MedPAC Sinks Deeper Into the MACRA Tar Pit

The Medicare Payment Advisory Commission (MedPAC) has done it again. At their October 4, 2017 meeting they agreed to repeal the Merit-based Incentive Payment System (MIPS), an insanely complex and evidence-free pay-for-performance scheme within the larger program known as MACRA. Instead of examining how they made such a serious mistake in the first place (MedPAC has long supported turning fee-for-service Medicare into a giant pay-for-performance scheme), they repeated their original mistake –- they adopted yet another vague, complex, evidence-free proposal to replace MIPS.

MedPAC’s history gives us every reason to believe that when they discuss their “repeal and replace MIPS” proposal at their December 2017 and January 2018 meetings, they will refuse to discuss their “replace” proposal in any detail; they will not ask for evidence indicating their proposal is safe and effective; and in their March 2018 report to Congress they will foist upon CMS the dirty work of figuring out how to make their lead balloon fly. CMS will dutifully write up a gazillion pages of gibberish describing how the new program is supposed to work, it won’t work, MedPAC will return to the scene of the crime years later and, pretending they had no part in creating it, propose yet another evidence-free tweak. And so on.

MedPAC is caught in a trap of their own making. They endorse health policy fads without any evidence and without thinking through the details; then when the fads don’t work, rather than review their defective thought process, they endorse other iterations of the fads, again without evidence and without thinking through the details. The tweaked version of the fad fails, and MedPAC starts the cycle all over again. Two analogies for this trap or vicious cycle occur to me. One is the tar pit where mastodons got stuck and died; struggle only caused the dimwitted creatures to sink faster. The other is the hedge fund that gradually becomes a Ponzi scheme. Investors like Bernie Madoff make bad investments, and when the investments go south, instead of admitting their mistakes, they induce their investors to throw good money after bad.

In this comment I will explain why MedPAC’s MIPS-repeal-and-replace scheme deserves ridicule. In my next comment I will describe the process by which MedPAC built the MACRA tar pit or, if you like, the intellectual Ponzi scheme, that now traps them.

Excellent diagnosis

The October 4 meeting opened with a statement by MedPAC staffer David Glass about why MIPS was bound to fail. The staff’s most fundamental objection to MIPS is that it’s not possible to measure accurately the “merit” or “total performance” (to use MACRA’s goofball language) of individual doctors. They cited several reasons for this, including: Small sample size; the freedom CMS gives to doctors to select their own “quality” measures from a list of “around 300” (page 5 of the transcript of the meeting ), which guarantees apples are not being compared to apples; and the poor correlation between most of these “quality” measures and, um, quality.

Oddly, Glass’s otherwise thorough critique of MIPS failed to mention the attribution problem. In order to measure physician “value” or “merit,” one must first decide which patients “belong” to which doctor. The MACRA statute instructs CMS to follow a bizarre attribution scheme based on whether the doctor was the “lead” doctor or a “supportive” doctor, and whether the condition was acute or long-term (see my discussion of this section of MACRA here). Understandably, CMS totally ignored these instructions and adopted a slightly less bizarre method of attribution: Medicare beneficiaries are attributed to doctors based on the plurality of primary-care services provided. This plurality method guarantees that doctors are rewarded and punished for patients they never see or, in the case of patients they do see, for treatment decisions made by other doctors. The attribution problem by itself guaranteed MIPS would be difficult to administer and that MIPS scores would be useless or at best difficult to interpret.

Despite overlooking the attribution problem, MedPAC’s staff reached the right conclusion: MIPS’ grading system is useless, both to physicians and to patients. As Glass put it, “[I]t is extremely unlikely that clinicians will understand their score, or what they need to do to improve it” (p. 7). The staff noted in addition how costly MIPS is to physicians. “CMS estimates that the clinician cost to comply with MIPS in the first year of the program is over $1 billion,” reported Glass (p. 6). Glass offered no information what it costs CMS to administer MIPS.

