AAPS News August 2016 – MACRA: Pokemon Go for Doctors

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Volume 72, no. 8 August 2016

The latest fad, a “free” smartphone app called Pokémon GO, has reportedly exceeded even Twitter and pornography in popularity. One hospital has banned it for employees because they were glued to their screens instead of interacting with patients.

It’s called an enhanced or “augmented reality” game that places an imaginary monster in a physical location to which the player is directed by the smartphone’s GPS application. The idea is to rack up points by “capturing” the monster. One player came into a uniform shop in search of a Pokémon “egg.” To some retailers, it’s a nuisance, but some place “incense” to attract Pokémons and thus foot traffic. Criminals can do that too. Two men were reportedly so engrossed in the game that they fell off a cliff.

The Electronic Privacy Information Center is asking the Federal Trade Commission to investigate the game’s spying on consumers. The software developer Niantic granted itself full access to users’ Google accounts when it released the app. That allowed the company to view users’ contacts; view and send email; view and delete Google Drive documents; access search and map navigation history; and view private photos stored in Google Photos.

Niantic’s founder and CEO John Hanke has previously been at the center of a privacy controversy concerning Google Earth, which admittedly collected “vast amounts” of WiFi data (http://tinyurl.com/hqkwrqv).

MACRA

We are indebted to Nicholas DiNubile, M.D., for this insight on Twitter: “#MACRA will be the #PokemonGO for physicians. Running around for imaginary prizes?”

More than 3,900 comments were submitted about the 962-page rule implementing the Medicare Access and CHIP Reauthorization Act of 2015. Organized Medicine expressed some concern about the “pace” of implementation, but Bob Doherty, senior vice president, American College of Physicians, writes:

“Relax, it’s only MACRA.” It won’t be a “sky-is-falling” disruption. ACP is developing tools and has recommended ten steps to take immediately. It will be less burdensome than what we have already. Penalties (“downward adjustments”) will be less—until 2022, and penalties will get redistributed to high-scoring physicians instead of going to Medicare. Positive adjustments are at least theoretically possible (http://tinyurl.com/j9ccclu).

AMA has asked for a 6-months delay “to allow MACRA to achieve its promise to create a more value-based health care system” (AMA Morning Rounds 6/28/16).

CMS acting administrator Andy Slavitt is open to finding “ways for physicians [to get used to] the program before the impact really hits them” (http://tinyurl.com/jeqyhrb).

Slavitt invited AAPS director Kris Held, M.D., to discuss her extensive pointed comments. Will anything change? He tweeted: “We’ve now conducted 134 physician events around the country! And we’ve trained nearly 60,000! 13 more next week!”
MACRA allows “choice” and “flexibility.” Doctors can pick the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APM). Under MIPS, doctors will have to report in four categories (http://tinyurl.com/jdpxlx5). “Quality” is 50% of the score. Unlike with PQRS, doctors will have to measure performance as well as collect data. And they can’t pick any 20 patients but must include a high percentage.

“Resource use” is 10% of the score. It requires reaching out to patients to “make sure they’re not overusing services.” This data goes to CMS from claims.

“Quality” includes use of the electronic health record. This is one of the top five PQRS measures used by neurologists, neurosurgeons, and internists. The fifth highest for neurologists, according to the American Academy of Neurology, is: “Deep venous thrombosis prophylaxis for ischemic stroke or intracranial hemorrhage [sic!] (#31)” (http://tinyurl.com/h6tb8nl).

MACRA is a zero-sum system, and the aim is to steadily decrease the total. Rewards will be as substantial as Pokémons.

Data Capture

While physicians are trying to score points in the MIPS game, the systems programmers are capturing data to use like Poké balls to tame monsters allegedly created by outlier physicians. MACRA co-author Rep. Phil Roe, M.D. (R-TN), takes aim at the epidemic of opioid addiction (see p. 2). Although he puts some blame on The Joint Commission’s quality measure, pain as the “fifth vital sign,” it’s physicians who get caught and constrained.

