The MACRA Test - Can You Survive the P4P Discrimination?
Use these criteria to determine the future of your local medical practice under MACRA (or your hospital under Readmissions Penalties).
- You already get paid less due to state or county location where services are most needed
- You have higher levels of Medicaid and Medicare patients (shaping deficits in local workforce and your practice viability)
- Your community has lower resources and supports to go with lower levels of health workforce (and usually your local schools get lesser funding too)
- Your local hospital (if still existing) has a higher readmission penalty rate
- Your local cost of living/housing/property values are lower
- Local income, education, and health literacy is lower
- Local care complexity is higher
- Local rates of obesity, diabetes, smoking, sedentary lifestyle, and other markers are higher
- More local people have indicated poor to fair health status
- Your practice is struggling the most due to rapidly chaotic health care regulation change and rapid increases in the cost of delivery
One or more of above criteria indicate that you are most likely to have even lower reimbursement thanks to MACRA or any Pay for Performance Scheme no matter what you do. If your local economy is struggling, chances are that your health care will also be struggling.
Sloppy Risk Adjustment and Attribution Guarantee that MACRA won't work - Sullivan. MACRA cannot even attribute outcomes to a single physician as too many other factors influence outcomes. MACRA cannot discern "quality." Very few measuring tools can assign a physician to a patient to an outcome with little noise or outside influence. Even the best as in NY CABG rates 80% of physicians no different than the average.
Lack of specificity, lack of discernment, and high cost all translate to worsening of health care under MACRA, worsening burnout, and increasing poor attitudes regarding EHR (also being abused by MACRA and CMS). Not only is MACRA bad for now, it is even worse for future health care.
- Inability to Measure Value - Berenson and Kaye, “Measuring a physician’s value….” New Eng J Med, 2013 )
- Inability to discern physicians from the average - Kate Bloniarz, MedPAC staff, transcript of January 16, 2016 MedPAC meetiing, p. 74 MedPAC has found its role advising Congress about Medicare to be more complex due to CMS and broke rank over the CMS failure to adjust Star Ratings for the hospitals caring for the most complex. CMS pays less where care is needed and rates the care lower - by designs for hospital and practice payments.
- Measures to date have a poor track record in identifying efficient physicians and practices. For example, 96 percent of physician practices were scored as ‘average cost’ using similar measures in the 2016 Value-Based Payment Modifier program.” (Clough and McClellan, “Implementing MACRA….” JAMA, 2016)
- From Sloppy Risk Adjustment and Attribution by Sullivan
Discrimination By Design
Over a dozen studies demonstrate that P4P is most consistent about paying less where less advantaged and more complex patients are found. Situations, behaviors, environments, and other people factors shape outcomes - not the 10% of influence attributable to clinical interventions.
Physician ratings and penalties are about their patients that they are attempting to care for despite lesser pay and increasing cost of delivery. The one rule of new health care is even more important than old health care - location location location which translates to cherrypick cherrypick cherrypick - as CMS did when using certain high performing entities as models for ACOs as Jha indicated as the first ACOs implemented in 2012 and those paid the most have done best. Highest pay for least complex always wins.
- Worse, one of the tables shows that doctors in small clinics will suffer far more than those in large systems. Table 64 shows that 87 percent of solo doctors and 70 percent of 2-to-9-doctor clinics will be punished while only 18 percent of doctors in clinic chains with over 100 doctors will be punished. CMS’s failure to say a word elsewhere in the rule about the disproportionate punishment meted out to smaller clinics, and CMS’s refusal to admit it will be dishing out this punishment on the basis of crude measurement, is appalling!
- Pay for Performance has backfired and there are reasons for this to happen. Care givers distracted from care giving may improve in some measures but fail to change health outcomes overall. Patients Should Be Changed, Not Physicians - Physician Behavior has been changed - the wrong way
- The major problem with Pay for Performance is still that outcomes are mostly about people factors and these can be impacted little by interventions designed to micromanage physicians.
Why Do Associations, Advocates, and Scientists Tolerate MACRA?
- AMA and AAFP should fight for physicians in most need of support, but are marketing new products and services while their leaders support the changes and claim victories in some small changes to MACRA implementation
- EHR advocates should fight against MACRA. We need to become more digital. Abuses of digital applications will set back digital progress. Regulations to force the use of software before the software was ready propped up bad software platforms that should have gone away. Instead these continue to abuse health care team members, morale, and productivity.
- Patient advocates should fight against MACRA and pay for performance schemes. Discrimination and policies that widen disparities should not be tolerated.
- Scientists should fight MACRA. RAND told CMS that they were exceeding design specifications. Clearly CMS has exceeded Congress, RAND, and reasonable limitations. Scientific-focused organizations should fight bad science. AAFP is 0 for 2 in its support for MACRA and Maintenance of Certification. At least the AMA, led by Pennsylvania, decided that Maintenance of Certification was not up to its claims.
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