Evidence-free cure

This would have been an ideal time for the staff and commissioners to stop, take a deep breath and ask, “How the hell did we fool ourselves into recommending a whacky pay-for-performance scheme to Congress, and why did it take us two-and-a-half years after MACRA was enacted to admit MIPS can’t work?” Or even: “How could we have done a better job of warning Congress not to pass such a useless bill?” That, of course, is not what happened. There would be no looking back to learn from history.

When Glass was done explaining why MIPS was a disaster in need of repeal, his colleague Kate Bloniarz presented two vague entities that might replace MIPS. Bloniarz and the other staff did not refer to these options as ACOs (they called them “groups”), but I will because they walk and quack like ACOs. The two options were: “Virtual” ACOs that doctors (with gobs of free time on their hands) will start up and “voluntarily” join; and geography-based ACOs that CMS will force upon all the retrograde physicians who refuse to move into “virtual” or existing Medicare ACOs (or other MACRA “alternative payment models”). The only information Bloniarz offered about these entities was that they had to be “sufficiently large to have statistically detectable performance on population-based measures” (p. 12) such as use of “low-value” services, “healthy days at home,” and the ever-popular “potentially preventable admissions” and a cost measure (“relative resource use”), all poorly adjusted for factors outside provider control. Doctors will, allegedly, be inclined to join some flavor of ACO –- virtual, geographic, or existing –- and be rewarded and punished for “performance” on “population measures” because, according to the staff’s proposal, if they don’t they will lose 2 percent of their Medicare FFS payments.

The one feature of Bloniarz’s vague proposal worth praising was the removal of the expensive MIPS reporting requirements. Bloniarz proposed that CMS calculate grades on the “population measures” using claims data only, that is, data doctors are already reporting.

If you were a commissioner and you had been exposed to Bloniarz’s annoyingly vague MIPS replacement proposal, what questions would have occurred to you? You’d want to know, among other things:

  • What the staff meant by “sufficiently large;”
  • how Medicare beneficiaries would be assigned to the new ACOs;
  • whether it’s possible for CMS to risk-adjust accurately the quality and cost scores and, if not, whether ACOs would avoid inviting doctors with sicker and poorer patients to join them;
  • whether ACOs of any stripe (existing, virtual, or geographically defined) will be available to all doctors;
  • whether doctors in any ACOs, but especially the “virtual” and geographically-based types, would have any way of influencing each other or knowing why their group was being punished or rewarded; and
  • whether ACOs anywhere are making enough money to at least offset the expenses of starting and running an ACO so that doctors would have some incentive to join.

With the exception of the attribution question, the commissioners as a group did a good job of posing every important question a rational person would think to ask. (Sloppy attribution is an obstacle to accurate measurement of physician “merit” at both the individual physician level and the ACO or group level.) But, sad to say, not one of those questions was answered by the staff or Chairman Crosson. The staff and Crosson either remained silent, or offered non-answers. To impress upon you how poorly prepared the staff was to defend their vague, Rube Goldberg proposal, I’ll use the rest of this comment to illustrate the non-productive, one-sided conversation between commissioners and staff.

Ask and you shall not receive

The commissioners who spoke first focused on whether it is reasonable to expect that ACOs in any of the three flavors will be available for all doctors to join. The importance of this question is obvious: If doctors are going to be robbed of 2 percent of their Medicare payments for not joining an ACO, they should at least have the opportunity to join one. These commissioners noted that the problem of ACO accessibility is two-fold: ACOs are not available everywhere, and many existing ACOs will want to avoid clinics and hospitals that serve poorer, sicker and more expensive people, such as clinics in rural areas and doctors who specialize in treatment of addiction. All the staff could say was that CMS might be able to create a “fall back option” for clinics and hospitals in rural or poor areas. (Note the staff did not say, “Excellent question, WE will figure out a good answer and not ask CMS to do the dirty work we refuse to do.”)

