MACRA Is Broken. It Needs to Go Away Now.

At its January 12, 2017 meeting, the Medicare Payment Advisory Commission (MedPAC) made it clear they had reached the conclusion that the Merit-based Incentive Payment System (MIPS) cannot work (see my last post ). MIPS is the larger of the two programs within MACRA; the Alternative Payment Model (APM) program is the other. The commission’s primary rationale for its conclusion about MIPS is that it’s not possible to measure physician “merit” (cost and quality) at the individual physician level.

But rather than recommend that Congress repeal MACRA (the Medicare Access and CHIP Reauthorization Act), MedPAC decided to try to fix it. At the January and March 2 meetings, the commissioners discussed a staff proposal to amend MIPS substantially and to tweak the APM program. Those discussions went nowhere.

I give MedPAC credit for finally stating unequivocally that MIPS cannot work. But MedPAC should never have volunteered to fix MACRA. It can’t be done. By proposing modest amendments to MACRA and thereby implying it’s fixable, they stepped into an intellectual tar pit. I will illuminate this tar pit by describing the commission’s unproductive discussion about the staff’s proposed amendments to MACRA. To give you a sneak preview of what that discussion was like, I give you two excerpts from the transcript of the January meeting:

[Commissioner Kathy Buto] As I look at this whole [MACRA] system, I worry about the complexity of it and whether it’s going to achieve anything.… Medicare has sometimes a way of getting into a system it can’t get out of, and this has that feeling about it, that we could go down a rabbit hole and not be able to get out…. (p. 290, transcript )

[MedPAC director Mark Miller] And the reality of MIPS right now is it’s dead in the water because of those complexities. And that’s what we grind tons of time on, and I just wonder sometimes how we’re going to get out of this…. (p. 298, transcript, January meeting)

Allow me to introduce Scylla and Charybdis

MedPAC’s staff, under the direction of Chairman Francis Crosson, presented its alternative to the MIPS program at the January 12 meeting. The staff proposed reducing MIPS’ reporting burden substantially but also increasing the financial pressure on physicians who refuse to flee MIPS and join a group where, allegedly, physician “merit” would be measurable. According to the staff’s proposal, physicians could either stay in MIPS and sacrifice 1 to 2 percent of their Medicare revenue, or flee to: (1) a MACRA APM (the ACO is the main APM prototype); (2) a “virtual group” (the staff did not explain what that might be); or (3) a group defined solely by geographical criteria that CMS would select (the staff did not explain this ephemeral entity either).

The staff was essentially proposing that the commission abandon one impossible mission (figuring out how to measure “merit” at the level of the individual physician) for another – figuring out how to jam all doctors into functioning groups so that measurement of “merit” can be more accurate. The staff didn’t warn the commissioners they were asking them to swap one impossible mission for another. The staff merely asserted that measuring cost and quality at the individual physician level is impossible because each doctor serves relatively few patients and that herding doctors into large groups would solve the small-numbers problem. As Chairman Crosson put it at the March meeting, “[T]he whole point of [the staff’s proposal] is to achieve a volume of care of Medicare beneficiaries that is actually measureable….” (p. 228, transcript  of the March 2 morning session)

As is so often the case when managed care advocates promulgate their proposals, the staff did not identify assumptions that have to be true for their proposal to work. The most fundamental of the unarticulated assumptions is that functioning groups of doctors (be they APMs, “virtual,” or geographically defined) will pop up all over the country so that all doctors who wish to flee MIPS will have a group to run to. In addition to being universally available, these groups must be real (not mere constructs on CMS or Dartmouth Atlas computers), and they must be functional – they must actually improve care and lower costs at the system level (not just for Medicare), something no previous managed care fad (HMO, ACO, “integrated” whatnot, “medical home”) has managed to achieve.

If Dr. Crosson and the MedPAC staff had bothered to articulate these and other assumptions, they might have grasped that measurement at the group level presents obstacles as insurmountable, and as mind-bending to contemplate, as measurement at the individual level. But they didn’t do that. Predictably enough, this failure to lay out the unarticulated assumptions caused the commissioners to descend swiftly down a rabbit hole where productive discussion became impossible.

Adventures in the rabbit hole: The January meeting

As I noted in my last post, when the staff finished presenting their proposal at the commission’s January 12 meeting, Commissioner Craig Sammit asked, “[D]o we have a sense of how accessible and feasible it will be for clinicians to join APMs?” Staff member David Glass replied, “I would say that’s a little hard to say right now.” (pp. 248-249, transcript) That was the commission’s first warning that a rabbit hole was opening under their feet. But no one noticed, and down they went.