A proposed Connecticut Health Authority to oversee Medicaid and state employees’ plans aims to mandate accountability measurement, reward value-based care, and identify “providers that exceed benchmarks or limits.” It would give unprecedented subpoena power for the attorney general to obtain private records (http://tinyurl.com/jr4r3y2). MACRA obviates the need for subpoenas, as Dr. Held noted (AAPS News, June 2016).

The data collection system itself can apply the “science of nudges.” Over the past 5 years, nearly 100,000 Americans in need of social services were “gently manipulated by teams of social scientists” in 15 studies. In 11, desired behavior showed a statistically significant (though small) change. Methods included making one option easier to implement than another (Science 5/27/16).

Pokémon GO knows where you are—but you don’t have to play. It’s harder not to play MACRA, but not playing is the only way to win.

ACTION OF THE MONTH
Yours can be one of the first Wedge of Freedom practices. Go to http://www.jointhewedge.com. Click on “join” and choose “doctors.” Enter the simple information requested.

Medicare Trustees Report

  • In 2015, Medicare expenditures consumed 3.6% of GDP. Under one scenario, this will grow to 6.2% in 2040 and 9.1% in 2090. General revenue now provides 42.4% of Medicare’s income. This will be more than half by 2030, when payroll taxes will provide less than 30% (Brian Blase, Forbes 6/29/16).
  • Currently, Medicare’s hospital payment rates have declined to 61% of private insurance rates (Trustees Report, http://tinyurl.com/jeewypq, p 193).
  • The Social Security DI (disability insurance) trust fund is already depleted. Funds are being diverted from the OASI (Old Age and Survivor’s Insurance) fund (http://tinyurl.com/gw8ygtd).

Hospital Surveillance

Your hospital knows where you are and where you have been. Hospitals are increasingly using extensive, sometimes hidden video cameras with audio capabilities to collect data on physicians, reports Lawrence Huntoon, M.D., Ph.D., chairman of the AAPS Committee to Combat Sham Peer Review. They are in the doctors’ lounges, doctors’ cafeteria, and many other places, often as dome cameras mounted on the ceiling. They may have pan/tilt/zoom capabilities controlled by a joystick in administration offices. Some PTZ cameras monitor doctors and nurses to see whether they are washing their hands. Or they may capture an anesthesiologist pocketing a vial of a drug he might need but can’t get immediately from a locked crash cart.

Hospitals also collect data from electronic badge swipe locks (doctor’s lounge, cafeteria, ICU etc.) and have used this against physicians in sham peer reviews. In one case a hospital contacted police and accused a doctor of the crime of cyberstalking, but then destroyed the purported evidence. The doctor’s attorney filed a Motion for Spoliation Sanctions against the hospital.

Pharmacy GO

The opioid epidemic is claiming more lives than gun shots or car wrecks, stated Sen. Lamar Alexander (R-TN), so Congress must do something. The Comprehensive Addiction and Recovery Act (CARA) passed the Senate 92-2 and was signed into law, although President Obama complained that it did not allocate enough money for treatment. CARA provides grants to states’ drug monitoring programs, but does not require states to ensure that doctors actually check the database before writing a prescription, writes Devon Herrick (http://tinyurl.com/z5fws7a).

Model legislation considered by the American Legislative Exchange Council (ALEC) would require doctors to check up on all patients before writing any prescription for any controlled substance (Schedule II-V). Herrick notes that e-prescribing could automatically check the database and flag patients who had excessive prescriptions. A study by Quest Laboratories reported that more than half of adults misuse medications (http://tinyurl.com/z5898r8). Then there’s the antibiotic overuse epidemic. An expert panel finds that out-patient antibiotic use should be reduced by 15%. Doctors are clearly out of control.

♦ ♦ ♦
“If there is no wealth creation, there is nothing left to redistribute.”
Alvaro Uribe, former President of Colombia, 2016

Economic Observations

The value of money is being determined by international currency trading, by far the world’s biggest industry, and 77% of it is controlled by ten banks. All the recent U.S. economic expansion is coming from the closed-loop economy between the Fed, the bureaucracies, and the big banks, writes George Gilder. Small business has actually contracted (http://tinyurl.com/hg8zza6).

