Physicians Should Just Say ‘No’ to MACRA

I can't recall the exact moment I crossed over from believer in today's version of the healthcare quality movement to skeptic. Perhaps it was when the office trash would fill with clinical summaries the staff dutifully handed out to patients to satisfy a “meaningless use” measure. Or maybe it was trying to convince a 75-year-old Mrs. Davis that we would really appreciate it if she logged on to our electronic health record (EHR) using the patient portal. To do what, she asked? I stared back at her blankly.

The election of Donald Trump and his subsequent choice of a former orthopedic physician, Tom Price, MD, has raised hopes among the independent physician community that relief may be coming from meaningless regulations that flow liberally from Washington, D.C. At the moment, there is no better embodiment of untenable regulations that have little to do with patient care than the Medicare Access and CHIP Reauthorization Act (MACRA).

Related: Guide to understanding MACRA

For those still blissfully unaware-and there are many-MACRA is a program seeking to transition the physician community to payment based on performance and value. This is a worthy goal, and one that I supported at its inception and for many years after. To put it mildly, the implementation leaves much to be desired. And the insistence to stay the course despite evidence and anecdotes to the contrary has forever cured me of the idea that the future of healthcare could ever safely lie in the hands of well-intentioned bureaucrats.

The passage of MACRA means that starting this year, physicians will be asked to participate in a new model. The practicalities of this for physicians are either complying with the Merit-based Incentive Payment System (MIPS) or ensuring enough of your patients are enrolled in an advanced alternative payment model (APM).

Most clinicians won't qualify for advanced APMs because they won't have enough qualifying patients. I still can't figure out which of my patients belong to the local accountable care organization (ACO), and even if I did there are only a few ACOs in the country that meet the criteria for advanced APMs (Only ACOs in a two-sided risk model qualify for advanced APMs). While there are other models for advanced APMs, the majority of clinicians seeking to play this game will be forced to use MIPS to “win.”

MIPS involves reporting on quality measures, completing improvement activities or doing meaningful use-like measures with your EHR to come up with a composite score.

There is nothing simple about any of this. Measures are converted to points based on performance relative to other clinicians reporting measures, total points are compared to total possible points and a Quality Performance Score is generated.

Hot topic: Is DPC a viable way to MACRA-proof your practice?

High performers are rewarded, and those that fail to report will accrue reimbursement penalties as great as 9%.

Societies jumping onboard

The hue and cry from physicians that resulted from the proposed version of the MACRA rule, especially from small physician groups, resulted in a pullback with regards to the immediate reporting burden. The on-ramp to the eventual utopia that is MIPS/MACRA was essentially made less steep, but make no mistake: the final destination remains unchanged.

Physicians, forever anxious about income, and certainly forever anxious for approval from superiors, will no doubt try to jump through these hoops. Reimbursement penalties will start to accrue in 2019 and at this point are slated to be at maximum 9% to those physicians who don't choose to jump through these regulatory hoops. Medical professional societies seem to be content to “help” physicians through this process, rather than provide resistance.

Next: My advice to physicians 

The motivations of professional societies are manifold, but expanding beyond the largely ornamental status they mostly serve for physicians is a powerful one. Here's a poorly kept secret: You don't have to be a good cardiologist, an ethical cardiologist or a competent cardiologist to be a fellow of the American College of Cardiology. You just pay your annual dues, and voila, Anish Koka, MD, is converted into the much more impressive Anish Koka MD, FACC.

Further reading: Weighing MACRA's long-term effect on healthcare

Attempting to become more than window dressing, societies are seeking to become an integral part of the infrastructure physicians will need to take part in MACRA. Now, along with your annual dues, may come enrollment into a registry to fulfill the quality reporting requirements for MACRA. The clear mantra: If you can't beat them, join them and expand the membership base.

Focus on care, not scores

My advice to physicians operating in this climate is simple: Don't participate. MACRA clearly is the law of the land, and while one may hope the implementation from a Trump-Price administration will have a much lighter touch than the Obama-Burwell administration, sustained resistance in the form of non-participation is a small but important message to send to policymakers.

For those who see little point in small messages, recall that other movements have faced much longer odds at much higher cost. Gandhi stood up to the British empire in 1930 by marching to the coastal town of Dandi, Gujarat, to make salt in defiance of British mandates. A small message that began with 78 people at an Ashram captured the imagination of millions.

More from Dr. Koka: Here's why a Trump presidency is good for physicians and patients

I don't mean to conflate the problems of privileged physicians in the richest country in the world with the Indian struggle for independence, but I would suggest we as physicians adopt an ethos that does not idly and meekly go along with mandates to medical practice that ultimately only hurt patients by diverting our attention from patients. Yes, there's a financial penalty at the moment for not participating, but I would strongly argue physician practices that focus resources on actually improving patient care will come out ahead in the short and long term.

Our obligation as physicians has always been to our patients. Have faith. Spend your time doing what's best for patients. Say NO to any version of MACRA that deviates from this mission. The world will come around eventually.
 

Anish Koka is a cardiologist in private practice in Philadelphia trying not to read the writing on the wall. Follow him on twitter @anish_koka.