The commission’s discussion of Dr. Sammit’s question focused at first on the difficulties small clinics would face in creating an organization that would qualify as a MACRA APM. One of the criteria for an APM is that it must bear “two-sided risk” (the risk that the APM will lose money as well as make money). Can small practices be expected to do that? Commissioner David Nerenz noted that very few of the groups that have signed up for Medicare’s MSSP ACO program signed up for the “track” that requires they take both upside and downside risk, so why should anyone expect small clinics to expose themselves to two-sided risk? “We have no good working examples of people willing … to step into the two-sided risk models of the MSSP,” Nerenz warned. “It’s a tiny, tiny fraction of those that are accepting two-sided risk. You can force people in. You could declare everything else to be a felony punishable by law, but we don’t have examples of how to do it.” (p. 268)

Commissioner Jack Hoadley asked the staff if they could refer the commission to “any history” of successful “physician groups” the commission might learn from “so that we’re not in the business of just creating … organizations that aren’t really doing anything….” (p. 291)

The staff had no answers for Nerenz, Hoadley, Buto and other commissioners who asked how small clinics were supposed to meet the two-sided-risk requirement for a MACRA APM. Commissioner Paul Ginsburg summarized the prevailing evidence accurately when he said, “I think that the reality is that for the fairly large percentage of physicians, they probably don’t have very extensive APM activities now.” (p. 250)

So if smaller clinics don’t want to stay in MIPS where they’ll lose 1 to 2 percent of their Medicare reimbursement, and if they can’t flee to an APM because they can’t handle two-sided risk, maybe they could flee to one of the other two types of groups proposed by the staff – “virtual groups” that doctors might form, and geography-based groups CMS would define. The commission discussed that scenario next. But that discussion also led nowhere. The commission wound up agreeing that groups of any sort (APM, virtual, geographical, whatever) make sense only if the groups are built on a shared culture – a consensus among the participating doctors about how they want to practice. This shared culture cannot be fabricated top-down by CMS or hospital executives seeking to expand their empires. They must arise organically.

At this point MedPAC’s director, Mark Miller, could see that the commission was beginning to realize they had swapped one impossible mission (measuring at the individual level) for another (measuring at the group level). But rather than advise the commission that the problem they were having was the intractability of the obstacles to measurement at both the individual and group level, Miller blamed the commission members for being unable to complete either mission. “[M]easuring in the aggregate, measuring in the individual, you guys are the commissioners. I don’t care,” he began. Then he complained that advocates of measurement mania are damned if they try to measure at the individual level and damned if they try to measure at the group level (as if the measurement advocates were the victims here). “[B]ut at some point in time, somebody has got to decide how this is going to go.” Miller offered no way out of the rabbit hole he had led the commission down. He instead offered only his own frustration at finding himself in the hole. “What are we doing here?” he asked. (p. 274) [1]

As the January meeting drew to a close, both Crosson and Miller expressed their confusion about how to summarize the commission’s discussion, presumably for the purpose of setting the agenda for the March meeting and to begin writing a chapter in the June 2017 report to Congress. Crosson was reduced to saying “[W]e need to take, you know, a much more effective approach, and I couldn’t describe it right now.” (p. 303) Commissioner Buto gamely tried to help Crosson by asking, “Are we essentially saying that on MIPS that … we don’t think it potentially is going to work the way it’s structured? … I think we still need to fill in the blank as to what we think should happen.” (p. 304) No one could answer Buto’s question; no one filled in any blanks.

Crosson ended the meeting with this plaintive question to the commission as a whole: “So a paper with suggestions. Is that what you’re saying”? (p. 307)

Further adventures in the rabbit hole: The March meeting

Crosson and the staff apparently learned nothing from the January meeting. They returned to the March meeting with the identical proposal they had presented at the January meeting, with one addition: They proposed to change the way in which primary care physicians (PCPs) who participated in ACOs would be paid, but not the amount they would be paid. The staff’s refusal to alter its proposal, and their addition of a partial-capitation method of payment for PCPs, made no sense. Here is my guess at the staff’s rationale for adding the PCP bauble. They left the January meeting aware that the commission was worried that small clinics wouldn’t have any groups to flee to; many of these small clinics have PCPs in them; if the PCPs were given more upfront financial support, smaller clinics might be able to join or start an ACO and survive two-sided risk. I realize this doesn’t make sense, but that’s the only rationale I can imagine. [2]

Following the staff’s presentation, the commission took up where they left off at the January meeting – posing questions about how the staff’s proposals for measuring “merit” at the group level would work. Commissioner Jack Hoadley led off with a question about why doctors in “virtual groups” and geographically defined groups would have any influence over the cost and quality measures they would be subjected to. “[I]t certainly doesn’t feel like it has any potential for anything I do as a clinician to make those measures go up or down,” he said (p. 207, transcript of March meeting).

Commissioner Brian DeBusk asked whether the staff had “explored” whether groups in lower-income areas would be punished by the proposed “quality” measures because of factors outside physician control. (pp. 209-210) Commissioner Kathy Buto said, “I do not know what we are trying to do with primary care….” (p. 235) Commissioner Alice Coombs (a doctor) said she was struggling with the question of “finding a home for the primary care physician [within] MACRA.” She asked her fellow commissioners to “have a little mercy on the onesie-twosie groups.” She said the “whole notion of attribution [of patients to doctors] within a geographic region” is riddled with problems. (pp. 222-223) [3]

Again, the staff’s answers to these obvious questions and concerns were grossly inadequate. Staff director Mark Miller was especially unhelpful. He implied the commissioners were spoiled brats asking for the moon. He said they needed to remember how bad MIPS is now and that anything would be better than MIPS. For example, after a brief discussion about whether hospitals could serve as the staging ground for an ACO when few doctors follow their patients into hospitals anymore, Miller said:

In listening to you guys, you are absolutely right. Tons of physicians do not set foot in a hospital, but you could almost have the hospital-based physicians … say, “Okay, let’s reach out and get these sets of physicians so that we can all be measured together.” And then I will just say this again: Keep in your mind, what is the alternative?…. [E]ach time you guys say this I am going to … force you back to the status quo…. [Y]ou are right, this has a bunch of problems; so does the status quo…. And so if there is another idea, that is what we are searching for. (pp. 228-229) [4]

But no one offered another idea. The closest thing to “other ideas” were bromides like, “I really think that we need to give up on … repelling people from unorganized care and drawing them into organized care” (Ginsburg, p. 237), and, “I think it is time to put our thumb on the scale for ACOs” (DeBusk, p. 246).
What next?

