May, 2016


By Michael J. Katin, MD

(Disclaimer: This does not profess to be a definitive explanation of the proposed system but at the same time is not expected to be much more inaccurate than any other interpretation.)

Now that we have survived multiple sleepless nights over the possible implementation of the Sustained Growth Rate decrement (reaching 23% as of 2015), we have the prospect of sleepless days dealing with the realization that our public servants have come up with a new system that makes the SGR look good in retrospect.

On April 27, the Center for Medicare and Medicaid Services published the proposed rule regarding the Medical Access and CHIP Reauthorization Act of 2015, afterward and infamously known as MACRA. This latest example of a horse designed by a committee shows what happens when bureaucrats are allowed to run unfettered. There has been produced a complicated and potentially unachievable way to ratchet down Medicare and Medicaid expenditures by setting up hurdles that even Edwin Moses would have difficulty overcoming. The best part is that it allows proliferation of acronyms that could beget extensive punning, but which also may ultimately make it impossible for those who do not work directly with the depths of this program to carry out a meaningful conversation. This is perhaps a tribute to the innovative medical oncologists of the past who came up with MOPP, m-BACOD, COP-BLAM, EPOCH, and other combinations, but we also should recognize that other sections of the government bureaucracy had been the ones who gave us START, NAFTA, and SDI. Regardless, it needs to be recognized that MACRA itself is the most appropriate name that could have been selected for this monstrosity.

The idea is to reduce Medicare and Medicaid payments to all but the most obsessive-compulsive and determined individuals who are able to keep up. Gone are the PQRS, value modifiers, and MEHR specifications. In their place is the Merit-based Incentive Payment System (MIPS ) as an "advanced" alternative payment model. Keep in mind that at the same time physicians are going to be reduced by for participating in an alternative payment model (not "advanced") for which , of course, most practices will be unable to qualify, such as Accountable Care Organizations (ACOs)

The actual goal is to empower additional bureaucrats and consultants to further take up the limited amount of money available to spend on health care, i.e., what is left over after managed care CEOs and pharmaceutical companies consume the majority. There already are the Health Care Payment Learning and Action Network, the Physician-Focused Payment Model Technical Advisory Committee (PTAC ), and even a National Association of ACOs (NAACOS )! Of parenthetical interest is that there are already so many bureaucratic organizations that the abbreviation for the Physician-Focused Payment Model Technical Advisory Committee, PTAC, also happens to be the abbreviation for the Procurement Technical Assistance Centers for the Small Business Administration, the Privacy Technical Assistance Center of the Department of Education, and, most of all, the Professional and Technical Advisory Committees of the Joint Commission for Hospital Accreditation. This is not to be judgmental -- the stimulus from teleconferencing setups, traveling, hotel rooms, and dinners associated with these meetings probably is all that is keeping our economy going at this point.

An "Advanced" Alternative Payment Model (AAPM -- confusing to those of us in radiation oncology) program will allow practitioners to "earn"price increases up to 5% by 2024 , exceeded only by price increases in rent, electricity, bathroom tissue, and employee salaries and benefits. If one is not involved in an AAPM program, it will be necessary to go through the labyrinth described below, in a presumably non-advanced payment model.

The Merit -based Incentive Payment System is an amalgamation of Meaningful Use, PQRS, and value-based modifiers. The parameters are fascinating, and will require multiple apps to track adequacies of compliance. The best part is that our performance in 2017 (only 7 months from now) will be used to determine payments in 2019. Are these to be addressed during the time we're supposed to be delivering patient care or after hours? An example is that there will have to be 2 to 3 Clinical Practice Improvement Actions (CPIA) carried out for at least 90 days in 2017. Ninety CPIAs have been suggested, most of which would have no pertinence to an oncology practice. This will constitute 15% of the MIPS score. 25% will depend on Advance Care information. Fifty per cent will depend on achieving six quality measures, one cross-cutting and one outcomes. The remaining 10% will reflect a cost/resource use category. Got it?

The result is expected to be that for every physician who has income raised by the MIPS system there should be another who has it lowered, to keep it budget neutral. With all the different formulae, the total gained or lost could be as much as 4% in 2019 but 9% in 2022. This could result in practices having to cut back on personnel, minimize time spent with patients, and totally eliminate any amenities such as waiting room furniture.

If all this is able to be implemented, there are reports that the MIPS program will be augmented after 2019. CMS has studied methods of measurement from the American College of Physicians Fellowship requirements, the Mormon Tabernacle Choir,, the British Royal Marine Commandos, and the NFL combine, as well as other organizations Beginning in 2020, physicians in the MIPS program will, among other requirements, have to publish a minimum of three papers in peer-reviewed journal, demonstrate proficiency in at least one non-Indo-European language, and be able to run the 40 yard dash in 7.0 seconds (very lenient, actually -- although it has to be done carrying a 65-pound pack). .

It would be unfair to express displeasure at this proposed system, which has to have been the result of thousands of hours of effort by hundreds of economists, social scientists, and hospital administrators, without presenting an alternative. This was produced as a result of fifteen minutes of intense discussion with medical practitioners.

Pay us by the hour. It works for attorneys, architects, plumbers, and hookers. If we need to find out everything about a patient's psychosocial history who's being treated for a skin cancer, that's fine. If we're supposed to find out how many guns a person who has CML has in his or her house, why not? If we need to counsel a person with metastatic lung cancer whose BMI is over 30, we'll do it. If it takes longer to finalize a treatment plan when there are several alternatives, that's ok. The number of persons treated per day may be decreased, but since there are a limited number of hours per day, medical expenditures will be very easy to project. Problem solved.

Billable hours for this column: 3.75

Emanuel Countdown: Dr. Ezekiel Emanuel's biographies list his birth year as 1957 but, interestingly, do not list a birth date. Giving him every benefit of the doubt, he will have his 75th birthday no later than December 31, 2032. Including May 1, 2016, this leaves 6,089 days to his goal.