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Is Dr. Halamka Right When He Says that MDs Might Leave Practice over Health System Reform?

May 9, 2016
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Dr. Halamka criticizes what he sees as excessive complexity in the new proposed rule from CMS

Anyone who hasn’t been living in a cave for the past few years already knows this: the U.S. healthcare system is changing rapidly—so rapidly that it’s becoming difficult for healthcare professionals of all types to keep up. Simply keeping abreast of new policy developments alone is becoming a challenge these days.

So it should come as no surprise to many that the release on April 27 of a proposed rule on the part of the Department of Health and Human Services (HHS) that has many moving parts to it, is probably taking many practicing physicians in this country a bit unawares.

As we reported in a news article on that date, “In a dramatic policy move, federal healthcare officials announced on Wednesday afternoon, Apr. 27, that the Centers for Medicare & Medicaid Services (CMS) is introducing a new program that will replace the meaningful use program under the HITECH (Health Information Technology for Economic and Clinical Health) Act, for physicians participating in the Medicare program (for the moment, hospitals will be unaffected). The new program, called Advancing Care Information (ACI), was introduced Wednesday as a Notice of Proposed Rulemaking by the Department of Health and Human Services (HHS), under the terms of the Medicare Access and CHIP Reauthorization Act (MACRA). The new program,” we noted, “with its associated changes, was announced on the CMS website, and via two succeeding press conferences, the first one involving Andy Slavitt, Acting CMS Administrator, and Patrick Conway, M.D., Deputy Administrator for Innovation & Quality and Chief Medical Officer for the agency, and the second one involving Slavitt and Karen DeSalvo, M.D., National Coordinator for Health IT, along with Kate Goodrich, M.D., Director of the Center for Clinical Standards and Quality at CMS.”

While the announcement could not be said to have been totally unexpected, it is important to note that, with all the recent developments in so many areas, only those paying very close attention could probably have anticipated the Apr. 27 announcement very specifically and planfully.

So, it happened, and for the most part, most commentators, including John Halamka, M.D., CIO at Boston’s Beth Israel Deaconess Medical Center, expressed general support of the new proposed rule’s focus on quality and outcomes, on the day of the rule’s release. But then on Thursday, May 5, after having analyzed the rule’s details, Dr. Halamka made a different kind of statement, in his blog, as we reported.

Before he editorializes extensively about it, Dr. Halamka, in his blog, explains a great deal about the proposed rule, going into some detail to explain the measures contained in the proposed Advancing Care Information program that will replace current meaningful use requirements for physicians, and explaining what physicians and other eligible clinicians (“ECs”—the term replaces the term “eligible providers,” or “EPs,” that has been used under the meaningful use program). There is a lot that is very much worth reading, and Dr. Halamka has done everyone a service by reading through and analyzing the full 962-page proposed rule.

Now, here are the editorializing comments from the full blog itself, entitled, “A Deep Dive on the MACRA NPRM,” that I found fascinating:

“After spending 20 hours reading the MACRA NPRM, I had one overwhelming thought.  Sometimes when you remodel a house, there is a point when additional improvements are impossible and you need to start again with a new structure.  The 962 pages of MACRA are so overwhelmingly complex,” Dr. Halamka writes, “that no mere human will be able to understand them.  Above, I have only covered the HIT related concepts, which are a small subset of all the changes to payment processes.  This may sound cynical, but there are probably only two rational choices for clinicians going forward –become a salaried employee delivering clinical care or become a hospital-based clinician exempted from the madness.”

What’s more, Dr. Halamka writes, “The folks at CMS are very smart and well meaning, but it’s hard for me to imagine implementing the NPRM as written in the timeframes suggested.  I will watch closely for comments from organizations such as the AMA, AHA, and clinician practices.   I’m guessing that many will see the ONC Surveillance provisions as overly intrusive and the "advancing care information" requirements as creating more burden without enhancing workflow.   Maybe the upcoming Presidential transition (whoever is elected) will give us time to pause and reflect on what we’ve done to ourselves.    As a practicing clinician for 30 years, I can honestly say that it’s time to leave the profession if we stay on the current trajectory.”

So, let’s unpack some of this, shall we?

Let’s start with the fact that Medicare officials, with this move, have taken yet one more step to make it clear that they mean business. They are putting the agency’s conceptual foot to the conceptual metal here, and leveraging the MACRA law to rework federal physician reimbursement incentives, big-time. Essentially, Medicare-accepting physicians will have two options: to participate in an alternative payment model, post-haste, or to participate in MIPS, with its evolving requirements. Dr. Halamka essentially seems to support that move.




Hi Mark,

Great blog! I had the same response that Dr. Halamka did to the language of the rule. Obviously the rule can't be 2 pages long when it is changing such a huge and important part of the healthcare economy, but I tried to picture my primary care doc (in a 2-physician practice) reading through the 900-plus pages trying to figure out what she sould do and I just couldn't imagine it. 

Interesting that you mention that those types of docs would run to employed status to get the support of an organization. At the Health Datapalooza conference this week, Francois de Brantes, executie director of the Health Care Incentives Improvement Institute, said this: ‘Consolidation of healthcare providers has one effect: increasing prices.’


I agree with David Rath that you wrote a great blog.  It was helpful and appropriate to call out that John Halamka has a long track record of being thoughtful, well-reasoned and better informed than possibly any other Health Information Technology and Informatics executive and leader. 

His thesis that independent MD's might leave practice given the complex nature of health system reform on these MDs is relevant. 

To complete the picture, I would call out the HIMSS presentation (pdf freely available here by Carrie Nixon and Mark Engelen.  Here's the title:

Navigating the Health IT Policy Landscape with New Payment Models: A Primer

Nixon and Engelen remind us of of the Schoolhouse Rock video of "How a Bill becomes a Law" (2015 Vox updated version) that CMS is constrained to promulgate and enforce the bill (slide 19).  In this case, MACRA.  They also remind us of the "Outside Influences" (slide 20).  Lastly, they surveyed their install base including the ambulatory practice users of Greenway, and found the experience with prior legislation (PQRS, VPM, and HITECH) were too often what they termed "a losing game" for MDs.  That presentation was written and delivered two months before the NPRM was released that Dr Halamka reviewed for us.

Instead of going to the Bill and the NPRM for a vision of a path forward, I think we need to look to successful, large-scale pilots that have demonstrated better health, healthcare, costs, and care Team models that preserve primary care providers, while addressing all of the elements that drive the MIPS Composite Performance Score (Quality, Resource Use, Practice Improvement Activities, and technology use).  So, to really complete the picture, I would call readers of this blog and CMS to study this second HIMSS presentation (pdf freely available here:, created by Manu Varma and Julie Reisetter, and co-presented with Dr Brian Rosenfeld.  Here's the title:  

Volume-Based to Value-Based Care at a Pioneer ACO 

The presentation describes the ability to deliver the practices necessary to address the goals of the law, while incorporating proven re-engineering practices and pioneering experience previously endorsed and encouraged by the government. 

There were dozens of other presentations at HIMSS that showed other successful pilots by other providers and vendors deploying telehealth, intensive ambulatory care, customer relationship management, and other, necessary evolutionary practices proven in other industries. 

And, to Dr Halamka's point, these models illustrate a path that does not drop an onerous and unnecessary burden on MDs, and, by extension, their patients.  These presentations highlight that there is objective experience that underscores Halamka's implied assertions that there are much better ways to institute the law.