At the end of the January meeting, Chairman Crosson made an attempt to summarize the commission’s confused and unproductive conversation. It was embarrassing; Crosson sounded incoherent (see pp. 301-303, transcript, January meeting). His attempt accomplished nothing other than to drive home how much time the commission had wasted discussing the staff’s proposal. But Crosson, whose term expires this month, made no attempt to summarize the commission’s discussion at the end of the March meeting. Instead he ended the meeting abruptly with this cryptic happy talk: “We will be returning to this issue probably early in the next MedPAC term…. We are going in the right direction.” (p. 247)

Crosson himself observed at the January meeting that the commission could not just sit on the sidelines “and watch a dysfunctional thing unravel.” (p. 305) But it appears now that’s exactly what MedPAC intends to do. For the foreseeable future, it appears MedPAC will do what MedPAC always does after they identify defects in a managed care nostrum they previously endorsed – they will dither.

[1] Here is a lengthier version of the statement MedPAC director Miller made at the January meeting expressing his frustration with the commission’s inability to figure out how to make measurement at both the individual and group level work:

[T]here has been a 15, 20-year discussion about this, where it’s like, okay, you can’t do anything but measure me at my individual level, and … you have to tell me precisely how you are measuring me. [T]he physicians groups argue this. Then they are upset that it is too burdensome, that the comparisons aren’t fair, … and nobody is happy. [This] exchange [about individual versus group measurement] … basically … just stopped the process because it’s too complicated. So then, as an analyst, you’re sort of like, “I don’t know what to do, except go to a more aggregated level and measure.” Then everybody says, “But this isn’t me, and that’s not fair.” So fine, but at some point in time, somebody has got to decide how this is going to go. And I’m going to throw just one last bomb into the middle of this. A few meetings back, [commissioner] Paul [Ginsburg] said, “Why are we measuring and paying for quality?” and I’ll just ask that question. I mean, as long as this is so complicated and nobody can come to any agreement on this – and any model you pick, you’re going to have a bunch of unhappy people and a bunch of logical or analytical failure. Then maybe Paul’s point should come into the conversation and say, “What are we doing here?”…. [W]hat the hell. (pp. 273-274)

[2] Here is how MedPAC staffer Ariel Winter explained the partial-capitation payment method at the March meeting: “[T]he … approach would allow primary care practitioners in two-sided ACOs to receive an upfront, lump sum payment…. PCPs in ACOs would not receive new money for this upfront payment; instead, they would be shifting some of their own revenue from fee-for-service payments to the upfront payment.” Why, you might ask, should doctors feel happier about being swallowed by an ACO and bearing two-sided risk if they receive no increase in revenues, only a change in the chronological distribution of those revenues (more in January and less over the remaining months of the year)? Winter offered this non-explanation: “The advantage of this upfront payment is that it would give providers more flexibility to invest in infrastructure and staff for care coordination activities.” (pp. 199-200).

This “explanation” illustrates the free lunch syndrome . Winter is saying primary care doctors would now be “free” to spend money on something Medicare won’t currently pay for, for example, nurses stationed at nursing homes to reduce emergency visits, but new revenue to pay for the additional nurses would not be coming from CMS. Let’s see here, where might the extra revenue come from? Tinker Bell?

[3] Commissioner William Hall also commented on the attribution issue. “It seems to me that with MIPS … we are [telling] a group of physicians who call themselves primary care providers … ‘You are responsible for some kind of a catchment area…. And as we look at your area …, you have some problems – like maybe diabetes is not being cared for … very well, or there seems to be too much alcoholism in your community.’ And we are saying: ‘Why don’t you fix that?’ …. I think we have very muddy expectations what modern primary care should do.” (p. 238)

[4] The following conversation between Chairman Crosson and Commissioner Alice Coombs about whether hospitals could create “organized staff models,” taken from the transcript of the March 2017 meeting, illustrates one of the many dead ends the commission ran down in their search for the prototype of a physician group that would want to take on two-sided risk:

DR. CROSSON: So, Alice, … let’s just think about the organized medical staff model for a moment [Crosson was for many years an executive within Kaiser Permanente]. As you well know, … it’s kind of a group but not really a group…. Essentially, everybody is … nominally working in the same institution …. Historically, the organized medical staff has had a role … in trying to oversee and manage quality within that institution, right? Now, some are effective, and many have not been, and in fact, the enthusiasm for the value of the organized medical staff model has kind of waned over the last couple of decades. So at least one of the ways I’ve been thinking about this … is that … joining an A-APM would be an option, but then you would have the other option, which is to organize your organized medical staff to be the unit of measurement on these population-based measurements.

DR. COOMBS: So there’s an underlying assumption that you just made. … In our community [Dr. Coombs is from Massachusetts], 80 percent of docs don’t even come to the hospital. The hospital’s program has superseded … every single service. Pediatrics has an inpatient hospitalist. … [B]elieve it or not, the majority of care happens outside the hospital…. In the olden days, you’re right

DR. CROSSON: Yeah. [pp. 226-228]

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17 replies »

  1. We were disappointed in the MACRA MIPS incentive payments. But, we would be doing the quality improvement work anyway. And we use Medcurity for the Security Risk Analysis, so that’s easy to manage. Submitting the data was OK through the EHR – only a couple hiccups.

