MACRA Needs to Use Evidence-Based Interventions

Whether applied to policymaking for individuals, large populations, or administration of health services nationwide, it is imperative regulatory decisions be anchored to empirical evidence. The official MACRA rule has now been released.  It is 2,000 pages based on the opinion of many non-practicing physicians, Dartmouth economists, and government administrators with input from a few doctors on the front line. In my opinion, what began as a certain death sentence has commuted us to life in prison; MACRA will regulate physicians without representation. 

Let me acknowledge my opinion is limited by my own “small” practice bias. 380 thousand “small” practices (having 15 providers or less) will be exempted if they have less than 100 Medicare patients.  Your definition of small and mine are strikingly different.  Every single independent practice in my hometown of that “quasi-small” size, has sold to the local hospital already.  The “small” practices remaining in my community have 1 or 2 physicians, so I will refer to those as micro-practices for clarity.  My micro-practice serves more than 400 Medicaid patients, with a waitlist of more than 50.  MACRA rules do not seem to have an answer for when there are not enough micro-practices remaining with which to form a “virtual” group. 

I humbly suggest you expand the options in your “flexible” plan, to include a control group composed primarily of 1-2 physician practices.  Please, do not overlook the importance of tailoring interventions to the unique needs of small communities in order to ensure the existence of micro-practices in the long-term. The fates of millions of Medicare (and presumably Medicaid) beneficiaries is at stake.  It is absolutely essential that new payment plans are evaluated in comparison to a control group prior to arbitrarily being applied across the nation. 

A recent article in the NEJM evaluated early performance of ACO’s by using a control group, which is vitally important to the evaluation process.  Researchers concluded the first year was associated with early reductions in Medicare spending among 2012 entrants (1.4%, P=0.02) but not among 2013 entrants. Performance on quality measures was improved in some areas and unchanged in others.  And surprise, surprise, savings were consistently greater in independent primary care groups than in hospital-integrated groups among entrants in 2012 and 2013 (P=0.005 for interaction).  How on earth can CMS ignore yet another study showing independent primary care groups save money before someone important realizes MACRA (as it stands now) is on the bridge to nowhere?

Policymaking must use scientific research to guide decisions at each stage of the process in every branch of government. According to the Washington State Institute for Public Policy, there are three designations to grade the rigor of research methods and the amount of evidence available to guide sweeping program interventions: Evidence-based, research-based, and promising. 

Evidence-based programs have been rigorously studied; using randomized controlled trials, and found to be effective. Research-based programs have been tested using rigorous methods (studies using strong comparison groups, as I am proposing) but do not meet the evidence-based standard.  Promising programs have been tested using less arduous research designs and typically use well-constructed logic or theories to support ideas. 

Postulating and theorizing by Dartmouth economists has left us all on treacherous ground. These experts assembled data, “interpreted” it creatively, and then drew unsubstantiated conclusions upon which to base recommendations for creation of PCMH’s and ACO’s.  The fruits of their “promising, yet non evidence-based” labor have generated unimpressive outcomes, yet their poor quality decisions will not affect their income.  Culpability must be incorporated in the process this time.  Government agencies, their managers, and those economists now advising them must be held accountable for their outcomes this time before holding physicians responsible for ours.

Confidence in these experts is fading because Patient Centered Medical Homes (PCMH) and Accountable Care Organizations (ACO) are not holding up their end of the bargain, demonstrating miniscule savings at best, while making the life of a physician far more cumbersome.  A thorough critique by Kip Sullivan summarizes the research on three PCMH’s and three ACO’s showing little to any cost savings, further exposing the weak platform on which CMS has built their Quality Payment Program. 

In that same vein, CMS is estimating how much value-based payments will bring down medical costs while guiding patients toward better health.  The word “estimate” appears far too often in the Executive Summary of the MACRA Rule for me to be comfortable with this plan.  CMS intends to impose “promising, albeit not evidence-based” options on all physicians treating Medicare patients in less than 3 months.  Where is the conclusive data demonstrating cost containment and improved quality?  It does not appear to exist. What if your estimates are incorrect?  The consequences will be catastrophic for independent solo practices if your “estimates” are wrong.  Should I be forced to make this blind leap of faith without being certain?

