OP-ED

Is DRexit Next?

Sean MacStiofain said “most revolutions are caused… by the stupidity and brutality of governments.” Regulation without legitimacy, predictability and fairness always leads to backlash instead of compliance.

Here’s a prediction for you: If something is not done to stop MACRA implementation, more physicians will opt-out of Medicare and Medicaid than is fathomable.

Once DRexit begins, there will be no turning back.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is destructive to the physician patient relationship because it prevents physicians from prioritizing patient care. MACRA supporters like to point out this legislation was passed with bipartisan support; in reality, it was passed simultaneously with repeal of the Sustainable Growth Rate Formula.

The Sustainable Growth Rate Formula was enacted through the Balanced Budget Act of 1997 and was designed by lawmakers to control Medicare expenditures. The SGR formula limited the annual increase in cost per Medicare beneficiary to the growth of the national economy. Under the SGR formula, if overall physician costs exceeded target expenditures, a reduction in payments would be triggered. Expenditures continued to climb, so Congress stepped in 17 times with short-term legislation (referred to as “doc fix”) to avert the payment reduction since 2002.

These patches kept increases in physician payments below inflation which ultimately resulted in a huge discrepancy between the actual level of Medicare physician-related spending and the target in the SGR formula. In 2015, if Congress did not act by March 31, payments to Medicare physicians would have been reduced by 21.2 percent.

Enter stage left, MACRA, known as the Permanent Doc Fix, which was passed concurrently with the Sustainable Growth Rate Formula repeal legislation. This was the original repeal and replace. MACRA established yet another new (and untested) method by which to pay doctors. MACRA is the largest scale reform on the American health care system since the Affordable Care Act in 2010 and the jury is still out how great (or not) that system is working for the American people.

Under MACRA, the Secretary of the Department of Health and Human Services was tasked with implementation of a Merit Based Incentive (MIP) program which consolidated three useless incentive programs into one big colossal unworkable program for eligible physicians everywhere. The legislation also allows for Advanced Alternative Payment Models (APM), which shockingly, are not actually saving money on care.

Even better, MACRA related regulations also addressed incentives for use of health IT by physicians and other care providers. Similar in scope to the Meaningful Use (aka Meaningless Abuse) Program except, now on steroids. The Government Accountability Office in partnership with the DHHS have been assisting with the implementation of electronic health records (EHR) nationwide, while at the same time comparing and selecting programs for providers.

So to recap, Congress has been working on a “doc fix” system in conjunction with every lobby possible on the planet EXCEPT that of Practicing Physicians since 1997. They “repealed and replaced” SGR (first disaster) with the atrocity known as MACRA, which will end in a mass DRexit. They are rapidly moving ahead with non-evidence based payment methods intended to decrease costs, yet are highly unlikely to be successful based on recent studies. On top of all that, they are selecting computer systems for physicians which incentivize computer data entry while discouraging the placement of hands on patients. Did I miss anything?

Recent studies show physicians spend twice as much time on technology than we do with patients. Maybe with full MACRA implementation, we can be retrained as data entry clerks to treat conditions instead of people. Imagine if we just called in prescriptions for hypertension, diabetes, or even started chemotherapy regimens without seeing patients at all? MACRA pays us more for “doing less,” so now we can practice “drive-by medicine.” I wonder if health outcomes will improve and mortality will be lower when compared with “drive-by shootings.”

Controlling costs involves four major pillars of change to our healthcare system, about which I have been writing for some time. Listening to a talk given recently by the executive director for the Association of Independent Doctors, Marni Jameson, helped focus the strategy. The first cost control pillar is to educate patients and lawmakers as to how consolidations of hospitals and medical practices raise costs, reduce quality, decrease access, eliminate jobs, and result in unnecessary testing and procedures. The second pillar is to increase price transparency, so consumers can compare costs and choose the most affordable option. The third pillar is eliminating the onerous ‘facility fee’ to bring payments of hospital-employed doctors in line with the lower payments to independent doctors for the same care. The final pillar is ensuring hospital profits are taxed equally across-the-board, regardless of whether they are non-profit or for profit institutions.
In the next four posts, I will cover these issues in more detail as each deserves its own separate discussion. It will be an interesting mathematical exercise to calculate the forecasted cost savings of these four interventions alone. If you are reading this post, you have skin in the healthcare game, whether as physicians, lawmakers, economists, hospital administrators, government, or IT experts alike. As I have said before, we will ALL be patients eventually.

