Just recently, our beloved Congress repealed the dreaded Medicare sustainable growth rate (SGR) formula and passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), with huge bipartisan support and much fanfare. The President gleefully signed it into law. Hurrah!
In this summary in JAMA, Prof. Robert Steinbrook gives an unvarnished quick look at MACRA. The reader can figure out the details by reviewing the article. What I found fascinating (and quite worrisome) were the catch phrases…and their real world meanings.
“The momentum in Washington for continued payment reform is strong”- Washington is driving this cart and will decide how payments for medical services will be made.
“The patches imposed administrative burdens on the CMS” – the yearly SGR patch exercise imposed too much work on CMS bureaucrats. We didn’t ask for that absurd Law in 1997, Mr. Clinton and Mr. Gingrich. Perhaps CMS workers should have written to them to complain.
“Only about 6600 physicians and other professionals had opted out of the Medicare program” – doctors will never leave Medicare; they are addicted to it.
“In 2019…MIPS will replace and consolidate 3 existing incentive payment programs…payments to individual clinicians would be subject to adjustment depending on whether they participated in MIPS or approved alternative payment mechanisms” – either play the game or be eliminated – the Borg Collective doesn’t sound like a fantasy any more.
“Such models involve a risk of financial loss and a quality measurement component” – doctors may actually lose money just for caring for Medicare patients. Doctors are being forced to indulge in risk management, they are no longer just highly-skilled professionals, but rather need to function like an insurance company. The only difference, insurance companies don’t have to care for patients, and actually have trained to manage risk, unlike doctors! Patients – when you can’t differentiate between your doctor and your insurance company, you’re on your own. Don’t panic yet…read further please.
“Composite performance score of each eligible physician on a 1-100 point score…new incentive payments will be complicated and many details remain to be worked out” – SAT exam for doctors all over again, but with a twist; it’s more convoluted and we won’t know how it works until we are ready to play the game. Ready, set, go…
“CMS is already engaging commercial payers and states…to support payment and delivery system reform” – if doctors opt out of Medicare, there is still no escape, because they will come after physicians from multiple angles (slavery by any name is still the same).
“Clinicians who receive a substantial portion of their revenues from approved alternative payment mechanisms will not be subject to MIPS; instead they will receive a 5% bonus each year from 2019-24″ – heads they win, tails you lose!
“The legislation protects physicians against malpractice suits by specifying that the quality of care standards in MIPS or other guidelines/standards in Medicare cannot be used in malpractice or product liability cases” – patients – if your doctor just checked all the correct boxes, followed the government-approved protocols and shared your data with the government, you can’t sue him, even if you had a terrible outcome due to such protocols. Sorry patients, you are just a herd of sheeple.
“Starting in 2018, premiums for Medicare Part B & D would increase for some high-income beneficiaries” – so you paid more than others to support Medicare, but we will ding you more when you retire; oh, by the way, we will also slap you with 3% more Medicare taxes while you work, and you are paying for someone else’s Obamacare-sanctioned insurance, which he/she can’t use because he/she can’t afford the deductible! Dang, you shouldn’t have worked so hard and made a good buck! Perhaps you will teach your kids and grandkids better.
“The SGR fix, however, should not be viewed as a permanent solution to the ferment over the physician payment system and uncertainties about beneficiaries’ access to care” – it ain’t over yet folks.
“In 2025, (there will be) payment reduction for most physicians according to CMS Office of the Actuary” – boohoo! It was fool’s gold!
“At some point, the cumulative effect of the new payment updates will not keep up with physician costs, unless the volume and cost of services substantially decrease, which is the same underlying issue as with the old payment updates” – SGR by any other name will still stink as bad!
“Within the decade, its replacement is likely to be under scrutiny as well” – sad to say, we told you so. Long live SGR!
So my friends, physicians, and patients, what will you all do? Will you allow the government to decide what kind of medical care you will provide or receive? Will you slavishly agree that government should decide what constitutes “value” and “quality”? Will you, doctors and patients, be willing to accept the fact that doctors will now be “managing risk”? Dear patients, will you ever be able to trust your doctor like you should, when you make life or death decisions?
After MACRA, life is no longer the same. The ground beneath us has shifted. Physicians are no longer caregivers, healers or even “providers”. We are now risk managers and data-collectors for the government. So, dear patients, forget about checking if your doctor is well-trained in his specialty; rather please make sure he has accurate risk-management skills. Otherwise, you might be out of luck.
I shudder to say that MACRA makes SGR look so much better. What a sad day for our profession, but more critically, our patients.
Dr. Arvind Cavale is an endocrinologist in private practice in Pennsylvania, you can follow him on Twitter @endodocPA
Photo by SpeakerBoehner 