  2. It is broken, but at least they are trying to fix it.

    MACRA will be re-introduced in 2019, and will be a significant change in healthcare reform as a new model for Medicare reimbursement. The current model reimburses the provider based on volume. The new model will now require the provider to provide information on the quality of service being given, how valuable it is to the patient, and accountability that provider has to the treatment being performed. In order to measure these parts of service together, MACRA has a three part system put in place:

    PQRS, Physician Quality Reporting System
    VBM, Value Based System
    EHR, Electronic Health Record

    We wrote more on it here: http://medwave.io/2017/08/are-you-ready-for-macra, including where The Physicians Quality Reporting System (PQRS) aims at having individual and group practices that bill for Medicare under Part B, to report the quality of care they are giving their patients. Participation in reporting the data can take place in two ways.

  3. I really do hope Steve engages…it could be very illuminating.
    I especially liked your allusion to the incentives/motivations of managed care advocates: ” Is there any research on incentives that influence managed care advocates and, if not, why not?”!!!! They almost always manage to claim the high minded altruistic ground free of scrutiny!

  4. Steve,

    I wouldn’t be writing for THCB or any other blog if I didn’t think evidence-based debate was a good idea. So, yes, let’s debate, and let’s discuss facts and research. And yes, let’s carve out some bite-size topics that don’t require 40,000 words plus long reference sections.

    Of the three topics you propose, only one is sufficiently limited for a blog, and that was your last one, which reads: “Is there any concrete, good-quality evidence that financial incentives change physician behavior in ways that improve the quality of care?” My preference would be to expand that question to address cost as well as quality, and to include this additional question: Is there any research on incentives that influence managed care advocates and, if not, why not? But adding the second question would immediately make an already broad subject too big for a blog comment, so let’s forget I suggested that for now. But let’s keep in mind that your proposed question reflects a bias characteristic of virtually everyone who publicly promotes the managed care diagnosis (fee-for-service is the original sin) and managed care solutions (ACOs, “homes,” P4P, etc). That bias may be summed up as follows: Physician incentives are worth investigating; the incentives influencing managed care buffs and health policy analysts are not worth mentioning, much less investigating.

    I’d be interested in reading and responding to an article by you that reports on any “good-quality evidence” which addresses your question about physician financial incentives under one condition: That your definition of “good-quality evidence” exclude any research which (1) fails to describe the mechanism(s) which caused physician behavior to change, (2) did not control for differences in resources between the experimental and control groups, or (3) did not adequately control for differences in factors outside of physician or hospital control, including patient health.

    Managed care advocates routinely celebrate research that violates one, two, or all three of those conditions. Let me give you an example of “research” which violates all three. “Research” which finds that 70 percent of diabetics treated by ACO doctors had their kidney function checked during a performance year while “only” 65 percent of diabetics seeing non-ACO doctors had their kidneys tested violates all three criteria if the study:

    (1) failed to describe the mechanism that made doctors pay more attention to kidney tests for diabetics,
    (2) made no attempt to determine whether doctors shifted resources away from non-diabetics to patients with diabetes or otherwise invested more resources into their diabetic patients, and
    (3) made no effort or an insufficient effort to determine whether the ACO patients were healthier, enjoyed more social support in the community, or had higher incomes.

    If you don’t want to write such a paper, or can’t write such a paper, I understand. In that event, let me suggest plan B. I suggest you write essays defending the following statements, all made by you in response to something I wrote, with “good-quality evidence”:

    (1) MACRA is based on “an overwhelming body of research”;
    (2) “we absolutely can … measure quality … at the individual doc level”;
    (3) “But, again, doc quality and performance measurement, at the individual and group level, is in no way undoable/impossible”;
    (4) “But the problem I find repeatedly with your critique is that it’s so biased against the basic notions of MC, and ignores the evidence indicating that some of its functions, tools and ideas have successfully improved quality, efficiency, safety, accountability, transparency, care itself, and helped keep costs in check to varying degrees”;
    (5) “ACOs and PCMHs are not ‘managed care fantasies’….nor will APMs be. There are hundreds of experiments going on across the country that are proving these concepts.”

    These five statements are just a few of the statements I had in mind when I said you’re creating a paper trail of statements you’ll live to regret. With the possible exception of some portion of statement 4, you can’t defend any of those statements with good-quality evidence. You can repeat those five opinions six ways from Sunday, but you can’t defend them with good-quality evidence that meets my three criteria. But go ahead and try, and I’ll be the first to comment.

    Finally, if you don’t want to defend any of your five statements listed above, let me suggest plan C. Why don’t you take just one of my posts over the last year in which I discussed research (cf my dissection of a report on ACOs in “How not to research ACOs,” my criticism of New York’s heart surgery report cards for being unable to distinguish one surgeon from another, my criticism of CMS’s lousy risk-adjustment method, or my criticism of papers by McWilliams and Nyweide claiming to find that CMS’s ACO experiments reduced costs by tiny amounts) and demonstrate to our readers that I presented a false description of those papers or in some other way made a serious mistake.


