Prevent MACRA to Do No Harm

Do no harm is still considered a top principle in health care - especially for physicians. Physician associations should advocate for their patients and should not advocate policies or practices that cause harm - especially harm to vulnerable populations by commission or omission.

Harm can be caused in a number of ways in health care. Harm can be caused by cost too high or by quality problems or by access to care barriers. 

  • MACRA claims to be focused on quality but studies question whether quality can be achieved by clinical interventions. Failure regarding the ability of electronic interventions is already documented. MACRA cannot even discern differences in "quality."
  • CMS agrees that excessive costs due to regulation must be addressed and then minutes later CMS officials promote the burdensome MACRA implementation without possibility of delay
  • MACRA has a focus on cost cutting with no better than break even regarding payment change overall for areas such as primary care and mental health. 
  • MACRA does not redistribute payments from higher paid to lower paid or address other inequities in the current payment design
  • MACRA continues payment too low for cognitive/office/basic services with payment too high for procedural/technical/specialized - the design that defeats generalist and general specialty careers that are needed most now and are increasing fastest in demand
  • MACRA continues to defeat the major causes of access barriers - insufficient payment to sustain workforce where needed (where CMS patients are concentrated) and insufficient workforce by type and location
Access harms have become so common that they may be outside of the ability of many designers and health care leaders to comprehend them. This has been made worse by a focus on special programs to address access barriers. Of course the amounts set aside for special programs are too small and fail to help most of the practices on the front lines not to mention the administrative excesses of such programs and the ease of cutting them out entirely.

MACRA will cause harm

  • MACRA is essentially fee for service with a continuation of fees too low to sustain many small and solo practices that provide lowest paid services such as primary care and mental health. Many still do not understand that primary care and mental health are paid less and that practices bigger and where care is concentrated make more per service while practices smaller where care is needed make less. MACRA continues this disparity.
  • MACRA continues to pay less where access to care is most needed. Elderly, poor, Medicare, Medicaid, fixed income populations and populations with low paying plans are in harm's way under MACRA because the payment design plus penalties will result in even less payment, less viability, fewer team members to deliver the care.
  • MACRA will particularly single out practices where family practice MD, DO, NP, and PA are the dominant health professional - small group and solo, practices on the front lines of health access. Family practice professionals are the only ones that can be shown to have population based equitable distribution such as 36% found in 2161 counties with lowest concentrations of physicians where 40% of the US population is found (0.9 ratio or above is population based compared to other specialties 0.2 to 0.6) This will make it even harder to obtain and sustain family practice recruitment and retention - the number one demand for many years because of payment design deficits. This will result in worsening of the vicious cycle of more paid for recruitment, retention, brokers, consultants, and other administrative costs with less remaining for care delivery.
  • MACRA payments have already been shown to pay less by government investigators for many if not most primary care practices (disputed of course by MACRA designers). Harm caused to primary care harms people through access barriers, access barrier deaths and disabilities, increased overall health costs, and worsening of local economics. Places where practices are closed or compromised lose out in local income, jobs, education, transportation costs, outflow of local citizens for other services, and decreases in organization for care.
  • MACRA payments force an increase in the cost of delivery due to software, hardware, maintenance, update, and other additional costs. There is no design in MACRA for a compensatory increase in revenue to cover any of the recent forced increases in cost of delivery due to regulation. 
  • Payments for the last decades have continued to compromise primary care and mental health to the breaking point.
  • MACRA diverts attention from the necessity of restoring access to care in two ways. It focuses attention away from paying more. MACRA diverts funding away from the team members delivering the care via regulatory burden.

MACRA is worse than the previous patches prior to MACRA.

MACRA is about harm to basic health access. MACRA will worsen shortages of workforce where workforce is most needed and where demand for care is growing fastest.

MACRA should be opposed by those who truly champion "Do No Harm" - physicians, physician associations, and especially those who advocate for patients, primary care, and care where needed.

Those who promote MACRA are responsible for the declines in access to primary care and mental health that result from MACRA.


MACRA will make each of these problems worse by impairing access, increasing cost of delivery, increasing regulatory burden, increasing pace of change, increasing access woes, decreasing productivity, and decreasing morale.

MACRA = Harm by Design

For prevention of harm, for population based health, for primary care, for mental health, for care of the elderly, for care where needed - PREVENT MACRA

Recent Posts and References  

Talk About Unpaid Stressed and Abused For Decades - a journalist wakes to health care abuses, but then there is primary care. 
No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure

Population Health from Above or Below  - population health must not be another new crop to harvest for consultants, associations, and institutions. In must remain about the health of the population, not the wallets of those already doing best.
Stop the Promotion To Restore Mental Health Access - claims of mental health care reforms or improvements are a stark contrast from the reality of lowest payment, highest complexity of care, unreliable payment, and poor support other than lots of rhetoric




Lack of Accountability for Accountable Care - Roll on regardless of consequence




Primary care can be recovered and should be recovered, 
but cannot be recovered when moving the wrong directions

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