By MICHAEL BANKS, MD

We decided that if MACRA is good for physicians, then the same thinking is probably a pretty good idea for the US government. We need Value-Based Government. It’s clear that past methods of paying for US Government services have been terribly inefficient. Costs keep going up. Quality keeps going down. We thought about doing this nationwide, with all US government personnel, but we will just do CMS leaders for now. Let’s call it a demonstration, we’re calling it  GACRA, Government Access and CMS Revaluation Act.

Eventually we want all US government employees to be value- based, no more salaries. This is an obvious improvement on how we will pay you,  The way you are paid now does not seem to work. Everyone agrees our government is too expensive to run and nothing gets done.

Here’s how value-based government works:

Every CMS leader will send in a code for every 10 or so minutes of work and exactly what they did. Yes, Andy Slavitt and Sylvia Burwell, you will not be paid as you were previously.

You will now be paid for value.

With GACRA, you will need to document every thing you do, but we will only pay for meetings and rules you make.

You will be paid for each meeting in this manner: You need to document the history of the meeting, what you discussed, how complicated the problem is, did you review any prior documentation, did you do an adequate review of the pertinent materials?  You will document a level 1,2,3,4, or 5 depending on the complexity, history etc. Don’t document a 4 if it was really a 3, thats fraud, so pay attention, its a complicated formula, but you have time to figure it out.

Now also you will need to code the meeting, there are 70,000 codes to chose from…like “Meeting to Discuss the Burden of MACRA on Physicians, While Riding on Waterski’s that are on Fire”. Be specific, if you want to be paid. Remember, we do not pay for scribes, Andy and Sylvia, you must do all this data entry and documenting. Don’t forget, you cannot bill us until you finish you documentation and sign it.

You will be paid for every rule you produce. If you go back to the rule within 90 days to work on it, you cannot charge us for the rule. Every rule has a specific code, be sure it matches the codes for the meetings that you used to make the rule, if they do not match to our liking, you will not be paid. Remember you will need to create an electronic claim to file with a clearinghouse all your meeting and rule codes.

Remember, you do not get paid for phone calls, emails, text, Twitter, vacation, only when doing what we think is measurable work.

For EVERY meeting and rule, you will now with GACRA, have to answer at least 6 Quality Questions about the meeting or rule. This is a big improvement from 9, so be thankful. We will give you a list to pick from. You will need to select at least one cross cutting measure and one outcome measure.

This is the Quality portion of GACRA we changed the way we pay you and give you financial incentives for providing high value government or penalties for half of you.

We want to be sure you are using the computer correctly, to document all this. So we’re introducing a new program that will called Advancing Government Information. There are at least 6 objectives with multiple measures in each that you will need to report on for MU/AGI. It used to be more objectives and measures, so be thankful its just 6 with multiple measures in each. For instance, your work on your computer needs be shared securely and your records can easily be exchanged with the DOD and VA (not 5 years from now), and physicians and citizens can access through a portal the work done you claim you did on meetings and rules, all within a day or so, etc.

Again, there will be at least 6 other Advancing Government Information objectives with multiple measures in each objective we want to monitor. This will be reported separately, but it will affect your pay, just wanted to let you know. Also if ANY of this information exchanging gets lost or a cyber criminal takes it, we fine you. You may call that victim blaming, but we need to make an example of you. But keep sharing all your data, but don’t lose one byte. You have to sign a form that you are NOT in anyway trying to block any information in anyway, even if you don’t totally understand what that means nor can you control the software, we want you to sign that.

I also want the CMS leaders to tell me what Government Improvement Activity they are participating in. This is a separate and new part of GACRA. You have to get a score of 60, so you will have to do at least several activities of high or medium weights. Look at our list, for instance, you, yes you, will need to be available 24/7 for your answering questions about your meetings and rules, you offer same day meetings for concerned physicians/citizens, employ shared decision making with physicians. Good stuff. This too will be added to the equation to see if they are penalized. You are not doing enough already, we want you to do more. We want value and these are laudable goals.