  5. Kip – You’re on! With respect to a debate over the evidence. But on several conditions, given time and space constraints etc.
    (1) we keep the debate to the science, objective evidence and facts, and NOT the politics or philosophy. (We will not agree on that, for sure).
    (2) John Irvine agrees to one or more posts that would present what we both bring to the table.
    (3) We carve the debate into several parts, agreed to by both, with several core questions.

    My initial, quick framing of those Qs: “Is the clinical behavior of physicians affected by the financial incentives and forces they are subject to?”
    “Are financial incentives the best way to get physicians to change their clinical behavior in ways that improve the quality and safety of care?”
    And of course: “Is there any concrete, good-quality evidence that financial incentives change physician behavior in ways that improve the quality of care?”

    Let me know.

    Although THCB is a bit different, blog platforms are not generally a place where you have to bring evidence, references, citations etc. Few people have or take the time for that. On THCB, you cite support for some of your claims but other times you do not, just as everyone else, including me. But I do appreciate that most of the time you make a bigger effort than most to support your arguments, and present them engagingly. But, that said, we all have our biases. That’s a big part of what peer review is designed to detect in the research lit. Blogs don’t do peer review; they serve a different purpose, of course.

    So if the terms above are acceptable and John agrees, I’m happy to engage further and spend the (precious) time. It could make for a very informative and lively debate that would be of broad interest.

  6. Yet another wonderful post. Too bad no-one cares whether it works or not.

    The reason MACRA won’t go away is that the Deming-esque movement to measure the crap out of medicine is actually a religious movement. It doesn’t matter than any of this stuff doesn’t pencil- e.g. doesn’t save taxpayers money or measurably improve quality. It doesn’t matter. It is justified on first principles: FFS=Bad. Measurement and “constructive incentives”=good. Evidence be damned.

    This “movement” of which MACRA is a part is actually penance paid for medicine’s spotty quality in the face of astronomical costs. Hail Mary, Full of Grace! The fact that libertarian conservative docs in Congress voted unanimously for MACRA doesn’t mean they believe MACRA’s “habitrail for business professionals” will work. They voted for it to prove they cared about “quality”. But mostly, they voted to make the 18 year old Sword of Damocles handing over medicine’s head-another goofy idea called the Sustainable Growth Rate- to go away, and with it the perpetually looming 27% fee cut.

    They would have voted to drink vials of rattlesnake venom in the Capital Rotunda to make SGR go away. . . Watch Dr. Price carve enough exceptions into MIPS to let his people go free.

    And, as if no-one noticed, there will be massive non-compliance with either track, and docs will just to a few more procedures or tests to make up for the penalties.

  7. Thanks, Steve. I enjoy this discussion. Let me make a general observations about MedPAC, and then two quick points about your reply.

    You referred to my article as an “analysis,” which is fair. But I’d like you to notice that it contains a lot of simple reporting — this commissioner said that, that one said this, and director Mark Miller said that. My purpose in quoting the commissioners and their staff at length is to let you and other readers see for yourself how hard commissioners and staff are trying to fix MACRA and yet how fruitless their conversations about MACRA have been. I want you to know these smart commissioners actually asked the questions they asked, the staff actually said “we have no idea how to answer you,” and the chairman threw up his hands at the end and spoke incoherently or evasively. I want you to read what was actually said so you an see for yourself what a mess MACRA is and how utterly resistant to rehabilitation by smart, well-intentioned people it is. By reporting to you the statements commissioners and staff made, I make it hard for any reader to say, “Kip is exaggerating how clueless the staff and Chairman Crosson are,” or “Kip is grossly exaggerating the intractability of the obstacles facing MACRA.”

    For these reasons, I intend to keep reporting here on MedPAC’s actual deliberations on MACRA and the other managed care Rube Goldberg nostrums Congress keeps foisting on CMS.

    I have two reactions to your reply.

    First, your statement that Mark Miller “in no way said that MACRA as a whole was pointless or unworkable” is precisely what I said. I don’t know who you think you’re arguing with. Miller’s refusal to admit that MACRA is an unfixable mess is precisely the problem I’m talking about. So thank you for driving my point home for me.

    At the end of my comment I predicted MedPAC will simply sit on the sidelines and “dither,” or in Chairman Crosson’s words, watch “a dysfunctional thing unravel.” I predicted that because MedPAC will take a long time, possibly forever, to admit that BOTH MIPS and the APM programs are unfixable. Because Miller is MedPAC’s director, his refusal to concede that fact will be a primary reason for MedPAC’s indefinite dithering.

    The second point I want to make is that you are creating a longer and longer paper trail of statements about measuring physician “merit” you’re going to live to regret. I urge you to get into the habit of (a) speaking far more precisely than you do and (b), whether you’re speaking precisely or making one of your sweeping predictions of success for MACRA and “merit” measurement in general, citing evidence for your statements.

    It would be one thing if you conditioned your extravagant predictions for MACRA and measurement science in general with caveats. You don’t do that. You simply declare that accurate measurement of physicians at both the individual and group level will happen some day, some how. To make matters worse, you never cite research for your prediction that some happy day scientists will figure out how to measure physician “merit” and then MACRA will finally improve quality and lower costs.

