The MACRA Management Reproach

It is a sad day when something can be implemented that is so wrong for health care delivery overall as demonstrated by the evidence and is also so discriminatory across access to care where needed. 

MACRA cannot measure and discern performance. MACRA methods are known to punish smaller practices, raise costs of delivery, and distract from care focus. Inability to discern and sloppy methods plus wide variations (between practices, patients, year to year) will result in inaccurate feedback. The impact will likely be greatest to compromise care where needed. 

SloppyRisk Adjustment and Attribution is Part I of Kip Sullivan’s MACRA review

 “Outside the bubble where Congress and CMS live, there is a widespread recognition that CMS cannot measure physician “performance” accurately.” KS backs this up with evidence from Journals and MedPAC.

"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!"

In Assessingthe Validity of MACRA, KS in Part II MACRA Review does one of the most evidence based reviews. Kip Sullivan is an attorney with Physicians For a National Health Program Minnesota.

“The feedback doctors will receive from CMS under CMS’s proposed MACRA rule will arrive in two forms: Money (more or less of it) and data. Neither form of feedback will be accurate. For that reason, the behavior desired by Congress and CMS – “smarter care” (as CMS puts it) producing lower costs and higher quality – will not materialize.”

“In this installment I review the risk-adjustment problem and CMS’s irresponsible claim that it can measure physician “merit” even with sample sizes as small as 20 patients.”

“The purpose of risk adjustment is to adjust cost and quality scores for factors doctors cannot control. The patient’s health, socio-economic status, and quality of insurance coverage are the three most important confounders that must be accounted for in any pay-for-performance scheme (MACRA is, of course, one great big P4P scheme) or any report card that could steer patients toward or away from a clinic or hospital. If risk adjustment is not done, or is done poorly, the signals doctors receive from the P4P scheme or report card will be useless, and even worse than useless if doctors who treat sicker and poorer patients are punished unjustifiably. Dozens of studies have shown that P4P schemes and report cards are already harming sicker and poorer patients (see, for example, Werner et al. ), Dranove et al.. , Chien et al. , and Friedberg et al. )."

The blog goes on to review the best quality report card with years of experience – and notes that it falls far short despite high cost. Medicare Advantage is another scheme that has much evidence of too much variation and discrimination against those associated with the sickest and poorest. 

“My purpose in examining the CABG report card and CMS’s HCC method is to give you a sense of how primitive even our most sophisticated risk-adjustment methods are and how unfixable that problem is. CMS, however, gives the readers of its MACRA rule no hint that risk-adjustment is still in its infancy and will never grow out of its infancy. To the contrary, CMS conveys the impression that CMS has already created risk adjustment methods sufficiently accurate to punish and reward physicians.”

CMS Implies Validity and Reliability in MACRA - Not So

“In a report entitled, The Reliability of Provider Profiling: A Tutorial, the RAND corporation said exactly what I’m saying. CMS is well aware of this report: I found it in a document on CMS’s Physician Compare website (see p. 25). RAND made it crystal clear CMS has no business conflating its “reliability” test with accurate risk adjustment. RAND stated:  Validity is the most important property of a measurement system. In nontechnical terms, validity is whether the measure actually measures what it claims to measure. If the answer is yes, the measure is valid. This may be an important question for physician profiling. For example, what if a measure of quality of care is dominated by patient adherence to treatment rather than by physician actions? Labeling the measure as quality of care measure does not necessarily make it so.”

The measures are not fully controllable by the physician or practice.The measures are not properly adjusted for variations in case-mix, year to year, or other wide variations.

“I think we can go beyond “problematic” in criticizing CMS’s proposal to use patient pools as small as 20. I believe “reckless” is the appropriate word.”

Bad feedback is worse than no feedback. “In fact, CMS’s feedback could be worse than useless. It could have the net effect of raising costs and lowering quality, especially for the poor and the sick.”

Will MACRA Affect Small Practices by Kyle Murphy at EHRintelligence Summary: 

The statements implicate MACRA as an attack of the aggregators and note the many problems of short time line, long term impact, weighing every practice down with reporting requirements, and rapid acceleration of penalties four, five, seven, nine percent in just 6 years. The penalties are noted as chilling to those who might try to stay in practice despite the costs and penalties and to those who might start up or join small practices.

There is also a notation of surprise at the lack of action to address MACRA critically by those most threatened such as in family medicine.

What we actually can point to for best evidence about quality measurement demonstrates the inability to discern plus a consistent discrimination against those smaller, caring for more complex, caring for those with less resources, caring for those with more difficult situations…


Increasing cost, decreasing quality, and reducing access are exactly the wrong ways to go in health care and clearly the small practices, small hospitals, and front lines of access are impacted most - especially family practices.

In other words, there is little benefit to MACRA at all unless your job is related to the billions going into this new business (or your position in government which is your future position in business).

Over and over the programs and policies that compromise people in need of care also compromise family medicine and all on the front lines of health access. 

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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