Commissioner Kathy Buto asked about “isolated providers” who might find it difficult to form groups large enough to create pools of patients large enough for statistical accuracy and, if in the event that large numbers of isolated providers could be herded into one ACO, whether they would feel they had any input into or control over the ACO’s decisions (pp. 18-19). All Glass could say is those problems afflict all ACOs. Commissioner Dana Gelb Safran asked, “[A]re we creating a kind of mini-version of the problem we had with the SGR where individuals really aren’t accountable to each other, even though they are grouped together…?” (p. 58) No one answered her.

Commissioner David Nerenz asked how big an ACO’s pool of attributed patients would have to be to make “population measures” accurate (by MedPAC’s low standards, I would have added). Bloniarz answered 1,000 to 10,000 depending on the “measure.” When Nerenz asked how it would be possible to apply a common set of measures to all ACOs if some didn’t have big enough patient pools for all measures, Bloniarz had no answer. When Nerenz rephrased his question to ask how many doctors an ACO would have to have, Glass replied, “It’s hard to say.”(pp. 20-22) When Nerenz asked how the staff proposed to weight the half-dozen “quality” measures and the cost measure prior to deriving an arbitrary “composite” score, Bloniarz excused the staff’s inability to answer on the ground that their proposal is “a bit exploratory.”

When Commissioner Pat Wang asked the only question any commissioner raised about attribution, staff dodged again. Wang asked if attribution would be prospective (meaning ACOs know in advance which patients are “theirs”) or retrospective (ACOs don’t find out till the end of the performance year who “their” patients were). Bloniarz replied, “I don’t think we have weighed in on [that issue].” “I don’t think we had a reaction to that,” added Director Mark Miller helpfully. (pp. 24-25)

When Commissioner David Grabowski asked what would happen to providers who take care of a disproportionate number of dual eligibles, Bloniarz replied, “I don’t think we have a great answer for that,” and then added wistfully, “[T]here would be risk adjustment,” as if CMS’s grossly inaccurate risk-adjustment method would solve the problem. (p. 29) Grabowski seemed dissatisfied. “If you don’t get the risk adjustment right …, you’re going to magnify disparities,” he replied. “You’re going to widen that gulf between the haves and the have nots.” (p. 31) Staff had no further comment.

Nerenz also warned that inaccurate risk adjustment put the poor and the sick at risk. He urged the commission to adopt criteria for the “quality” and cost measures that would guarantee they can measure quality and cost accurately. Nerenz quoted an article from BMJ that found that failure to adjust readmission rates for socio-economic factors punished hospitals in poorer regions. He warned that if the staff’s proposal was “rolled out” today it would “exacerbate socio-economic disparities.” (p. 72) Nerenz also cited a paper that found that quality of care is better in small clinics than in large networks, and yet the staff’s proposal will encourage further consolidation of the medical sector into large groups. The only reply Nerenz got was a “thank you for that” from Crosson and an “amen” from Commissioner Coombs.

Commissioners Safran and Craig Sammitt asked how the virtual and geographic ACOs would differ from existing ACOs. Neither Crosson nor staff answered.

Summarizing the unintelligible

At the end of the MIPS segment of the October 4 meeting, Chairman Crosson attempted to summarize the unproductive conversation that he and his staff had forced upon the commissioners. He began by saying “I’m going to try to summarize where I think we are. (p. 83) ….We have very close to consensus that MIPS should be repealed.” After that, his ability to construct complete, meaningful sentences deteriorated rapidly. I quote him at length so you can see for yourself what I mean: “I think we have consensus that it would be good to advance population health as the basis for accountability. [84] …. Where we had a difference was like how to do that –- well, I guess, whether we can do that at all with a replacement which would be the – – well, let’s just replace MIPS –- I mean let’s just eliminate MIPS and leave nothing with respect to measuring accountability for cost and quality in that practice environment. I think my notion was that we could take that direction, but we ought to try, before we do that, to think through whether or not there are some ideas that we could put forward which would — I guess I ‘m not sure I like the term ‘replacement of MIPS’ but to substitute something ….” (p. 85)

Will the other 16 commissioners insist on answers to their questions before they authorize the staff to write up some vacuous version of the staff’s MIPS replacement proposal and send it over to Congress? Don’t bet on it. The commission has caved into their staff and chairman repeatedly throughout its history. The commissioners are capable of asking obvious questions about the half-baked proposals their staff and chairman cook up, but they have never shown an ability to force the chairman and staff either to clarify a proposal and cite evidence for it, or to throw it away.

