November, 2017

MIPS and Chains, Part I

By Michael J. Katin, MD

Only fourteen months now until 2019 and the event that seemed theoretical a few years ago is getting ready to occur, reminiscent of the devil's coming to foreclose on Jabez Stone's soul. There the similarity ends, since the medical profession doesn't seem to have a Daniel Webster equivalent to get us out of this. Rand Paul? Tom Price ---well, I guess not. Maybe even Daniel Webster couldn't get us out of this. SGR starting to look pretty good, isn't it? Better the devil you know than the devil you don't know Yes, the MIPS (Merit-Based Incentive Payment System) is getting ready to land.

For those who are new to this subject, there have been efforts to curtail expenditures on medical care once it turned out that medical science had a lot more to offer people than was planned when Medicare and Medicaid were passed In 1965. Within only a few years medical costs rose dramatically due to new developments in intervention for cardiac disease, improvements in diagnostic imaging and laboratory techniques, and the ability to salvage victims of illness and trauma with expansion of intensive care facilities. Interestingly, the origin of "intensive care" was recognized in Europe from the time in 1953 that Bjorn Ibsen set up a unit to care for some of the hundreds of polio victims who needed respiratory support, but the claim for development of "critical care" is made by the University of Southern California, albeit in the late 1950's. Regardless of who did it, now even if someone were not salvaged from the jaws of death, a sizeable expense could be generated. If a person were saved, he or she could then live many more years, consuming even more health care dollars. It is currently estimated that 5,000,000 people per year in the United States spend some time in an ICU. Even as long ago as 1996 the estimated cost for a one-year survivor from the ICU was $282,618.00! During that same decade the cost of pursuing the impeachment of President Bill Clinton was at least $79.3 million, to put things into perspective.

Now consider that advances in radiation therapy and chemotherapy became very rapid after the 1970s and that patients with cancer could live longer and benefit from multiple types of treatment compared to the situation in the 1960s. For all types of cancer taken together, the five-year relative survival rate went from 48.9% in 1975-1977 to 69.2% in 2007-2013. It was obvious that medical care, by becoming more successful, would have to become more expensive.

The question was how can our government afford to pay for aircraft carriers, fighter planes of dubious design, nonproductive investigations, ($17 million was spent investigating whether Secretary of Agriculture Mike Espy took $35,000 in gifts improperly), questionable subsidies and favors for private industries, and, of course, $458,542,287,311.80 to service the national debt.

The obvious way to solve the fiscal problems of the United States was to stop spending money on medical care, or at least slow it down. The Medicare Sustainable Growth Rate (SGR) was a brilliant concept included in the Balanced Budget Act of 1997 to limit increase in Medicare expenditures (per Medicare beneficiary, to be fair) to no more than the growth in Gross Domestic Product. This failed miserably and was bravely addressed by Congress by postponing implementation of the formula each year until by 2014 the cumulative decrease in the conversion factor to make up for the rise in Medicare expenditures would have been 24%. This was then repealed by the Medicare Access and CHIP Reauthorization Act of 2015, the dreaded MACRA, but it was considered that this "concession" needed to be offset by measures that would balance the amount given up. Again, the devil was in the details.

Which finally brings us to the present. By sheer brilliance, the Congressional committee staff recognized that money could be saved by setting up a series of obstacles that physicians will need to overcome to break even or possibly even slightly enhance their income, with the hope that many will find it unnecessarily challenging and just accept the decrement. For 2019, the increase or decrease could be 4%, based on data collected since 2017. Ultimately the difference could be 9%, plus there's the matter of a Medicare "scaling factor," which could be up to three times the adjustment! This is sort of like getting a mortgage that can go up every year and thinking that you've made a good deal. Considering that in 2013 the average private practice office had a net profit of 12.7%, that doesn't leave a lot of options. It will be necessary to play the game and conform to all the requirements of MIPS or drop out of Medicare, which may be the true goal desired by the legislators. Interestingly, if everyone conforms to MIPS there will be no savings, and it is therefore necessary that half the practices fail these standards or nothing will be saved.

There are, however, ways that we can work with the system to ensure that coverage for medical procedures can be maintained at adequate levels to allow planning for the future. This would include such measures as

Editor's Note: This month's column was cut by 4% to reflect failure of the author to conform to quality standards.

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 November 1, 2017, this leaves 5,540 days to his goal.