nor I have admitted a single patient to the hospital for asthma or dehydration in more than 15 years, we see sick patients the same day, and our families are rarely seen in the ER except for true emergencies.  Before you think we cherry pick patients, understand 45-50% of ours are on Medicaid.  I know these families as well as any who walk through our door. 

If I am paid for my time spent talking to another human being, teaching them how to use their inhaler regularly, and helping them avoid hospital admission, it is far cheaper than the cost of a 3 day hospital stay.  But CMS is missing the forest for the trees.  They believe saving on the cost of the office visit altogether is better for their bottom line.  Do you honestly believe value-based payments will benefit physicians and patients?   If you do, I have a bridge to sell you. 

The bottom line is value-based care will result in lower reimbursement to physicians and death to private practices in rural towns where access is less than optimal.  The metaphor of the boiling frog should be a cautionary tale against the creeping normality of “assembly-line” medicine. When attempts were made to drop us in the boiling vat called socialized medicine years ago, physicians and patients both jumped out.  Now, we have been dropped into cooler water and CMS has slowly turned up the heat.  MIPS will do little to enhance patients’ lives or physicians’ livelihoods.  I can guarantee it will boost the bottom line for capitalists in control.

There are 826,000 physicians in this country.  We must refuse to tolerate a reimbursement scheme until its parameters help us provide better quality health care to the human beings we serve.  Our collective future wellness is at stake.  Do not allow patients and physicians to be boiled to death.  Is the statistical framework and useless data collection a necessary part of health care or are thriving patients and contented physicians more essential?  Do not settle for more robots and fewer humans.  We will all be patients someday. 

Niran Al-Agba is a physician in private practice in Washington State.

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5 replies »

  1. Thank you for your comments. I will always stick up for primary care. We are the backbone of the health care system and we are sorely needed. Your thoughts are absolutely right on the money. It is killing me to know what is going to happen in the next few years. Out here in rural Pacific Northwest we have major health care disparities. I have a waiting list with more being added every day. We cannot keep up with the rising demand for decent health care for children. I am now the LAST pediatric office accepting medicaid patients. I have an idea for what small, rural and primary care offices can do to work around MACRA. We would need many of the 225,000 small clinics to band together and charge some out of pocket, but if it keeps our offices alive, so be it! Stay tuned.

  2. Thanks for sticking up for rural Primary Care. CMS is setting up a public health disaster. Small practices cannot just belly up and sell, many small hospital systems are not buying, and many rural clinics are outside of anyone’s sphere of influence. They simply will disappear, along with access to care. CMS likes to talk about health care disparities, until it comes to the ones they create and reinforce. We are going to find out a lot about what CMS “values” in the next few years and I believe the public will be disgusted.

  3. Thank you for your comments. I am glad you are “getting it.” I hope if we keep writing I am hoping either they will listen or we will take matters into our own hands. I have a lot of ideas and have starting putting together some notes. Stay tuned.

    Hayward: I will help spread the message to as many as possible. We must end this atrocity or figure something out! Maybe we should work on this together?

  4. Thank you, thank you thank you.
    There were 99 comments on the MACRA gov’t website, through which comments have now been closed. I’m guessing not one of those comments was positive. Now our great Medical societies are backtracking to try to clean up this mess they created when they fought for SGR repeal. See this:
    The question is, will anyone there listen?