MACRA/HR2 is a death knell for professional integrity and a danger to patients

Doctor Robert Geist writes his Senators:

Please vote NO on HR-2, the current SGR “doc fix” bill. Repeal is necessary; but not this version.

Here is what the bill really does: “…shifting Medicare reimbursement from fee-for-service to pay- for-performance.” This is Orwellian double-speak for P4P “value” pay; the PPACA cost control stratagem, which only reproduces decades of the failed HMO capitation experiment.

Why is this not good?

1) The bill is a death knell for professional integrity—a serious danger to patients. Doctors at the bedside are literally paid (“bonus rewards”) for restricting use of “payer” money (government/corporate) for patient care under the guise of “stewardship”, “value pay”, “choosing wisely”, or whatever slogans can sell this bedside gatekeeper rationing bill.

2) The mini-HMO-ACOs (often integrated) will alone be in the income stream. Corporate ACO clinics will be “at risk” financially, when ordering“too much” patient care. This is the “clinic cost of care index” formula that determines the pay-for-performance (P4P) of HMO-ACO corporation gatekeeper doctors at the bedside. They are “incented” to decrease (ration) the volume of care ordered for patients…a great“value” to the corporations, but not to patients.

3) The bill is also the death knell for independent practices outside of an ACO-HMO roof. It will put out of business many MN small (1-10) clinic businesses (est. ~3000) unable to afford the progressive yearly decreases in payments. [Please read the Congressional Committees’ summary and an op-ed letter about last year’s version of the bill:, and]

4) What is apparent is that many supporting professional medical associations did not read the bill, or think that their doctors will gain power and better pay with the “fix”. Their doctors may not be happy with a gatekeeper role crafted for the interests of the “payers” bottom line.Promising an increase in pay is a cruel joke for the unwary.

5) Most devastating of all, HR 2’s P4P scheme doesn’t work! [Please see the extensive literature review by: Himmelstein DU, Ariely D, Woolhandler S. Pay-For-Performance: toxic to quality? Insights from behavioral economics. International Journal of Health Services. 2014;44(2):203–214:]

Again, please vote NO on HR-2, the current SGR Repeal “doc fox” bill.

Robert W. Geist MD
St. Paul, MN

2 thoughts on “MACRA/HR2 is a death knell for professional integrity and a danger to patients

  1. How would you reform HR2? Is the ideology of P4P generally accepted as being a positive goal for a compensation model? If not what are your ideal objectives in reducing healthcare/ins/etc costs?

    • MACRA HR2 was ill inspired and the hospital and medical community was baited with SGR repeal. Allowing positions to balance bill patients for services would allow patient engagement and choice in the process. Networks and participation or ridiculous limiting concepts that have no place in healthcare.

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