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NCPA Senior Fellow Calls MACRA “A Poor Solution”

July 20, 2016
by Rajiv Leventhal
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A report from the National Center for Policy Analysis (NCPA), a public policy research organization, has assessed that the "doc fix” contained in the Medicare Access and CHIP Reauthorization Act (MACRA) is fiscally irresponsible, and will only increase federal control over how doctors practice medicine.

The new report was written by National Center for Policy Analysis Senior Fellow John R. Graham, Ph.D., former vice president at the Advanced Medical Technology Association and Director of Health Care Studies at The Pacific Research Institute. Dr. Graham refers to Centers for Medicare & Medicaid Services (CMS) Acting Administrator Andy Slavitt’s comments last week during a Congressional hearing about possibly delaying the start date of MACRA, noting that “Physicians and patients should not hope that it will go away for good. As with the federal imposition of electronic health records [EHRs] in 2009, ‘delay’ just means more confusion, complexity, and compliance costs. For consumers, this translates to higher costs and more difficulties getting access to timely and quality care.”

Graham says that there are two major reasons MACRA, scheduled to begin Jan. 1, 2017, is a poor solution. First, he says, it is not paid for. Less than 4 percent of the increased spending authorized by MACRA is offset by other government spending cuts. The result? An estimated $141 billion increase in the accumulated deficit over 10 years and $500 billion over 20 years, he says. Second, he notes, it significantly increases federal control of the practice of medicine. Clinicians will face increasing requirements to comply with federal regulations in order to get paid. These regulations will likely include greater reliance on government-certified electronic health records, which have already proven to frustrate doctors and do nothing to benefit patients care, despite an investment of $30 billion taxpayer dollars.

In the report, Graham spends the bulk of his time questioning many of MACRA’s components and its complexity. He references the comments of John Halamka, M.D., CIO of Beth Israel Deaconess Medical Center in Boston, who was very critical of the rule in his review of it a few months back. Graham further questions the composite performance scoring that eligible Medicare physicians would be subjected to under the Merit-Based Payment System, or MIPS. “It will also likely be difficult for the administration to get physicians to buy into CPS [composite performance score], given their resistance to its predecessor, the Physician Quality Reporting System (PQRS),” he says.

Graham also notes how current federal accountable care organization (ACO) and Bundled Payments for Care Improvement (BPCI) models are not generating enough savings. He says, “Participation in MIPS will effectively be mandatory, so we can anticipate the vast majority which have not participated in experimental payment reforms will struggle to reduce resource use.”

Additionally, Graham takes issue with the “new” meaningful use program set to take place under MIPS— the Advancing Care Information component. He says, “Complying with previous criteria has proved increasingly challenging for physicians, and these new criteria are similar enough they do not address three challenges that have become apparent as EHR adoption has become institutionalized.” The three challenges, he continues, are that EHRs are harmful to the physician-patient relationship; that that federal payments did not compensate clinicians for the cost of installing, maintaining and using EHRs; and that EHR interoperability has not yet been accomplished.  

Graham adds that there are some opportunities advocates of consumer-driven Medicare should recognize and advance: integrating Medicare Part D (prescription drug) claims into Medicare Part A (hospital) and Part B (physician) claims so the value added by prescription medicines to healthcare overall is adequately recognized; and moving away from the resource-based relative value scale to paying for “bundles” of care.

He further says, “As it stands, the proposed rule appears likely to continue the trend of imposing more burdens on clinicians with mixed clinical results and little or no cost savings. Nevertheless, this is the way of the future, and CMS remains open to changes as the new payment system rolls out.” Graham concludes, “Future regulatory and legislative reforms must do both more and less than the currently proposed rule does. They must reduce the role of the federal government in setting fees for physicians and determining what quality is, while continuing to move the locus of control to patients and doctors, by continuing to move away from paying for individual procedures toward paying for episodes of care.”

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