Andy, good science will be good for your conscience. CMS policymaking must be based on rigorous research that is supported by empirical evidence, even if the results are equivocal.  Presuming, opining, and educated guessing are not adequate methods for imposing non evidence-based programs upon large populations.  Before CMS officially implements sweeping payment modifications on January 1st; please consider allowing a control group option, composed of small practices with 1-2 physicians.  I, for one, would like to be at the top of the list.  Do not throw the “fee-for-service” baby out with the bathwater before being absolutely certain your non-evidence-based payment models actually contain costs and are better for patient care quality than what is already in place. 

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15 replies »

  1. Anish, though there are some similarities I believe the incentives of DPC are different from capitation (correct me if I am wrong since I am not sure how all DPC functions). DPC doesn’t have to worry about expensive hospitalizations, consultations, post-hospital care, testing, etc., only what the physician does in his office. That office care is sometimes what makes HMO’s look good so they can grab market share. The money is saved on other things.

    Question: Do DPC’s collect on insurance owned by the consumer?

    One of the concierge practices seen in a wealthy area is VIP. They have a fixed fee of ~$1800 per year and they collect from insurance carrying a maximum patient load of 600. Would that be considered DPC as well?

    Thank you for all your well-done postings.

  2. Dr. Holm – Creepy is a perfect description for what is going on these days. Sadly, It is going to get a lot worse before it gets better….

  3. Anish, I caught the gist of what you were saying. The capitation model from the 90s was not a great experiment and I think if we use that term in connection with DPC, it will confuse more individuals who are not familiar with the idea. I, like you, believe the DPC movement has clear merit and is preferable to current constructs. It is likely in the future for both of us if we wish to remain independent. I am not convinced we should refer to it as a capitated model, and that is just my opinion or maybe it is PTSD 😉 leftover from the experimentation in the 1990’s. My dad was in the same private practice then we are in now. I was filling out FAFSA’s in medical school, so I know what his income was during that time. Yep, it might be PTSD after all.

  4. Your experience exemplifies many of the problems with these models. First of all, your doctor is still very likely paid on MGMA/FFS production. In other words: crank office visits. Converting visits to wellness exams is very hip right now and is frankly encouraged, frequently without patient consent, because it makes the copay disappear, so who cares. You may have no risk factors for Hep C. Who cares? There is a metric now that says order the test. I’m sure it has nothing to do with the pharmaceutical companies making a fortune off of the “cure”. You don’t look old enough to require a pneumovax from your photo. Once again, better to give someone an untimely and inappropriate vaccine, with scant evidence behind doing so, than suffer the bludgeon of not meeting the metric. It is one of the most outrageous and irresponsible forms of overutilization I have seen in 20 years of medicine. There is no way in hell that organizations like the PCMH or ACO will ever save anyone money with this sort of fanatical regimented philosophy. They have been tainted by the same lobbying and political influence that taints our government. Similar outcomes: unsustainable cost, waste, fraud, consensus inertia, etc. Isn’t that creepy: the feeling that someone else is controlling the visit between you and your physician?

  5. Agreed, interesting to hear about your experience. The leash is tight, but the war is lost only if we say its lost! The odds are long but not insurmountable..

  6. Agreed allan – I was reffering to DPC as a capitated model which I think is preferable to current constructs.

  7. Free Markets are akin to scientific experiments. Millions of people vote with their own dollars as to what is the most effective use of their money. The free market doesn’t exclude HMO’s or any system because it permits individual choice. The free market doesn’t exclude government subsidies to help those in need.

    I took note of the comment “I would support capitated models of care with physicians in control. ” That is fine if the patient actually chose the HMO over another source of healthcare delivery, but I wouldn’t deceive myself into thinking that a doctor wearing the hat of the CEO of an HMO doesn’t think more like a bean counter than a physician. There are plenty of physicians running HMO’s whose primary purpose is NOT to serve the patient. Doctors treat patients, CEO’s treat companies.

  8. Re: ” I would support capitated models of care with physicians in control. I don’t see why a DPC model couldn’t work even within the medicare construct.. I don’t mind capitated models if we’re in control. We need to get the regulators off our back.”

    I agree, with one addition: patients get to choose to be treated in a capitated environment. My new primary care doc (in a large group practice) wouldn’t renew my script without an office visit…..I see a brochure in the waiting room telling me the group practice is a patient centered medical home/ACO……nice warm homey language. When the doc spent more than 10 minutes with me glued to her computer screen I realized this was being coded as an annual physical exam….not the brief visit to monitor minor hypertension….I suspect to get me counted as part of the Group’s virtual ACO….and then she strongly encouraged me to have blood work to test for HepC (negative) and get a pneumonia vaccination (must be part of CMS monitoring stats).

