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Brookings Fellow on MIPS: “It’s an Open Invitation to Cheating”

October 12, 2016
by Rajiv Leventhal
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Niam Yaraghi, Ph.D., has strong opinions about what’s wrong with MACRA, data blocking, and more

As the healthcare industry continues to await the Medicare Access and CHIP Reauthorization Act (MACRA) final rule, expected to drop any day now, discussion around some of the proposed rule’s core health IT elements, and how they will affect participating physicians, have begun to heat up.

Last week, Healthcare Informatics published an interview with notable health IT figure Farzad Mostashari, M.D., who called out both electronic health record (EHR) vendors and hospitals for actively engaging in data blocking. (That interview can be read in full here, and a blog post written by Healthcare Informatics Managing Editor Rajiv Leventhal that took a deeper look into Mostashari’s comments on data blocking, can be read in full here).

What happened next was a Twitter discussion about the MACRA regulations, and about data blocking, led mostly by Niam Yaraghi, Ph.D., a fellow in the Brookings Institution's Center for Technology Innovation, with extensive background in the economics of health information technologies. Yaraghi disagreed with Mostashari’s perspective on data blocking, noting that it’s the Office of the National Coordinator for Health Information Technology (ONC) regulations that allow vendors to “game” the system. He unleased several tweets about it, including this one:

Yaraghi then took to the Health Affairs blog, penning a piece about why the MACRA proposed rule “creates more problems than it solves.” Following that, Healthcare Informatics caught up with Yaraghi to talk further about his perspectives on all of the above—MACRA, data blocking, EHR vendors’ moral and business obligations, and more. Below are excerpts of that interview.

You have been pretty outspoken about MACRA. Can you summarize your top gripes with the proposed rule?

My major criticism is with the MIPS [Merit-Based Incentive Payment System] part, which in the beginning is going to affect most physicians since very few will be in the advanced alternative payment model [APM] track. I believe it’s an open invitation to cheating. The MIPS composite score in the first year consists of different domains; three of those domains constitute 90 percent of the weight and are self-reported. If you ask a physician to self-report without having a mechanism to detect and deter cheating, then they will cheat. People don’t like to think of doctors being concerned about money or financial matters, but they are. That’s the truth. If you create a system that is so heavily based on self-reporting, and those self-reported measures could determine between a 4 percent bonus and a 4 percent penalty at a minimum—which is an 8 percent difference in Medicare payments—then people will cheat.

This is not a new idea. Medicare has been running something similar among nursing homes with a five-star rating system based on two self-reported measures of quality and staffing and one measure of on-site health inspections conducted by auditors. So the health inspections are done by the Centers for Medicare & Medicaid Services (CMS), but the other two measures are self-reported. There is already anecdotal evidence, as reported by the New York Times, about five-star nursing homes that tend to be very low quality, although those star ratings don’t reflect that. It’s primary because they cheat on self-reported measures. And cheating has a very negative connotation, but the data just looks very suspicious.

Even if people wanted to report the true measures [for MIPS], it’s really burdensome. What will happen is that the smaller and solo physician practices who do not have capability to report will have to stop seeing Medicare patients—and I see some people doing that—or they will have to join a larger practice that can support the overhead cost of all these reporting requirements.  


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