If Medicare wants value, it should cancel MACRA

From the CMS website, October 30, 2017, “Today, Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma discussed the agency’s efforts to streamline quality measures, reduce regulatory burden, and promote innovation … We need to move from fee-for-service to a system that pays for value and quality — but how we define value and quality today is a problem. We all know it: Clinicians and hospitals have to report an array of measures to different payers. There are many steps involved in submitting them, taking time away from patients. Moreover, it’s not clear whether all of these measures are actually improving patient care.”

Then cancel MACRA, Ms. Verma. You’ve just admitted it’s a bad plan. Cancel it while there’s still time.

MACRA, for those who don’t know about it yet, is the next way that the federal government is going to ruin health care. It’s another layer of senseless rules, data collection, and more rules—this time based on the new fad known as “value-based payment.” This new form of government excess is an amalgam of every failed attempt to do the exact same thing in the past. It didn’t work then, and it won’t work now. Here’s why.

MACRA has four categories of value: quality measures, advancing care information, cost, and improvement activities. Data is collected for each of the categories and doctors will either be paid more, or penalized, based on the results.

Quality measures replaces the government’s PQRS program, where the government collects data that purportedly reflects the “quality” of a physician’s clinical practice, things like blood pressure control for patients with high blood pressure, and glucose control for patients with diabetes.

Let me tell you one of the reasons why there is little point to collecting this data. Here’s an actual appointment that took place last week. A patient with Medicare D prescription coverage came in for a number of problems. First, though, she showed me two letters she had received from CVS Caremark, her Medicare D prescription administrator. The first was a cancellation notice for her long-time blood pressure medication, a generic beta blocker. The second was a cancellation for her statin.

The letter asked her to have her physician call a phone number to discuss the issue. I dialed the number, and was put on hold for about five minutes. Then, Debbie picked up, and I explained the issue. She put me back on hold for a few more minutes.

I decided to use this hold time as best I could. I held the phone in the crook of my neck and began discussing the patient’s two other medical issues. After a few minutes, someone came back on the line. I explained about the letters. She said that she was not the Medicare D person, and put me back on hold. I continued to interview the patient. After a few minutes, Monique came on the phone. I again explained what was going on. Monique figured out that both letters were in error. She said she would fix the mistakes. Total time on the phone: about twenty-five minutes.

Here’s the system of value within which we practice. To bring value in this sense, which is to control patients’ blood pressures, I have two options. I can encourage the patient to eat right and to exercise, which I always do. But I have a limited ability to control that aspect of their lives. Second, I can prescribe appropriate medicines. But, as we see above, the federal government, in the form of this Medicare D prescription service, makes this quite difficult.

I am held responsible for value when I have, at best, limited control over such things, and at worst, a system that blocks genuine value at almost every step.

The second value category is advancing care information, which replaces the government’s failed EMR program, meaningful use. With this program, the government hopes to force doctors to use EMRs more “meaningfully.” What they fail to acknowledge is that for many doctors, EMRs are the worst thing that ever happened. They slow them down, distract them, force them to write inane long notes, and just don’t work in a multitude of other minor and major ways. Maybe worst of all, they disrupt the connection between doctor and patient, because many of them are just so clunky that they divert the doctor’s attention completely away from the human being (the patient) sitting in the room with them.

There is no value in using such systems, no matter how much data the federal government collects or how much they penalize doctors whose data is not up to snuff.

The third category is cost. The government is going to compare the relative cost of each doctor’s patient care. This makes no sense at all. I have no control over what tests or treatments cost, and very little control over where my patients receive their care, other than my office. Some hospitals charge a great deal more than others. Not only that, I don’t have any idea what anything costs. No one does! Hospitals make this information a state secret.

And what if I just so happen to take care of a larger number of sick patients than other doctors? The clear incentive is to withhold care —
no matter what the patients need!

And finally, there are practice improvement activities. To fulfill this requirement, I am participating in my state’s controlled substance monitoring program. I have to access the state PDMP website now every time I prescribe a narcotic or benzodiazepine. Of course, they couldn’t have made the website more unwieldy. I have timed it, and it takes about a minute and a half to look up each patient — time I don’t have.

There cannot be value until patients have affordable access to the care they need. There cannot be value until doctors can get patients the care they need without having to jump through massive hoops; until there are EMRs that actually deliver on their promise rather than make life miserable for doctors and their patients; until we have some transparency regarding the monetary value of our patients’ care; until the layer upon layer of useless, excessive, wasteful rules and administrative hassles are wiped away. Then, and only then, can we begin to work on value.

Matthew Hahn is a family physician who blogs at his self-titled site, Matthew Hahn, MD.  He is the author of Distracted: How Regulations Are Destroying the Practice of Medicine and Preventing True Health-Care Reform.

Image credit: Shutterstock.com

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