In my next comment I will explore the history of this habitual failure. I will focus on the commission’s endorsement of pay-for-performance in 2003 and how that endorsement led the commission into the MACRA tar pit.

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13 replies »

  1. “It’s also pretty clear that the fee for service payment model provides incentives to provide too much care”

    Clear to whom? That’s a slogan, it’s not data.

  2. please excuse me Cataract costs were4 6,000 which I did pay out of pocket vs $17,000 which I declined, at a hospital( every one I called)

  3. I AM a primary care physician who runs her own office and I understand much of this from many angles. A few things: 1 the blog criticizes MedPAC in blow by blow detail- but hows about a suggestion See no one has any that CMS and Congress and the insurers will play with,so we have endless blog posts on what everyone else is doing wrong.Really frustrating to those of us out here on the ground.I am a patient also – $6.000 for bilateral cataract surgery at the free standing center would have been $7,000 at the hospital!1 Site neutral would not be enough
    2 Physician leadership? Please. When we propose things we are told we proposed something not simple and elegant- it was crude;we told we do not know about risk adjustment -everybody wants me to take insurance risk now- adays.But speak up? One exposes oneself to the pushback of being labelled a whiner.
    3 Now lets do some math I have If you look at the longer training of say a specialized surgeon, remember that person was being paid in those yrs. Ok so was the primary care doc who finished after 3 yrs of residency. PCPs made more while the surgeon was in training. Then wham when the surgeons graduated they make so much more immediately that within a few yrs they are caught up. But we pay them millions more over their careers, paying them 3-5 times what a PCP can ever make and for 20-30 yrs. Ok ,now they do take call .They take no more risk than I. I run the risk of misdiagnosis and miscommunication that leads to law suits and need cognitive skills that are exhaustively complex. But call is onerous. I take calls as a PCP but admittedly only have to talk or go to a computer not go in. If you sit down and do that math to give call a value, you get that specialists should be paid 50,000 a year more than PCPs to equalize pay. And that is what is done in other countries. I know PCPs making 70,000 or 100,000 yet funny how their med school cost the same as the dermatologists- who go home earlier and are never called on the weekends.Speak about this? Not PC.
    The cost of the Ct scan the meds etc are certainly partly driven by docs but lets get real. Sometimes I need a CT. It is not my fault it costs too much As to price transparency?Patients make decisions emotionally and by what the neighbor had and so on and in rural areas why save 100.00 if you have to drive 2 hrs when you are already having trouble seeing and hearing. I live all the parts of this hence lots of emotion here. PCPs need to be paid more and SIMPLY. Which of you fills out a complex form for every 1 5 min of work then gets paid part of that depending on the mailing address for that particular 15min,eh? SIMPLE is what we will not do in this country Once a professor at U Mass explained why the Australian system works so well “because of Australians”
    I have little hope that we w can soon do anything sensible this country Lobbyists rule and Cms made me return a humiliating 32.00 becasue it couldn’t understand its own rules. On the ground PCPs should be heard, but noone ever is willing to put into action what we suggest
    I have no hope

  4. The reason we have the highest health care prices in the world is not mysterious.

    There are only two ways to bring down prices that work: competition and monopsony purchasing (a single or a few large purchasers). We have neither of these in health care: Large hospital systems are monopolistic and have market power (ability to affect prices.) Physician groups are trying to do this. Unions exert market power. Large governments, federal and state, refuse to exert large purchasing on pharma because they needed manufacturers to support the PPACA, etc. The same holds for government purchasing from any large political constituency. Our government won’t do it. Other governments in the world will do it. That’s why we order drugs from Canada.