Now that the Bureau of Economic Affairs effectively counts a tax as part of economic growth, the ObamaCare tax constituted 58% of U.S. first quarter growth (http://tinyurl.com/z926763).

U.S. government entitlements constitute the sixth-largest economy on earth. Some 110 million citizens receive some form of means-tested benefit. If Social Security is included, 160 million Americans get a check from Washington, at a total cost of $3 trillion. The $1.7 trillion increase in transfer payments since 2000 is nearly half the gain in wages and salary disbursements to 150 million employed persons (http://tinyurl.com/jpxjp6l).

The Congressional Budget Office warns that U.S. federal debt will reach 141% of GDP by 2046. Annual debt service is projected to quadruple to $839 billion by 2026, 59% of federal discretionary spending (http://tinyurl.com/gkscx8v).

Government regulations added since 1980 cost the American economy $4 trillion in 2012, according to the Mercatus Center. Had regulations been held steady at 1980 levels, the economy would have been 25% larger (http://tinyurl.com/zj9nsjv).

ObamaCare Accounting

For the first time ever, JAMA carried an article by a sitting President, much of it in the first person, applauding his own policy. Barack Obama, JD, claims credit for 20 million additional insured Americans; a slowdown in the growth rate of health-related spending; and 87,000 lives saved because of a decline in hospital-acquired conditions, despite obstacles Obama attributes to “hyperpartisanship.” Four accompanying editorials were largely supportive (http://jama.jamanetwork.com, Online first 7/11/16).
In NEJM, Benjamin Sommers of Harvard weighs in: “Why the Sky Isn’t Falling.” The projected 37% ObamaCare premium growth might not happen (NEJM 7/21/16). James Capretta addresses the unpleasant realities Obama omitted, such as the effect of the bad economy on spending (http://tinyurl.com/z2qusvc).

ACA spends at least $5,400 per person to avoid one year of uninsurance. Accepting optimistic assumptions about the effect of insurance on health, we are spending $208,000 to $300,000 for each year of good health gained. The uninsured themselves are willing to spend only $200 per year to protect against the financial risk of no coverage (http://tinyurl.com/gm8fz7t).

AAPS Calendar

Sep 22-24. 73rd annual meeting, Oklahoma City, OK
Oct 5-7, 2017. 74th annual meeting, Tucson, AZ

Need More Data

CMS currently has a petabyte (1 million gigabytes) of claims information, and is hiring more “data natives,” employees who have grown up amid computers and data, to identify suspicious billing practices or aberrant provider behavior. The Office of Inspector General can place questionable billing practices on a map, rather than an Excel spreadsheet, to make it more accessible to non-analysts. Tools such as the Peer Comparison Generator can support OIG investigations and audits or be used by grand juries. The OIG can get a complete history of a beneficiary’s medical care. “A central question for the agency is how to get more people to use more data,” said chief data officer Caryl Brzymialkiewicz (BNA’s Health Care Fraud Report 7/6/16).

No Fraud Audit, No Payment

Three Florida clinics had to refund all payments made by Allstate ($663,241) because their medical director failed to comply with the requirement of Florida’s Health Care Clinic Act to conduct fraud reviews of billings. The director had only reviewed five randomly selected claims from each clinic per month. The jury decided that wasn’t nearly enough, though there is no defined minimum standard. The court said a cursory review should have uncovered improper billings (Allstate v. Vizcay, 11th Cir., No. 14-13947, 6/23/16) (BNA’s HCFR 7/6/16).

Sham Peer Review International

At the inaugural meeting of the Health Practitioners Australia Reform Association (HPARA), physicians and nurses told of the ruinous effects of unfair hospital peer review and malicious anonymous complaints to regulators. The keynote speaker was Dr. Lawrence Huntoon, “the global doyen of ‘sham peer review’ exposure” (http://tinyurl.com/zpkfmtz).

“It is clear that the tactics characteristic of sham peer review in our country are the same ones used in Australia,” he reports.

Dr. Nouman Alvi of Karachi, Pakistan, writes that he expects the same patterns to occur in developing countries, to promote commercial interests and achieve political supremacy. Anesthesiologist whistleblowers are at particular risk. He suggests a registry of doctors who are found to be making false complaints, and making hospital administrators accountable (Anaesth Pain Intensive Care, Apr-Jun 2016, http://tinyurl.com/zqllcmr).

