MACRA (“Doc Fix”) Rule Can’t Be Fixed

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To great applause from the American Medical Association (AMA), Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), almost unanimously. It was hailed as the repeal of the notorious Clinton-Gingrich sustained growth rate (SGR) formula, which threatened large pay cuts for Medicare physicians every year. It was actually a “repeal and replace” with something far worse, writes ophthalmologist Kristin S. Held, M.D., in the fall issue of the Journal of American Physicians and Surgeons.

MACRA is not a step toward freedom, but is a more elaborate system of price controls. The rules implementing it are to take effect in January 2017. These represent a radical shift from paying for work done to payment for performance as judged by a government rubric or scoring guide, the Merit-Based Incentive Payment System (MIPS), Dr. Held explains. The MIPS concept for “scoring and grading physicians through financial incentives and penalties in order to drive behavior would, in other contexts, be called bribery and extortion,” she writes.

The Centers for Medicare and Medicaid Services (CMS) projects that 87% of “Eligible Clinicians” who are solo practitioners will receive a “negative payment adjustment,” as will 70% of those in practices of two-to-nine physicians, according to Table 64 in the proposed rule. The system is designed to redistribute income from poor compliers to good compliers. By 2022, the pay disparity is projected to reach 19 percent, Held states. MACRA replaces threatened SGR pay cuts, which were always postponed, with certain pay cuts for those who put patients ahead of system satisfaction.

Although supposedly just about Medicare, the rule creates a system for government to score physicians and collect data on all patients, including the commercially insured. Participation requires enormously costly Certified Electronic Health Record Technology (CEHRT), and physicians must attest to CMS that they will cooperate with ONC (Office of the National Coordinator for Health Information Technology) surveillance and will not block government access, even to patients’ individually identifiable health information. Dr. Held writes CMS could require unlimited access to all patients’ information, going back 10 years or more, without patient consent. This ends patient privacy.

Nearly 4,000 public comments about the proposed rule were filed.

“Ultimately, private physicians cannot ethically comply with MACRA,” Dr. Held concludes. “If this rule goes forward as promulgated, many more physicians will opt out of Medicare and commercial insurance to pursue successful practice models, providing an alternative for patients also,”

The Journal of American Physicians and Surgeons is published by the Association of American Physicians and Surgeons (AAPS), a national organization representing physicians in all specialties since 1943. AAPS has the motto “omnia pro aegroto,” which means “all for the patient.”

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  • Ver Auger

    I agree completely that MACRA should be revoked. This is more urgent than addressing the ACA because MACRA implementation is so imminent, and its massive harms so easily avoided. President Trump should exercise emergency executive authority to halt the implementation of MACRA, based on the fact that it is impossible for a working physician to read 2400 pages of regulations in 60 days, so the public comment period must be extended by at least another few months to afford reasonable scrutiny and analysis of MACRA.

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