    Price controls are only useful in temporary circumstances. They cause surpluses and shortages–take your pick; and, if in place for a long time, they cause the appearance of unfairness which becomes politically difficult. If you try to allocate resources by price controls you simply cannot go it properly because you will never get ALL the information necessary.

    Besides, no one wants low prices. Why would an insurer want less money to pass through it?…to grow smaller?….or a hospital system…? or a physician group? Who cares what anyone charges? The big rich insurance company is going to pay the bill and we don’t need worry about the details.

    The pitiful self-pay soul without insurance is too small a voice to hear.

    Third-party payer is the elephant in the room. It is the culprit. We either have to get rid of this–which is almost impossible–or we have to blunt its effects by causing the patient to feel as if he is paying at least part of the charge. Co-payments, deductibles, un-used health savings accounts that pass forward to the next year or to the estate, unspent vouchers that can be redeemed for money…..whatever.

  5. You would think they would be just as critical given the obvious path to failure. I think they planned on many additional revenue streams based on the chaos. They love to give lectures on professionalism and then completely roll over and get their bellies scratched over some ridiculous scheme that is going to harm the profession and patients. The only thing they came out tooth and claw over was ICD10. The reason was: it is the path to a DRG like system as suggested elsewhere on this post. That would impact specialists since it is the Primary Care physician taking care of the most diagnoses in the most efficient way. Can’t have PCPs getting ahead under the AMAs watch. Most of this MIPS nonsense lands in the PC department, so most medical societies could care less. Visit the AAFP website. Not a word about this disaster.

  6. Res Morgan M.D. – First, I absolutely agree with you about site neutral payment whether the physician works for a hospital or not and whether the imaging center, PT center, etc. is owned by a hospital or not. I’m not sure how one would reconcile the elimination of facility fees with site neutral payment though. Perhaps, hospitals would need to receive at least some of their operating funds from general tax revenue which is the way it works in Switzerland.

    I don’t support price controls on drugs but I do think payers should be more willing to just refuse to cover certain drugs that are deemed too expensive relative to the benefit they provide. This especially applies to ultra-expensive cancer drugs that may provide only marginal benefit in terms of extended life, often at low quality. Wealthy people, of course, are free to self-pay if they choose to.

    For EMR’s, what I would like to see is a central database into which I can complete a standardize set of forms that include my personal information including name, age, sex, health insurance carrier, surgical history, allergies, if any, pre-existing conditions and the like. Every time I go to a new provider, including a PT center, I have to fills out pages of forms asking the same questions over and over. It’s annoying. It would also be nice if hospitals could access prior surgical reports, imaging studies, etc. anytime and anywhere including on weekends or in the middle of the night if necessary. Personally, I keep as much of my own history as I can on my iPhone.

    I would also like to better understand how much it really costs to run a hospital assuming a decent occupancy rate and lean and efficient management. I’ve never seen a study comparing the number of employees per licensed or occupied inpatient bed for U.S. hospitals with hospitals in other developed countries.

    In fairness to hospitals, though, I recognize that there are significant differences among hospitals in payer mix – commercial insurance, Medicare, Medicaid, VA, and no insurance at all (uninsured). Case mix can vary as well but probably less so.

    Finally, I think primary care doctors should be paid more than they are now. However, I think specialists, especially surgeons, should make significantly more due to the extra years of training required. If they have to pay their own much higher malpractice insurance premium than a primary care doctor or psychiatrist, they need to have that extra cost built into their in their fees as well.

  7. “So what’s the answer to the cost conundrum?”

    For starters:

    No facility fees;
    Pay procedures and E&M does at the same rate, whether the physician is owned by hospital or in private practice;
    Price controls on pharma and DME of severity equal to those on physicians;
    No requirements on how to use or to use EMRs;
    Kill JC;
    25% penalty on all hospitals with fountain and/or grand piano in lobby.

    Not the complete solution, but a good way to begin.

    “their decisions to order tests, prescribe drugs, admit patients to the hospital, consult with patients and perform procedures themselves drive virtually all healthcare spending”

    Sp follow the advice of Willy Sutton: reduce how much we pay for tests, drugs, hospital beds. etc.