War on Pain Management

N.Y. State now dictates that physicians may prescribe only enough opioids for acute pain to last 7 days. This is so “someone who is addicted to them can’t sell them or give them away,” said a recovering heroin addict. Also, physicians will have to take NYS-sponsored opioid education every 3 years (http://tinyurl.com/h7zo6bw). State Medicaid agencies are limiting how many opioids clinicians can prescribe, as beneficiaries have a 3–6 fold greater risk of addiction. Cancer and sickle-cell patients are exempted. Referring to a possible 20-year prison sentence faced by a N.Y. physician (http://tinyurl.com/hqn5yrg), Dr. Huntoon writes: “Running a pain management practice is extremely dangerous, and if one does, being number one is not a good thing.”

Court Allows Fixed Indemnity Insurance

Citing “administrative overreach,” the U.S. Circuit Court of Appeals for the District of Columbia overturned an Obama Administration rule banning the sale of fixed-indemnity insurance as a stand-alone product, in Central United Life Insurance v. Burwell. Such insurance, which might pay $500 for a day in the hospital or $50 for a doctor visit regardless of the amount owed, has been exempt from federal insurance standards since 1996, and the Affordable Care Act (ACA) did not change that. About 4 million people might have such policies without major medical coverage, as they are far more affordable than ACA “minimum essential coverage,” even with the tax penalty. An amicus brief by Wisconsin and 10 other states called them a “rational choice.” The Administration argued that allowing this option undermined its goal of maximizing the number of people with comprehensive coverage (NY Times 7/5/16, http://tinyurl.com/gwxwcnw).

Insurers Sue over ObamaCare Losses

Despite billions of dollars in subsidies, insurers writing qualified health plans (QHPs) in the individual market have experienced huge losses, as the risk-corridor program to redistribute “excess” profits did not bring in nearly enough. Claims consumed 110% of premiums in 2014, and losses may have more than doubled in 2015. Plans from Oregon to Pennsylvania are suing. Even if a judge orders HHS to pay, it cannot do so unless Congress appropriates the money (http://tinyurl.com/j7zfdcv). Reinsurance and risk-corridor programs are set to expire in 2017. Obama does not allude to these problems in his JAMA article (see p 2).

Medicaid Demands Huge Paybacks

In Tennessee, 400 doctors received recoupment letters from Medicaid after taking advantage of enhanced payments offered under ACA. Unless certain complex requirements were met, only board-certified physicians qualified. Doctors who spent the money to buy equipment or open outreach clinics must borrow money to pay back $300,000 to $400,000 or more—or TennCare will stop paying current billings and choke off cash flow. Tennessee apparently started federally mandated audits earlier than other states, and many rural physicians are not board-certified. The Tennessee Medical Association is trying to mitigate the damage. About 250 audits were found to be in error, and the estimated physician overpayment has been reduced from $7.5 million to $6.5 million (MedPage Today 7/13/16, http://tinyurl.com/zlncob6).

Mandated Death Care

  • Vermont: Alliance Defending Freedom sued the Vermont Board of Medical Practice for requiring physicians to perform or refer for physician-assisted suicide (http://tinyurl.com/zlbs99j).
  • Belgium: A court fined a Catholic nursing home for refusing to perform euthanasia. Assessed “moral” damages were small, but a precedent was set (http://tinyurl.com/god7sn4).
  • Quebec: Health minister Gaétan Barrette ordered McGill University Health Centre to repeal its policy exempting its palliative care center from performing euthanasia on its premises (http://tinyurl.com/hwpv9mb).