    Let me quote an example of one of your remarks that is (a) made with great confidence and without caveats or reservations and (b) totally undocumented: “The overall intent of the law [MACRA] is sound and its thrust is consistent with an overwhelming body of research and experience ….We absolutely can–and must!–measure quality and results at the individual doc level in MIPS.” You posted that comment in reply to my comment “The mess that is MACRA.” https://thehealthcareblog.com/blog/2016/04/21/the-mess-that-is-macra/

    Paul replied to you and asked you for some of the “overwhelming research” that you claimed MACRA was based on; you didn’t reply. Let me repeat Paul’s request here: Will you ever post any portion of the “overwhelming research” that supports your utter conviction that someone some how some day will measure physician “merit” (cost and quality) accurately at both the individual and group level? Will you ever post a shred of empirical evidence (as opposed to raw opinion) that the fee-for-service system has been shown to be the cause of America’s high health care costs?

    I urge you to get in the habit of posting research supporting your sweeping statements. I concede that I sometimes make equally sweeping statements (eg., MACRA won’t work). But I back my statements up with essays about specific studies and, as in this case, numerous quotations of commissioners struggling in the MACRA tar pit. You back up your sweeping remarks with exactly nothing.

    In your reply here, you said, “In a quick glance at the comments below, they seem to be mostly grounded in an anti-government, anti-regulation philosophy.” Two can play that game. Watch: “Steve’s reply appears to be grounded in a pro-government, pro-regulation philosophy.” So there, now we’re even. What does that get us? I don’t accuse you of a “pro-government, pro-regulation philosophy” because it’s mere bloviation. We have way too much of that in health policy.

    Please start speaking more concretely and precisely, and please start citing evidence for whatever you say.

    Looking forward to further discussion with you.

  8. Paul, pj, and meltoots, thank you very much for your warm comments.

    Paul, I’m not sure Price and Trump “will put and end” to MACRA madness. Price has clearly indicated he has doubts about some aspects of MACRA, but he has not made it clear what it is about MACRA he doesn’t like. To my knowledge, Price has said nothing at all about the obvious MIPS mess, and has limited his oblique comments about MACRA to MACRA’s alternative payment model (APM) program.

    The most worrisome statement out of Price’s mouth to date is a statement he made recently to the Physician-Focused Payment Model Technical Advisory Committee. (I want to gag just repeating the title of that committee.) According to this article in BNA, Price told that committee fee-for-service is the problem https://www.bna.com/hhss-price-urges-n57982086587/ and “alternative payment” is the solution. That’s complete nonsense. Fee-for-service is not the problem, and shifting risk to doctors is not the solution. High prices and the factors driving price through the roof, including galloping oligopoly encouraged by managed care nostrums and rapidly increasing administrative costs also aggravated by managed care nostrums, are the problem.

    However, Price has also hinted he doesn’t like “one size fits all” APMs. Exactly what that means is unclear to me. To my knowledge, Price has aimed his criticism only at bundled payments, not ACOs or “medical homes” which are the APMs CMS and the rest of the illuminati are counting on to make the APM program within MACRA work. Bundled payment is the least obnoxious of the APMs CMS approved under Andy Slavitt and Obama. As long as the bundled payment “model” is the only APM Price is upset about, and as long as Price has little to say about MIPS and the fantasy that physician “merit” can be measured at the individual level, we should hold little hope that he will eventually realize MACRA is not fixable.

    I say the bundled payment model is the least obnoxious because it’s the most focused of the Big Three models — ACOs, “homes,” and bundled payment. The more Price and the critics of MACRA can move MACRA away from the super-structures that have bewitched managed care advocates for a half-century (HMOs, ACOs, “homes,” and MIPS) and toward payment methods that focus on specific diseases and services (eg., education of diabetics by patients who have diabetes), the better. But even bundled payments can be far too unfocused. For example, bundling all payments made to doctors, hospitals, and post-acute care facilities for congestive heart failure is far too expansive given how crude our risk-adjustment methods are today. Such an “alternative model” would only inflict more pain on docs and hospitals who serve a disproportionate share of the sick and the poor and possibly lead to below-the-radar denial of necessary services to sicker patients. Far better to invent a code for nurse follow-up of heart attack patients and pay for that specific service.

    My guess at this date is that Price and the GOP Doctor Caucus will be content to focus on (1) bundled payments and (2) exempting smaller clinics from MIPS for a few years. They’ll remain agnostic about the goofy ACO and “home” experiments until it becomes clear those “models” are doing nothing to lower Medicare’s costs. But what then? If you think FFS is the problem, what the hell do you do then? Invent a new name for HMO/ACO and try that?

    Finally, let’s not forget that like all good Republicans and Democrats, Price appears to be totally unconcerned about the overpayments to Medicare Advantage insurers. Medicare Advantage is just MACRA administered by the private sector.

    But we do have some reason to hope. Price is clearly more skeptical about CMS’s interpretation of MACRA than Sebelius, Burwell and Slavitt ever were.