    Don’t nickel and dime me to death for dealing with patients with 28 problems and 30 drugs in 12 minutes. I’m not the problem, and, yes, all I want is to be left alone to take care of patients.

  8. It seems pretty clear that defining and measuring quality in healthcare has long been an enormous challenge and remains one. We also don’t want to create disincentives for doctors to be willing to care for the highest risk, most complex patients. It’s also pretty clear that the fee for service payment model provides incentives to provide too much care and HMO’s provide incentives to provide too little care. We also have too much defensive medicine because our society is inherently more litigious than others.

    At the same time, healthcare costs rose from around 5% of GDP in 1960 to between 17% and 18% of GDP today partly because of huge advances in what modern medicine can do for us patients and partly because of high prices, especially for drugs, devices and, to some extent, imaging. Moreover, most patients can’t afford to pay for the expensive procedures without health insurance. Balance billing, if we had it, would be an additional cost burden that wouldn’t count toward insurance deductibles and OOP limits. That would be a big problem for most people as well.

    At the end of the day, what I want as a patient is good care, from both primary care doctors and specialists at a cost that won’t bankrupt me or the country. What those of us who invest in healthcare and health insurance companies want is for them to be sufficiently profitable to produce an adequate risk-adjusted return on our capital relative to other investment alternatives, again without bankrupting the country.

    So what’s the answer to the cost conundrum? My own preferences include price transparency to allow both patients and referring doctors to identify the most cost-effective, good quality providers in real time, comprehensive tort reform to reduce defensive medicine, more use of data analytics to go after fraud, especially in the Medicare and Medicaid programs, and a lot less futile care and the end of life much of which patients don’t even want.

    While doctors claim that they only account for 10% of healthcare costs after deducting practice expenses, their decisions to order tests, prescribe drugs, admit patients to the hospital, consult with patients and perform procedures themselves drive virtually all healthcare spending.

    The docs are in a position to have the best ideas to bring healthcare costs under control relative to GDP but their preference is to be left alone to take care of patients. As Steve2 noted in a recent blog post, nobody cared about healthcare costs when they were 5% of GDP. At 18%, we have to care. Where’s the physician leadership on this issue?

  9. And the most sickening part is that our old-school medical societies (without exception, as far as I know) enthusiastically support this. We know that they can’t all be this stupid – the level of corruption is mind-boggling.

  10. I don’t think it is possible to assess quality in an efficient, facile way.

    One early idea I had was to try to look at the shape of the health expenditure curves with relationship to the ICD-10 diagnosis. This would be easy, I think. E.g. a new case of rheumatoid arthritis, if it is managed efficiently and well, would probably have a sudden rise in the expenditure curve owing to diagnostic lab and radiology expenses, then to be followed by a few months wherein the trial of disease-modifying drugs and pain drugs and physical therapy expenses would occur, then to be followed by a tapering of the expenditures toward a base-line maintenance level of expenses owing to follow up visits, platelet and WBC counts, sed rates, etc. The expense curve would thereby have a typical shape, and all this data would be easily obtained as long as over-the-counter expenses were ignored. With cases that were not efficiently managed or had physiological complications, this expense curve would probably look quite different.

    Contrariwise, you don’t want to see in a terminal pancreatic cancer patient cost curve that zooms up to a very high level on the day before he passes away. This is would tend to show exorbitant hope for recovery when no such expectations are reasonable.

    All efficiently managed disorders would probably have characteristic cost curves for each diagnosis, which could be generated without any physician or hospital energy because these data are already routinely obtained.

    To collect and generate these curves, one would have to figure out some way to collect thousands of patient records and judge which ones were treated properly and efficiently and then look at the cost curves of each set of patients and try to get agreements as to which ones were typical of quality vs shabby care. Admittedly, there is going to be subjectivity here at first.

    And one could say, therefore, that physicians and hospitals and other providers associated with these patients who had these efficient cost curves, were quality physicians, etc. One could attach these patient curves to the doctors involved and say that if a physician ordered more than 15% of these costs, he was a good doctor….blah blah.