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meltootsKeith BerndtsonSteve2William Palmer MDAllan Recent comment authors
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meltoots
Member
meltoots

Mommy Doc, I am completely with you on all this. As a fiercely independent practicing orthopaedic surgeon, in a small group in a small town we are the last remaining group. ONC and CMS should be scared to death about the damage they have done and are doing to medicine. If they want to turn healthcare into the postal service or the DMV, they are well on their way. But there a some remaining fighters left. And I am going to fight for those that are younger. I could easily retire, but I am choosing to stay and fight. For… Read more »

Niran Al-Agba
Member

Meltoots, your comments made my night. I, too, am going to keep fighting. There is no doubt in my mind (and overwhelming evidence is on our side as well) that independents provide better quality for lower cost. Our local hospital recently bought the last independent ortho group left. The docs are absolutely miserable and cannot operate at the local ambulatory surgery center anymore. They are all good surgeons and good people. Costs are higher than they have ever been. Cheers to better care for our patients!
🙂

Steve2
Member
Steve2

“The first cost control pillar is to educate patients and lawmakers as to how consolidations of hospitals and medical practices raise costs, reduce quality, decrease access, eliminate jobs, and result in unnecessary testing and procedures.”

Our experience in our network has been a bit different. We have improved quality, jobs stayed about the same, many fewer unnecessary tests and procedures. Costs have been mixed. I think the literature on consolidation is mixed, but them will se how you define consolidation.

Steve

Niran Al-Agba
Member

So glad you are opening up questions about my next post. Actually, when you delve into the details of literature, it is overwhelmingly clear that consolidation increases prices as high as 15%. The closer the consolidating hospitals are the higher the jump in costs. The AHA does not want anyone looking into this topic further and have spent millions trying to squash the movement. Cost are NOT mixed. Once you include the facility fee in the total charges, the cost increase is astounding. If your network charges a facility fee, forbids procedures at an ambulatory surgery center and insists on… Read more »

William Palmer MD
Member
William Palmer MD

Health care has some astonishingly tough intellectual–mostly economic–problems. And they are all over the world. The worst is that we have to have someone else paying for everything. 3rd Party Payer. Can you imagine: buyer and seller and payer for every transaction. The entire machine is forever defective because of this one glaring defect in its construction. It is like an engine that has to have a wooden crank shaft. My own guess is that if we could make it appear as if all the money was coming from the patient that we could begin to see some healing of… Read more »

Niran Al-Agba
Member

I completely agree with have lots of work ahead. But this is such a complex problem, it is time physicians had input in helping to solve it. If it is only a one-sided effort, we will never turn things around.

The_PPAL
Member

Thank you for sharing the MD viewpoint, one which now feels a bit beleaguered. I am not an MD, so I offer my comments respectfully, reflecting my experience as a patient and a family caregiver advocate. I can understand why there is discontent – having worked in the healthcare delivery system in one form or another for more than 30 years, I can remember when MDs had total autonomy. Anything other than that must feel like “so much less.” Now retired, I wonder if anyone has any comments about Paul Starr’s work, The Social Transformation of American Medicine.” If not,… Read more »

Niran Al-Agba
Member

It only feels beleaguered to those who do not spend every day mired in paperwork and useless technology. I appreciate your respectful comments, but unfortunately you are missing my point. I provide health care, an embodiment of the social good about which you are talking. Maybe you should google me before answering glibly. The one-on-one relationship with my patients IS the point. I have spent much time writing about better metrics, more patient empowerment, more physician driven outcomes so you can compare and contrast the good and the bad. MACRA is not just technically difficult; it is asinine. Quality care… Read more »