Correspondence

Smart Phone Privacy App. Maybe we need a game like Pokémon GO called Privacy Gone. Instead of showing little monsters it could display stick figures with their pants down showing up at insurance company locations and all the government agencies able to access the patient’s private information. It could have infectious background music such as “Oh Where Oh Where Is My Privacy Gone?” to the tune of “Oh Where Oh Where Has My Little Dog Gone?” The app would be free, but one could purchase in-game “tools” showing how to protect privacy and how the HIPAA form signed in the doctor’s office does not do that. One tool could explain how third-party-free practices protect privacy because no insurance claim is filed.
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY

It Takes an Algorithm to Know a Lot about You. In the movie Minority Report, a trio of psychics called “recogs” had “pre-visions” of crimes yet to be committed. China Electronics Technology Group has been directed by the Communist Party to develop software to collect data on jobs, hobbies, consumption habits, and other behavior of ordinary citizens to predict terrorist acts. The U.S. Dept of Defense’s Office of Naval Research (ONR) called for research proposals to study social media and how it could facilitate insights into people’s real thoughts, emotions, and beliefs, and thus predict behavior. Facebook is collecting data on people’s beliefs, likes and dislikes, often prompting them to play silly personal discovery games cleverly designed to mine data. Software called “Beware” is being used to analyze social media activity, assigning a “threat score.” The FBI’s Office of Partner Engagement reportedly has revealed a new initiative based on Britain’s
“anti-terror” mass surveillance program. This requests high-school educators to inform on students who express “anti-government” or “anarchist” beliefs like “libertarianism or constitutionalism.” In our computerized world, “the lives of others” can be effortlessly watched and dissected to the DNA level and then controlled.
Ileana Johnson Paugh, http://tinyurl.com/hffgmyt

UnitedHealth Group’s Profit Center: Data. United is withdrawing from ACA exchanges, but making big money on pharmacy benefits management. The pharmacy software algorithms secretly score consumers and have started to bring in social network data. The algorithms date back to CMS acting director Andy Slavitt’s tenure at Ingenix (now Optum). Those surveys on HealthGrades, the most flawed site on the internet, are clickbait to gather information about you and bring in advertising revenue.
Barbara Duck, http://tinyurl.com/jenyw3n

Pain Medicine Rationed. At a hospital staff meeting we were told no morphine would be available for 2 months. Demerol was suggested, but it is on the Beers list of drugs inappropriate for elderly. Pharmacy did not know whether alternatives were in reliable supply, and there is no protocol for patient-controlled analgesia (PCA). I suggested that patients sign a consent to endure pain or cancel elective surgery like total knee replacement for which PCA is indicated. I was told that the government sets quotas for the amount of MS that can be made [http://tinyurl.com/hkb2guj]. Is this related to the war on drugs, to keep doctors from turning patients into addicts?
John Hey, M.D., Greenwood, MS

Physician Scapegoats for Opioid Abuse. In Florida, a physician can lose his license if he calls in a prescription for someone not his patient if he is on call and not practicing telemedicine. But Florida Blue Cross has a “Call the Doc” telemedicine program that violates this Board of Medicine law. Nurse practitioners and PAs can freely prescribe Percocet and Valium to publicly insured patients, but a surgeon may not prescribe a pre-procedure dose of the same medicine without certification in advanced cardiac life support and a crash cart on hand. Why the double standard?
Michael Riesberg, M.D., Pensacola, FL

Doctors Responsible for Impairment. Employers increasingly are demanding to know what medications are prescribed, along with a letter certifying that job performance will not be impaired.
Robert McQueeney, M.D., Marinette, WI

AMA Tries to Soothe MACRA Mania. AMA drivel about MACRA is the same as that which surrounded the passage of ACA: “Don’t worry, we’ll revisit it every year and make it better.” AMA has clearly made a deal with the devil. “Leadership” is in the tank for the government and its total takeover of medicine. That is why I left the House of Delegates in 2013 after 4 years of trying to change the organization from the inside. It can’t be done. Unless you are willing to play along with their scheme, your voice is ignored. They even have all board members agree to never discuss what goes on inside their closed meetings, and every decision must be openly supported by every board member.

Our only hope is to work together to create an alternate, free-market system outside of government control. So far, attempts have been limited in scope; no one offers full-spectrum independent care. It is hard to buck the third-party guaranteed payment. But any clinic, hospital, or physician who accepts the government money will be subject to ever-increasing control.
Robert Sewell, M.D., Southlake, TX, http://asurgeonsheart.com/

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