    It seemed like she was on a tight leash that protruded to her through the computer screen! It wasn’t too bad for me…but right now I am in good health…..but I think I will start to search for a primary care doc in a direct primary care practice. However, I suspect the war is lost to get the regulators off doctor’s backs…and patients backs.

  9. Thanks Meltoots. Always love to read your positive, supportive feedback!

  10. You know watching over the last 6 months as physicians retire and independents close their doors has shown me I will likely survive by the sheer need created now in this community for good quality doctor-patient relationship, but I too, am afraid CMS is unyielding and are driving off the cliff no matter what. I can’t wait until they need a parachute!!!

  11. Thanks Anish. I definitely was not defending ACO’s in this post, but I do understand the confusion. I was defending small independents as showing reduced costs no matter what model you put them in. My plug for research is that likely no matter how you slice and dice and ACO… it will never prove itself to provide better care than me and my patient in a room together ie control group. There are way too many people involved in providing “quality care” for there to be any cost savings with these ACO things. Completely agree with you these creations are a disaster because the rules are written by clueless individuals.

  12. Niran, Nice post – but I think your faith on research saving us may be misplaced. I don’t agree that physician ACOs are the answer for many reasons. Fundamentally, the lesson of the last 6 years is that we need to resist efforts from the center to control what happens in our patient rooms. I have lost faith that a group of bureacrats, no matter how well meaning, or intelligent can figure this out. Unless we want to have a discussion about getting rid of medicare – which no one is ready for – I would support capitated models of care with physicians in control. I don’t see why a DPC model couldn’t work even within the medicare construct.. I don’t mind capitated models if we’re in control. We need to get the regulators off our back. Independent physicians group ACOs is definitely better than Hospital ACOs..but will still set us up to fail – because the rules are again written by folks that are clueless (See this post – https://thehealthcareblog.com/blog/2016/10/22/making-accountable-care-organizations-great-again/).
    The back and forth on ACOs between me and a health policy follow at Harvard is also enlightening –

  13. Mommy Doc,
    Love your posts. I agree on all counts.
    MACRA is an abomination:
    1. Its written to report for dollars, not for true outcome or quality or lower cost, just self reporting how great you are and how well you can figure out the arcane reporting processes.
    2. ACO, AAPMs, CPC+ are all untested risky unproven programs. If anything, as Kip Sullivan sharply points out, they have already failed.
    3. There should be NO penalties for any physicians willing to care for Medicare patients. None.
    4. If a physician wants to play games, try experimental care models, then go for it, you may get a small bonus, but those in the trenches will not be penalized for your lack of work or vision.
    5. MU/PQRS have been around for 6 yrs. I’m pretty sure I have not seen any true (not BS studies) data showing this wonderful improvement in care, cost, usability, access, efficiency, safety, and most certainly not security. It has pretty much decimated the profession of medicine and somehow, someway, CMS wants to continue it.
    6. A teaser year with a few reporting options, then the hammer being slammed is not what providers are asking for…does ANYONE at CMS understand this?
    7. I think its pretty darned obvious that they do a “buzzword” advertising mission, “value based care” etc. etc. without ANY substance, evidence nor improvements.
    8. MACRA is going to fail and fail miserably. Its just another version of HMOs, which were supposed to save the world.
    9. Every practice, community, county, area of the country is different. Attempting to one size fits all everywhere never will work.
    10. Making physicians the scape goat for interoperability is nonsense. CMS and ONC both pushed for Cert EHR, they should be on top of EHR vendors for all of that. No us. Do you think I would like to see the X-rays from a nonaffiliated ED when a patient comes to my office the next day with an ankle fracture? Of course? Why does that not happen? Seems like a good place to start.Or read the note of the MD that saw them? Nope. WAY to complicated to even attempt. Fax is usually what works. Good job MU and $35 billion.

    What we really need at CMS is REAL front line providers telling CMS what we need. Not part time, never saw an EHR nor reported PQRS providers. But they don’t want that. They want fancy language and buzzwords. Good luck with that.

  14. Excellent points Niran, but I think CMS has chosen the road they are taking (despite not having a map) and are speeding down it with blinders on. The road is headed off a cliff, I’m afraid.