Keith Berndtson
Member

“It only feels beleaguered to those who do not spend every day mired in paperwork and useless technology.” This is so true, to the patients and physicians whose leeway to develop mutual understanding and collaborative relationships have been torn asunder by ever increasing time constraints on physicians. It feels less like beleaguered and more like the gang-rape of the medical profession, with patients left to make sense of why their doctors are too boxed to listen to them anymore. I opted out of Medicare, Medicaid, and commercial insurance. When productivity targets and non-translatable clinical guidelines started appearing from up-top somewhere,… Read more »

Niran Al-Agba
Member

“gang rape of the medical profession”. I could not have said it any better myself. “Meanwhile, the patient feels kicked to the curb, again and again.” This is what is hardest for me to watch. When I see new patients, sometimes I cannot believe how their care has been mismanaged because of the time crunch physicians face.
Good for you for already DRexiting! I know there will be many more to follow. Unless they exempt rural and small practices, we will all end up opting-out. The patients will be losing the most. 🙁

Barry Carol
Member
Barry Carol

Paul Starr’s book, while a comprehensive history of American medicine, was published in 1982. A lot of good things have happened since 1982 along with some that are not so good as Niran notes. As a patient that’s been through quite a lot over the last 18 years especially, I would not want to go back to 1982 medicine at 1982 prices. If I had to, I most likely would not be here today. That said, I hope Niran and her fellow doctors can lead the way toward systemic changes that will enable doctors to provide great care at low… Read more »

Allan
Member
Allan

It is near impossibile for physicians to do much of anything. People that think in a certain direction and you are part of that group have prevented physicians from acting and have made them servants of the state and the insurers. Stop blaming physicians. I’ll give one example. At my hospital the physicians would discipline other physicians. I was on that committee when one of the more powerful physicians was disciplined. He was practicing substandard medicine. For one year he was quietly watched and turned into a reasonable physician. Our hook was he would follow what was reasonable for a… Read more »

Steve2
Member
Steve2

“Today that cannot be done. ”

We still do this in our network. What would stop you from down it where you work?

Steve

Allan
Member
Allan

It may still be done elsewhere, but to a lesser extent. Laws were passed that opened up the records of the comittee. I don’t remember if they were federal or state laws. That inhibits the ability of physicians to police their own. Other things have had an impact as well. Physician power is almost non existent at the hospitals I know and since many of my friends practices have been bought up they are now employees on salary with little say as to what happens at the hospital.

Niran Al-Agba
Member

Yes, we must work to stop the constant consolidation and buy-ups of physician practices. It increases costs across the board.

Niran Al-Agba
Member

Yes. Barry, this is exactly the goal I am hoping for. System change that allows physicians and patients to work together for the best outcomes without breaking the bank unnecessarily. Thank you for seeing the forest for the trees.

roates
Member
roates

The net-evidence now clearly indicates current “value-based” performance metrics worsen actual patient outcomes. While annualized performance metrics can serve as useful, internal KPIs to monitor trends and strive toward improvements, basing $$shifts on them creates more harm than help. Claiming that the current, annualized performance metrics are proxies for measuring quality ignores the evidence base available.
So, if the current “value-based” metrics worsen actual patient outcomes, how can the APMs where health professionals are placed at financial risk possibly have a different outcome than the HMOs did?

Niran Al-Agba
Member

They won’t have a different outcome, unless the government keeps bailing them out. It is ridiculous for them to keep backing a losing team. Let doctors be doctors and do what they were trained to do. Thank you for getting it Dr. Oates.