  9. A few points Steven.
    1. Since we pay 100% of Mark Miller and Kate Goodrich’s salary, should we not be measuring their quality, with them attesting to their quality measures? And then penalizing them up to 9 % of their salary if they do not measure up? Again on measures that are completely meaningless, make no difference to outcome of their service, and actual real quality of their work? Should we make them prove practice improvement activity? Should they have to use certified IT that someone else decides what is important to click and data enter? All added to their day, distracting them from their real work?
    2. MACRA is a 2400 page abomination that does NOTHING but add complexity to the daily lives of MDs trying to care for you. It does NOTHING to improve that care, only burden them more with self reporting and gaming the system to achieve bonus versus penalty. The numbers are meaningless and you cannot attribute “value” to any individual MD. So penalize us for what? Not playing games with our patients/gov regs?
    3. If you want to pay me to stay home and click boxes all day and that is value, then great. But if you want me to take call, come in from home on a Sat night to fix your open tibia fracture, then pay me for my work. If you cannot accurately attribute my “value” by your elementary quality metrics, then DO NOT PENALIZE me anything for doing actual work. Remember, for me to disrupt my life for your Medicare payment for fixing that tibia and 90 days of care after is about $1000. Trying getting a plumber to come to your house of a Saturday night for less. Yep, thats it. So the US gov gets a pretty good deal. So stop pestering MDs about our “value” because tax payers pay for some of this. Fraud is unacceptable but it would be MARKEDLY cheaper to just let MDs be MDs and let us do our jobs without all this interference. If you drive me out, it takes 14 years and 18 years of experience after to make a new me. Thats 32 years. So its pretty important to listen to us. If we say you are burning us out, driving us out of practice, take that VERY seriously. The price could go WAAAAAAAY up if I decide NOT to accept Medicare as I do now as ONLY a civic duty. But if MEDPAC and CMS want to torture me more, I won’t take it. And then I get to charge what I want. Period. You may have NO choice as their we are the last and ONLY group left doing ortho at our hospital. We could EASILY stop taking all insurance and Medicare. Always put that in your equation. If we say MACRA is unworkable. Then change it. Period.

  10. Thanks Kip for this dig into the MedPAC transcripts and analysis.
    I attended a 3 hour Health Affairs briefing in DC yesterday (April 18) on the “future of value based payment.” There was much discussion of MACRA. MedPAC executive director Mark Miller was on one panel, along with Kate Goodrich, the CMS official overseeing MACRA.
    Your thorough analysis of the two MedPAC meetings don’t exactly jibe with Miller’s comments yesterday…though it’s possible Miller was was being more diplomatic in this more-public venue (at the press club in DC).
    Although Miller expressed concern about the complexity of the law, and thus the regs, and the inherent difficulties of implementation, he in no way said that MACRA as a whole was pointless or unworkable. He acknowledged, as Kip’s piece does, that the issues surrounding doc Q&P measurement were very tough and have been with us for years. He said MedPAC discussions have not as yet reached any formal recommendations.
    In a quick glance at the comments below, they seem to be mostly grounded in an anti-government, anti-regulation philosophy.
    As I have said many times on THCB, that gets us no-where folks…because in our system the government pays half the health care bill (with tax $$) and thus has a fiduciary duty to taxpayers and the nation to spend the money wisely That means oversight, regulations, etc. No escaping them!
    The challenge is to achieve that Goldilocks and the Three Bears balance…not too much, not too little, but just right.
    No one who has made a close study of MACRA or put it in context, in my view, could plausibly argue that MACRA is “too much” since it (1) does not kill FFS outright and (2) goes up to only 9% of Medicare payment and (3) has many outs, caveats and lotta flexibility.
    It’s another discussion, of course, how we evolve Q&P measurement in the next few years. Therein does lie pitfalls and rabbit holes…and Kip, you have raised many good points on that. But, again, doc quality and performance measurement, at the individual and group level, is in no way undoable/impossible. It’s just quote hard.

  11. “Just observing a basic fact.”

    No you aren’t. You are conflating different data with different problems and basing your conclusion on this warped attempt at statistics. That is not how things are done.

    To make things worse you then try and explain yourself saying social problems exist in other countries, but you don’t have any data and are just guessing. That is a problem as well.

    Finally, you try to confuse the issue blaming physicians for the opioid epidemic which is probably partly true but has little to do with your argument for centralized care. Bad science.

  12. Just observing a basic fact. Less central government involvement correlates with higher costs and poorer outcomes in some areas, like the cited Maternal stat. Some of that is undoubtedly due to social issues, but then those countries with lower rates also have their own social issues. Perhaps they do have a lower rate of social issues, but then maybe that is due to more govt involvement. Also, I hope you don’t think that the medical industry had nothing to do with the opioid epidemic in particular. (According to my OB fellow, the increasing rates have a multifactorial cause. Chronic diseases, obesity and heart disease are major factors.)

    “In 2007, Purdue Pharma and three of its top executives pleaded guilty to criminal charges that they had misled the F.D.A., clinicians, and patients about the risks of OxyContin addiction and abuse by aggressively marketing the drug to providers and patients as a safe alternative to short-acting narcotics. (Doctors had been taught that because OxyContin was time-released, it wouldn’t cause a high that would lead to addiction.)”



  13. I guess you believe that drug addiction and other social problems aren’t a cause of high Maternal Mortality Rates in the US. Your response seems to exclude a lot of variables which isn’t good to do when one is thinking in terms of policies.

  14. “It is ‘highly unlikely’ that our nation’s healthcare reform, especially the cost and quality of healthcare, will be solved with a centralized, nationally applied strategy based on universal health insurance and an integrated EHR.”

    Yet all of those other countries with better Maternal Mortality Ratios and first world medicine have more centralized care, and some even have an integrated EHR of sorts (France). Plus, they all cost much less. You should offer a rationale for why it is highly unlikely when it has worked everywhere else. And, while correlation is not causation, when the correlation is 100%, it certainly leans that way.


