By NIRAN AL-AGBA, MD

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

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

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By JOE FLOWER

The final MACRA rules are out. There is plenty of room for debate about them, but one thing is clear: They are a fine example of why we cannot expect the federal government to be the key and most powerful driver of change in healthcare.

This is not a political statement, not an anit-government slogan, not a libertarian assertion. This is a systemic observation.

This is not because the law or the CMS rule-makers are not well-intentioned. To the contrary, MACRA seems like a noble enterprise. Congress is to be congratulated for at least temporarily getting itself unstuck long enough to pass it. CMS is trying their mightiest to push healthcare in the direction of actually offering value for all the money we keep shoveling into it.

But just look at it: Over 2,000 pages, full of complexities, exceptions, subsidiary re-payment clauses, labels and circles and arrow that will keep healthcare lawyers and consultants in fine shape for quite some time to come. As THCB’s Kip Sullivan has pointed out, MACRA is supposed to be rewarding good “volume to value” behavior and punishing its opposite, but it is so complex that few physicians will be able to honestly tell whether they will get rewarded, how much, or for exactly what.

Operant Conditioning

Or when. Have you ever tried to train a dog? If you want them to stop some behavior, like digging in the garden or jumping up on you, you have to catch them in the act and give them a negative response right then. If you want to reward them for something, you have to give them the treat (or the clicker click that signals a reward) the moment they do it, so that they know what the heck you are talking about and how compelling the reward or punishment is. (My lab used to be all, “If it’s not cheese, don’t even bother.”)

People are not that different, especially people trying to run the increasingly complex business of a medical practice out of one hand while trying to actually practice medicine with the other. If you want them to do something that is both different and difficult, give them an impressive reward the instant they do it, a reward that is significant in comparison to all the other influences on their bottom line, and that happens in this billing cycle.

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By KIP SULLIVAN, JD

When I read the original MACRA rule that CMS published last April, I was appalled at its complexity, at CMS’s total disinterest in measuring “performance” accurately, and CMS’s willingness to hype the performance of ACOs and “medical homes” (the main prototypes for the “alternative payment models” [APMs] authorized by MACRA). I entertained the faint hope that CMS would come to its senses after hearing the reaction to its original rule and propose something less complex, or maybe even urge Congress to suspend enforcement of the law until it could be rewritten. Foolish me.

I have read a substantial portion of CMS’s final rule, published last Friday. It is clear to me CMS intends to implement its original rule with only minor changes. I predict the implementation process will be a nightmare.

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BY PAUL KECKLEY

In Campaign 2016, a recurring theme to date has been the trustworthiness of the leading candidates. As they debate for the third and final time this week, each will attempt to allay voter concern about their trust-gap and widen apprehension about the other’s.

In politics and business, trust is the most valuable asset candidates and companies own. Lacking trust between a candidate and voters or an organization and its customers and trading partners means elections aren’t won and a company’s, long-term sustainability is compromised.

Healthcare is an industry wherein trust is foundational. We trust our physicians to recommend treatments based solely on their effectiveness and appropriateness to our diagnosis. We trust our drugs and technologies are used solely because they work best. We trust our hospitals are safe and our insurance will help pay the bills. When we learn otherwise, we rationalize they’re the exceptions until recurring doubt leads to distrust. Stories about fraud, price gauging, denials of coverage and excessive profit cast doubt on our system and compromise trust in our healthcare system. The frequency of stories about these and social media lend to the growing distrust in healthcare.Continue reading…

BY DAN HOUSMAN

A couple of weeks ago I was discussing the opportunities for using block chain technology for medical record interoperability with a group of friends who unsurprisingly see their real experience as evidence that we haven’t made it easy to exchange medical records yet. While chatting, one of my friends asked the question – “Isn’t there some sort of security problem with Health Information Exchanges (HIEs), because block chain technology could solve security issues, especially if that is what is holding things back?” I thought about it and my immediate answer was “not really.” The sharing problem is about trust and finding a model that works for sharing records rather than just some underlying security conundrum.

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MICHAEL CHEN, MD and ADRIAN GROPPER, MD

This week, a non-commercial, open source proof of concept called HIE of One becomes the first standards-based patient-centered health record demonstration. It uses the emerging FHIR standard along with established standards for identity and security management to show how a physician-patient relationship can be independent of any particular institution and therefore as de-centralized as your smartphone messages or your Bitcoin payments.

The history of patient-centered health records begins in 1994 with the Guardian Angel Project at MIT and has inspired many of us. Implementations have come and gone over the past 22 years and today’s massively centralized and institutionally controlled EHRs seem to be headed further and further away from a patient-centered vision. Hacking and information blocking are a concern for patients and legislators. EHRs and government meddling are a source of frustration for physicians. Technology, however, is finally catching up with Guardian Angel’s promise.

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By MICHAEL MILLENSON

The Centers for Medicare & Medicaid Services (CMS) just released the final regulations for the most ambitious attempt in U.S. history to transform how medical care is delivered and paid for. But is it good for patients?

The impact of the Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program created a colossal chorus of kibitzers after the draft rule came out last spring: CMS received over 4,000 written comments. The gargantuan, 2,204-page final rule both sets out regulations and responds to commenters’ suggestions.

The rule is meant “to create a more modern patient-centered Medicare program by promoting quality patient care while controlling escalating costs,” says Andy Slavitt, CMS acting administrator, in a letter to clinicians posted online. The rule itself proclaims “high-quality, patient-centered care” as “the bedrock of the Quality Payment Program.”

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By NIRAN AL-AGBA, MD

Independent physicians are at the beginning of a challenging movement as we fight to stay relevant and solvent during the transition of health care from independence to “regulation without representation”.   In 1773, British Parliament passed the Tea Act with the objective to help the struggling British East India Company survive. Opposition to the Act resulted in the return of delivered tea back to Britain.  Boston left the ships carrying tea in port and on December 16, 1773, colonists in disguise swarmed aboard three tea-laden ships and dumped their cargo into the harbor.  The seeds were planted for the Revolutionary War. 

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