March, 2017

Not My CMS

By Michael J. Katin, MD

It will be only a few months now before the Centers for Medicare and Medicaid Services, CMS, come out with the proposed fee schedule for 2018. This annual ritual provokes fear in those still foolish enough to expect to make a living in the practice of medicine. To fulfill its goal of minimizing expenditure on health care, CMS redistributes its resources to reward those actions and procedures showing the most benefit based on evidence-based medicine and, more importantly, with the most effective lobbying efforts. The final rule is then published in November and it starts all over again.

Well, not exactly. As was cogently described in the May, 2016, edition of this column, the day of reckoning is arriving in terms of the roles of Merit-Based Incentive Payment Systems (MIPS) and Advanced Alternative Payment Models (AAPM). It wasn't enough that we had to be concerned about our fee schedules being arbitrarily lowered, but now we have to make sure that we're going through the appropriate exercises that would make the challenges in The Amazing Race seem reasonable.

Unfortunately, the medical profession has gotten itself into this predicament by becoming so dependent on government payments that decisions by bureaucrats can destroy one's ability to practice. This is affirmation that "whoever pays the piper calls the tune" but there's another saying, "don't take your harp to the party." There are two different approaches we can take to deal with this.

The most direct way is to agree to the fee schedule and the restrictions requested by CMS and then totally ignore them. There is historical precedent for budgeting to be totally overrun and nobody seemed to be very concerned about it. Certainly this is common in the defense industry, but the ubiquity is most blatant when it gets closer to home -- the Capitol Visitor Center was opened in 2008, three years late and $256 million dollars over the original $265 million dollar budget! Even the Washington, D.C., just over 2-mile long H Street streetcar line started three years late (just over one year ago) and costing over $200 million, much over its budget, with its being able to travel the route one minute faster than walking. One solution for us would be to continue business as usual and then, at the end of the years, charge CMS for the amount we consider necessary to have done our work for that year. Everyone else seems to do that to the government.

The second solution would be to refuse to accept the decision of CMS altogether. There is substantial precedent for this. Civil servants were restricted for years from petitioning for benefits outside of going through their immediate superiors, specifically addressed by an executive order by President Theodore Roosevelt in 1902, but they didn't give up and after years of ongoing pressure their rights were enhanced by the Lloyd -La Follette Act of 1912. Eventually the National Federation of Federal Employees was formed, in 1917 -- because they didn't cave in to the government. Many examples followed to indicate that resistance to the government can be successful -- the Postal Strike of 1970, Muhammad Ali's refusal to accept his having been drafted in 1967, and the Professional Air Traffic Controllers Organization (PATCO ) strike of 1981 (actually, better skip that last one). This is not to endorse physicians going on strike, since that usually results in a public relations backlash. I would propose that the word "rejection" would be the appropriate designation.

This is clearly the best approach. We are living in a time in which rejection is not only acceptable, but practically accepted. This trend may have started in 2015, when Siobhan O'Dell, a high school senior, rejected the letter from Duke University denying her a place in the Fall 2015 freshman class. This trend then continued, when, in 2016, Arnold Ray Jones rejected clemency granted by President Obama (it would have required enrollment in a residential drug treatment program). Even more recently, St. Louis Cardinals fans have decided to reject that the Chicago Cubs are World Champions of baseball, and, of course, there have been multiple demonstrations and other means of expression used by people who reject that Donald Trump won the Presidency of the United States. There is even a Journal of Universal Rejection!

My recommendation is that, based on these examples, it would be totally acceptable for radiation oncologists, if not the medical profession as a whole, to reject the 2017 CMS proposed rule and agree to go along with the, say, 2014 fee schedule. If we need any further reason to justify this, consider it a graft versus host rejection.

Or is it host versus graft? Interesting question.

Emanuel Countdown: Dr. Ezekiel Emanuel's biographies list his birth year as 1957 but, interestingly, do not list a birth date. He has expressed that he does not wish to live past his 75th birthday. Giving him every benefit of the doubt, he will have his 75th birthday no later than December 31, 2032. Including March 1, 2017, this leaves 5,785 days to his goal.