    But, alas, I don’t think even this simple, easy-to-do way to assess quality would work. Take three patients who all have exactly the same disease in the same stage. Let them all visit the same physician and receive the same workup and interventions. We all know from experience that one of these patients is going to do well, one is going to do poorly, and the other is going to respond so-so.[I admit this is grossly simplified] There are simply too many other bits of information that one has to discover–like the intelligence and motivation and baseline health of the patients–to assess quality amongst providers. And, all this other info takes a lot of energy and money to collect and is probably never going to be worth the benefit of being able to label docs or hospitals as ‘good’ or ‘bad’.

  11. Kip, can we be BFFs? You have a knack for putting into words exactly my feelings about all this mess of buzzword care and puffery language to assuage the politicos to feel that they are getting “Value” for their healthcare dollar. CMS and ONC and MEDPAC and all the others have made such a mess, it truly should be flushed. Attribution, There is no possible way to attribute costs to my part of the care for a fractured hip, when the patient has kidney disease, heart disease, GI problems, diabetes, etc. What part of the readmission within 90 days is “my” fault if I fixed the hip perfectly, but the patient suffered a hypoglycemic episode at 67 days? And how many click boxes, data entry points do I need to do? Do you really think that my reporting of preop antibiotics is anything but 100%? It always is. Yet somehow, MACRA MIPS values this, yet I have to report it ? Stupid. And its self reporting…no chance for inflation of “Value” by admins, right? All this counting of numerators and denominators and attesting has led to what, exactly? Nothing but burned out MDs that are distracted from real care. Worse, it drive MANY away from caring for the more fragile. less healthy, socially isolated, etc as it will make MY NUMBERS look worse if they have complications or higher resource use, like they are admitted to a skilled facility after a total hip, as they have no one to care for them at home, and they are anxious about going home. Is that my fault? Some articles in this blog has shown that public reporting of these “values” “Complications” etc are definitely driving MDs from caring for those that will ruin my numbers, even with 1 or 2 complicated patients. Think bundled care here. Why would I EVER operate on anyone that could kill my bundle and cost me money, punish me, report nasty numbers on me. Its just the nature of the beast. You punish me for caring for complicated patients both health and social, forget getting any kind of care. Thats EXACTLY what ACOs and BUNDLES do. MIPS MACRA are just the main stage of that mess. I found it extremely disheartening that MEDPAC is grasping at ANY buzzword straw to get themselves out of the MIPS MACRA mess and they initial thought was to just PUNISH providers for FFS no matter what, as FFS is obviously the devil to MEDPAC, so they are dying for a new set of abbreviations, mantras that can be the solution to the scourge that is FFS. What a nightmare, and they are in charge. They should be forced to read your blog. I love your work Kip, please keep it coming.

  12. Ah yes, “attrition” was always the problem with MIPS, as pointed out long ago by Kip. The long-term issue for “quality” in the healthcare industry is its governance. If we agree that it should be community driven, how would a national source for its governance by constituted. Arguably, it seems that the Med-PAC leadership process has failed the quality and cost problems of our nation’s healthcare. Most importantly, its ‘true believers’ have no long-term, evolving strategy to improve the “capitalization” of Primary Healthcare. There is an underlying paralysis within Medicare from its devotion to an actuarial basis for the funding of Primary Healthcare. In reality, it should be considered a pre-paid expense. Whatever the technical basis of the payment processes, any centralized institution connected with the reimbursement of healthcare and its associated quality will need a new level of governance. Med-PAC should be considered a relic of the past. The Federal Reserve is a good model as a semi-autonomous, Federally Chartered institution to manage our nation’s monetary policy. It was initiated by Congress in 1913, the same Congress that initiated the Cooperative Extension Service for agriculture in 1914. Two of our Nation’s most successful enduring institutions.
    For one alternative, see https:/nationalhealthusa.net/epilogue/appendix-ii-initial-organization/