Allan
Member
Allan

Much of the left wishes physicians to act as widgets and be paid salary and adhere to whatever their desires might be. The far left uses healthcare to control. Many Republicans are corporatists and do not understand Adam Smith’s “willing buyer/ willing seller. The more conservative Republicans and perhaps the populists have a better understanding of marketplaces. I don’t know where Trump stands, but I have confidence in him because he is a businessman not strongly connected to corporate interests that feed off of the federal government. If he goes the correct way he will be facing against almost all… Read more »

Barry Carol
Member
Barry Carol

I think it’s important for doctors to be willing to assume a leadership role in reforming the healthcare system in a way that works not only for them and for their patients but for payers as well. I agree with the first three of your four pillars. I’ve long thought that the anti-trust people have fallen down on the job when it comes to hospital consolidation but have been much more aggressive in opposing recent attempted consolidation on the insurer side. I’ve been advocating for price transparency, at least for care that can be scheduled in advance and thus lends… Read more »

Perry
Member
Perry

Barry, physicians will have to care about costs, both for themselves as patients, and patients they are treating in this era of high deductibles and high costs for pharmaceuticals and outrageous costs for hospital care. That being said, it’s impossible for docs to continually keep abreast of all costs, particularly when many are hidden. I will say though, I myself and many other docs will shift patients to non-hospital outpatient facilities for testing simply because they are much less expensive. I will also base prescriptions on lower cost when feasible. While I don’t expect the government and payors to “leave… Read more »

Niran Al-Agba
Member

Barry. Interesting points. At least if I have you agreeing on 3/4… that is a great start. It appears based on my research so far, the bigger profits are available in the non-profit hospitals… they should probably be paying their fair share except for exemptions for rural hospitals or those truly serving the underserved. I am not sure physicians are asking to be given a carte blanche regarding reimbursement completely without question. I am one physician who knows the cost of almost everything done in my own office and I think it is extremely valuable for my patients. You are… Read more »

Perry
Member
Perry

Yes, ironic isn’t it? Doctors will be paid for doing less. Spending less face to face quality time with the patient to make an accurate diagnosis. Spending less time explaining a treatment plan and outcomes.
The basis of quality for a physician patient encounter should not be a bunch of checked boxes, yet this is how docs will be judged in this new, great system.
Yes, I think a DRexit is required to make our lawmakers and even our so-called “societies” like AAFP, AMA and AAP understand this is not the way to conduct patient visits and pay doctors.

Niran Al-Agba
Member

Medicine is one of the professions that does not follow the economic rules making it so difficult to contain costs. Technology increases costs instead of decreasing them. If we could strip away all the junk (EHR, Value based reimbursement, fewer administrators and staff) we would have lower costs and better care. Simple, huh?

Perry
Member
Perry

What the powers that be seem to want is to control doc “cost”, but not that of hospitals and pharmaceuticals. Even if you “ration” care by not ordering tests, eventually someone will get sick enough to need expensive care, and those costs do not seem to be receding, just escalating.

Barry Carol
Member
Barry Carol

The thing is that doctors influence virtually all healthcare costs because they’re the people that order tests, prescribe drugs, admit patients to the hospital, refer patients to specialists, consult with patients and perform procedures themselves. With so much of healthcare costs attributable to the expensive stuff and the management of chronic disease, I can understand why payers think they need to focus their cost control efforts on how doctors practice. Patients in aggregate are never likely to pay more than about 25% of healthcare costs our-of-pocket at most even if everyone has a high deductible insurance plan and a Health… Read more »

Keith Berndtson
Member

I agree on using best evidence-based practices to cinch down chronic care costs, with a focus on the most expensive conditions and patient situations. I respectfully disagree when it comes to what patients are willing to pay to access medical expertise that is absent in all but a few medical settings. And when that expertise is unfettered by 3rd party bureaucrats, corporatists, lobbyists, and non-medical policy gurus, patients whose problems do not submit to easy answers grow increasingly grateful for an approach to medical care that relies on protocols that are data-driven and supplemented by unconstrained, experience-based, clinical judgment. Funny… Read more »