Among all this, if we as citizens and physicians feel they are not satisfied with your rules or meetings or you did not listen to them, the citizen can “rate” the CMS leader less than 5 stars, this will probably cause you to be penalized, so be sure to do whatever the citizen or physician wants, as you need 5 stars for each one. Citizen and physician satisfaction is a top priority now.

In the end, we will then do some calculations on all this and its possible the CMS leader may get a bonus or a penalty depending on other leaders at CMS, if they are doing a good job or not. You could be penalized even if you think you are doing a good job. Too bad, you are all competing against each other, we have to balance the bonuses with the penalties. I mean you all can’t be doing a good job, half of you are worse than the others. Isn’t this great, budget neutral! Half of you will get a bonus, the other half will get a penalty. And those bonuses and penalties will keep increasing every year up to at least 9 % of you fee schedule payment.

To document all this, you must use the software that we certify, you cannot use your own. No customized software. We know better on what you need, not you. You may think you have a better way, but forget it. We don’t want innovation or new ideas, we want you to use old, one-size-fits-none software, that they will charge you a lot of money to buy and support. Sorry that its pricey and it doesn’t work well, it is what it is, don’t whine about it.

As for how you get paid again, you will need to file these claims of work electronically with a clearinghouse, obviously use ANSI X12/5010 specifications, and we will decide if we want to pay you, it will take at least 14 days for every claim, maybe longer. You can call us if we decide not to pay you, and if we feel we didn’t want to pay, even if you did the service, we may or may not answer or help, or just tell you to refile, and then re-deny it because you already filed it. We may also send a company that we pay if they can find a reason to clawback your payment for work from years ago, they get paid to determine that you did not document your interaction to our liking. Sorry about that, those are the rules.

Now for those pesky quality indicators and such, you will need to use a fancy add-on section of your software or a separate registry or something similar for the value based measurements, like Quality and Advancing Government Information and Government Improvement Activities. Finding a registry and signing up, well, that is for you to pay for and figure out how to send the data.

We will also audit your attestations with GACRA. We want to be sure we are paying you correctly. We know these GACRA rules are complex and they will probably change every year (or less), get new names, new measures, lots of fun stuff, big long 1000 page rules, so much fun. Don’t let it stress you out, worst case, you will just have to pay us all your money back.

As a fun idea, we decided there is also an Advanced Leader Model that will allow leaders to create a fancy group, but you will have to use a software that we certify and the CMS leaders will must take some financial risk and their are lots of extra complex rules for this, most won’t want to do this. We know taking risks is usually for insurance companies, but hey we want you to get in the risk game, since its so complicated, we will most likely always win! Don’t be sad.  We never showed that this Advanced Leader Model stuff works, ever, but still, we think its neat. We are thinking of other untested, fun things too, like giving you a bundled payment for a rule with lots of problems, if they have more problems within a few weeks or months after you do the rule, you will be penalized or if we go outside your fancy Advanced Leader Model for help on rules you made, you may get penalized and have to pay us back. But you could make 5% more than normal if you are really quality leaders.

If we feel you were negligent, like implemented a rule without testing it or proving it works, or if it has always failed and you keep making us do it, or the rule did not get the desired outcome, we can sue you, so get malpractice insurance too, you don’t want to lose your house or savings.

Finally, we will also factor in if you cost a lot of money to do all these meetings and rule writings. If you cost more than we think you should have or used more resources that we feel you should have used, we will penalize you, there is no real way to measure this, but wanted to add that in too.

The final rules will come out in November 2016. This will be implemented January 1, 2017. Your pay will be affected in 2019. There is no way to check how you are doing. It will magically happen. You will not be paid to implement any of this. You have no recourse. Good luck. More hurdles to come. You should not feel burdened, this is such an improvement! Don’t you agree, we all want value based government, along with butterflies and rainbows. This streamlines all your work into one program, we listened to you. We want a better, smarter Government. Government meetings and rules made for physicians and citizens need to be open flexible and user centric.

#GACRA is Great!!