More Fed carrots? Or just a different stick? #MACRA #MIPS

Secretary Azar says HHS may cease reporting requirements for MIPS “value-based” care. Perhaps you’re beginning to think that they are finally hearing us, right?

However reading further, things get murky fast:

Instead of requiring physicians who participate in MIPS to submit patient data, the proposal suggests having the government use claims data and patient surveys to grade doctors in the program. “We would be able to independently look at data ourselves to decide their compliance with the quality programs rather than their having to even report anything,” Azar said at Thursday’s hearing.

Here’s what some physicians are saying about this “new direction” from HHS:

  • I’m not going to celebrate just yet. Think of how often HHS/CMS have replaced a bad idea they had, with an even worse idea. If they begin using patient surveys (Press Gainey, etc.) to determine whether or not physicians are given a bonus or penalty, I think that could actually make this awful MIPS experiment even worse.
  • We must be careful what we ask for- and we must control the conversation. There is no reason the government needs to be involved at all – that’s the beautiful thing about the free market – the patient receiving the service determines the value – but the patient must have an  appreciable fiduciary responsibility and they vote with their wallet – good restaurants are busy – bad restaurants are closed – really quite simple.
  • MACRA/MIPS  is fatally flawed.  Patients are individuals and cannot be reduced to an algorithm.
  • There is nothing salvageable or workable in the MIPS system. There is no way on paper and with claims that physician skill, judgement or even outcomes can be legitimately assessed. Further, major institutions are rethinking patient evaluations of physicians, realizing that it is a one way system-i.e. there is no way to evaluate the validity of the patient evaluation and no way for the physician to respond.
    In my opinion our best/only meaningful way of reform is to condemn the entire MACRA/MIPS construct as wasteful and invalid without adding anything to patient care. In fact a point can be made that it detracts from actual care.
  • We should have a say in the type of patient survey they set up. And this should decide only incentives not penalties. The only difference between this and MIPS is that with MIPS we can lose money after spending it on data collection, whereas here we avoid double jeopardy because they do their own data collection and we don’t have to attest to anything. Overall I think what they have suggested is better than MIPS.
  • I just had a very cranky daughter complain about the resident who called her sister rather than her when her mother took a turn for the worst. She would give that resident a failing grade. So much subjectivity makes those evaluation meaningless. Also, when grading a physician on outcomes, which physician can take credit for which specific outcome? Many physicians are often involved. This evaluation scheme is totally unworkable.

I think you’ll agree there is more than a bit of skepticism that CMS is going to meaningfully change things for the better. Tell us what you think!

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It is not only Aetna, but every major health insurer.

To: Mr. David Jones
Insurance Commissioner of California

Dear Mr. Jones:
I and many of my physician colleagues were gratified to learn in the news this week that you are opening an investigation into Aetna’s ‘prior auth’ practices. I share this little story from today, just so you know it is not only Aetna, but every major health insurer. This is a major reason why our country’s health care is the most expensive, and among the least productive in the developed world (the reverse of just a few years ago), and why U.S. life expectancy has now declined for the second year in a row. I have cc some great physician leaders that I have worked with in California.
Thanks,

Michael Strickland, MD
letmydoctorpractice.org

This is how tests were ordered 10 yrs ago:

Dr to staff: Get a Cat scan (CTPA) of the chest scheduled asap on this patient with recurrent chest pain (who called me last night with worsening pain), now coughing up small amounts of blood (which could become large amounts, at any time, until we know what is causing it), with abnormal fluid collection (pleural effusion).
Minutes later:
Staff: CT scheduled for 9 a.m. tomorrow.
Dr : Great. Next patient..

In 2018:

Tues afternoon:
Dr. to staff (above)
Wed. a.m., I haven’t heard when scheduled. Ask staff. “Hasn’t been scheduled yet. Anthem says it will take a couple of days for them to decide if this test is necessary.” (Note that if the patient gets CT done today and we find a problem, we still have time to do something about it. If Anthem approves it for Friday at 4 pm, there will likely be nothing we can do until Monday..assuming it has not become an emergency, during the delay.)
I call Anthem at 888-224-4902. Get transfer to “provider svcs” 800-345-4344. Get told I need to hang up and call ‘peer to peer line’ at 866-876-3184.

When I call, get voice mail that says “leave your information, and someone will get back to you WITHIN 30 DAYS” !!!!! (I left some information alright).

Call 1st no. back, tell them I want this test approved NOW, or get a Dr. or RN on the phone with me now, or I will send the patient to the ER, and Anthem can pay $5000 to get this done. (Then I remember, the patient has a $12,000 deductible. So, why is Anthem even involved?? “Oh, we still have to approve.”) An RN comes on the line. After a few moments, she says, “Well, a ‘case’ hasn’t been started yet. Your staff will need to call 800-554-0580.” I thank her for her help, tell her this is why I practice direct patient care and do not accept insurance, and ask if she’s seen the news this week that the state of California is investigating Anthem (oops, Aetna. Same thing) over its prior authorization practices.

Give staff above no. She calls and gets CT scan “approved”.

I spent 25 min total on phone w Anthem, plus 15 min w patient and staff, plus documenting (in case of bad outcome, d/t delay), i.e. about one hour of my (doctor’s) time, and staff tells me she spent about an hour on this as well, so 2 hours of the clinic’s time to get “approval” for a test that any 4th year med student would immediately know needs done, and needs done now. And 2 hours we did not do anything remotely resembling anything productive to patient care.

If you wonder why you can’t get into your doctor for days or weeks, and why it costs a fortune, look no further. This happens all day, every day, in every doctor’s office across America.

Next patient…never mind, I’m going to take an aspirin and lie down for a few minutes.

“Continuing Board Certification” sounds swell but harms patients.

Dr. Walter Wood writes:

I board certified prior to 1991 and have “lifetime” certification equivalent to an academic degree. I can attest that my younger colleagues and their patients are being harmed by costly and time consuming “requirements” to participate in “re-certification” and “maintenance” of certification, soon to be renamed “Continuing Board Certification,” which is not needed and not only does not help patients but harms them. Patients in need are harmed when a doctor is not taking care of patients because the doctor is busy preparing for or repeatedly jumping through hoops such as what lawyers experience once in a lifetime with their bar exam. I was somewhat stunned that an anti-trust judge thought it was necessary to demonstrate “harm to consumers” as a result of the egregious behavior of the ABMS and its colluding member boards. That judge needs to be asked whether s/he repeats the bar exam every ten years.

Walter Wood, MD, FAAD

P.S. I have posted these comments at certificationharm.org.

Pioneers and Powerhouses of DPC launch new organization

The Direct Primary Care Alliance launched on January 1, 2018 as a physician-led organization exclusively focused on growing the Direct Primary Care (DPC) movement. The Alliance was born from a grassroots network of practicing DPC physicians looking to provide a unified voice and resources for fellow DPC physicians. The motivations for launching the Alliance can be found in remarks from our inaugural president, W. Ryan Neuhofel, DO, MPH:

We now realize the transformative potential of the DPC model and are at the advent of moving beyond novelty.  But, many hurdles exist for us to achieve that vision. The challenges ahead of us are immense. Yet I can think of no better group of people to overcome these odds.