  15. Kip, your posts are like a warm blanket on a cold day. Love them. Wash DC really has to pause and think, are we capable of solving all this with big hyper-regulatory national policies. Further to penalize MDs for dysfunctional, obviously failing programs should frankly be illegal. MEDPAC and CMS and ONC and legislators really need to stop listening to “sounds good” but not proven models. This all started with arrogant, non-experienced folks at ONC that pushed for HITECH and MU and PQRS. They have had years of data, and cannot make heads or tails of it. Does forcing MDs to report numerators and denominators and attesting to whether they measured “did a patient send me a secure message” do anything to reduce cost, improve care/outcome and reduce burden on MD? Laughable no. Forced IT regulations do not improve EHRs, cost, outcome, care, or reduce burden.
    What should they really do? Its ok to give a bonus to groups willing to adequately and fairly test APMs. But do NOT penalize others because they are not doing it. Further, be willing to roll BACK regulatory complexity, not add more to it. Stop All EHR Cert. requirements. Allow groups to make custom EHRs to make them more efficient, usable , safe, secure and less burdensome, without having to fulfill all the centralized DC distractions. Remove ALL MD self reporting quality measures from any payment scheme. This will immediately save money, reduce burden and probably improve care as we can actually think about what the patient really needs for care. Ultimately, CMS should let MDs be MDs. Every time they say, “well then have MD just document this” or that, the person at CMS should be fined. Say it more than once, fire them. If I want home health care for my patient, let me order it without all the hassles. I know they need it. If I need an MRI on a knee for one of my patients or I think someone needs a total hip , let me order it without a single hassle or a clawback a year later because someone did not find that they did not get 6 weeks of ineffective therapy in some note. Give me some props for being a licensed, Board certified, 18 years of clinical experience MD. Maybe that should be a “virtual group”. The “We left them alone” group and compare OUR outcomes, costs, utilization, readmits, etc to the MEDPAC bright ideas.

  16. Thank you Kip Sullivan for this detailed view of this nonsense. The proper response to these “experts” is ridicule and derision….but I am afraid they are immune to being embarrassed. Do you think Dr. Price and Trump put an end to this?

  17. Kip,
    Thank-you for the persistence you have applied to this evolving THEME. As a corollary, the National Health Service in the United Kingdom abandoned a similar plan to use a claims process for quality improvement 25 years ago. AND, the National Health Service adopted a policy 4 years ago to abandon its centralized EHR. There is no substantial evidence that the over-all theme of our nation’s healthcare reform will improve much of anything.
    The cost of our nation’s healthcare is now hovering at 18.3% of the national economy according to the Altarum Institute that produces high-quality reports every three months. Recall that our nation’s Maternal Morality Ratio ranks 42nd worst out of the 51 world-wide nation’s that were rated by the United Nations as having a “very high” Human Development Index for 2015. Also, our nation is the only nation with a worsening maternal mortality ratio for 25 years. See Wikipedia “Developed country” AND World Health Organization for “Trends in Maternal Mortality: 1990 to 2015.” We would need to decrease our maternal mortality ration by 70% to rank among the best 10 nations. (i.e., achieve @400 fewer deaths related to a pregnancy a year)
    It is ‘highly unlikely’ that our nation’s healthcare reform, especially the cost and quality of healthcare, will be solved with a centralized, nationally applied strategy based on universal health insurance and an integrated EHR. Also, it is also ‘very unlikely’ that the social determinants of HEALTH requiring intervention could be solved any reform strategy from within the healthcare industry itself. I continue to believe that the only means to do this will require a nationally promoted and sanctioned, but locally instigated and funded collective impact strategy to augment the “Social Capital” asset of each community. The improved level of “Social Capital” will be necessary for the success of any collection trust project to improve the resiliency of the Common Good that is offered to each of its citizens. The is the basic model for the Cooperative Extension Service for agriculture (since 1914) and the successful effort to reduce homelessness beginning 10 years ago (“housing first’). A Community HEALTH FORUM should be locally sponsored, nationally sanctioned, and regionally advised to ‘annually revise’ a Community HEALTH Plan to:
    1) Evaluate the EQUITABLE AVAILABILITY of Primary Healthcare throughout their community including a plan for the involvement of local institutions to mitigate these deficiencies; [COMMENT: Mapping with use of population served by each PCP clinic and its level of over-lap with surrounding PCP Clinics would be useful.]
    2) Evaluate the prevalence and prominence of the community’s social determinants of HEALTH having a prominent impact on its citizens including a plan for the involvement of local institutions to initiate a specific collective impact plan for their mitigation [COMMENT: The themes of early childhood education, extended family traditions, adolescent health, homelessness, inner city employment training and nutrition, chemical dependency and homicide/suicide would be prevalent.]
    3) Document the status of the community’s Disaster Management Plan and the local process for maintaining its readiness and revision including its connection with the similar effort at the State and Federal levels of government [ COMMENT: Generally, most disasters that occur locally every 50-70 years are knowable. The timing and details of destruction may not be predictable. But the planning process should include the capacity to know in advance, the means to instigate measures in a timely manner for the mitigation of health related effects beforehand and during the recovery process. The occurrence of this planning and revision process then serves as the basis for the disasters that are not knowable. Also, there should be an acknowledgement for resource poor disasters, such as an influenza pandemic. ]
    A Community HEALTH Forum should be formed for @ 400,000 citizens or @ 800 nationally. See https://nationalhealthusa.net/communityhealthforum/