IP4PI to CMS: Exempt Independent physicians from ACA MACRA MIPS and APMs

CMS ACA MACRA MIPS and APMs discriminate against independent solo and small primary care practices, while unfairly advantaging hospital health systems who employ doctors. Please exempt solo and small physician practices of 9 or fewer doctors or less than 999 Medicare patients. CMS ACA MACRA MIPS and APMs will put small independent practices out of business and will deprive patients of their physician, jeopardizing their health.

Submit your comments at:

https://www.regulations.gov/comment?D=CMS-2016-0060-3944

MACRA = The Destruction of Medicare and Those Practices That Attempt to Comply

Greetings,

Here are my thoughts on reading my section of the “final” rules. If anything is apparent it is that there is no such thing as final rules, and in fact everything in the section I read was prefaced with disclaimers. I would like to entitle my section as, “The Destruction of Medicare and Those Practices That Attempt to Comply.”

This publication of the finals rules is almost of zero value to any physician or any patient, and in fact is a gobbly-gook of acronyms that hardly make sense and make the reading of the rules almost impossible without constant reference to their senseless definitions. There is nothing remotely suggestive of the actual practice of medicine. For example, CMS regards radiologists and pathologists as “non-patient facing MIPS eligible physicians.” One is struck with every rule and condition with the obvious question-how many bureaucrats at what expense would be required to track, collate, evaluate, and determine payment on over 800,000 physicians with this unwieldy payment system disguised as “quality not quantity” rewards. Continue reading

Final MACRA rule still byzantine and unworkable, patients lose.

The final MACRA rule expands exemptions, flexibility, claims ModernHealthCare.com but it is still byzantine and unworkable. Patients lose.

The 2,398 page rule can be downloaded here: https://qpp.cms.gov/docs/CMS-5517-FC.pdf

We haven’t read the all 2,398 pages yet but here are a few initial notes:

  • The low-volume threshold is now < $30,000 in Part B billings OR < 100 Part B Patients.The proposed rule was < $10,000 AND < 100 Patients.
  • The infamous table from the proposed rule showing 87% of solo docs would face a negative adjustment under MIPS has been “bleached.” The sanitized table no longer lists solo physicians separately, and claims that only 10% of practices from 1 to 9 physicians will will face negative adjustment.  Click here for image combining both new table and old table. Supposedly, overall, 94.7% of eligible clinicians will get a positive or neutral adjustment with 5.3% receiving a negative adjustment.

Another trouble spot to look out for (Page 1513):

“One commenter supported the inclusion of ABMS board certification and participation in Maintenance of Certification (MOC) Programs on Physician Compare. Another commenter recommended MOC participation as a measure in future rulemaking as part of quality performance data publicly reported on Physician Compare … We appreciate the points, concerns, and suggestions raised by commenters and, if feasible and appropriate under the statute, we may possibly consider these issues in future rulemaking. ”

Some other low-lights:

Re Privacy:

“We disagree with commenters who maintained that the disclosure of PHI to ONC or an ONC-ACB (authorized certification body) could be inconsistent with reasonable privacy or other organizational policies or would otherwise be an unjustified invasion of privacy or any other interest. As noted, the disclosure of this information would be authorized by law on the basis that it is a disclosure to a health oversight agency (ONC) for the purpose of determining compliance with a federal program (the ONC Health IT Certification Program). In addition, we note that any further disclosure of PHI by an ONC-ACB or ONC would be limited to disclosures authorized by law, such as under the federal Privacy Act of 1974, or the Freedom of Information Act (FOIA), as applicable.” (page 67)

Data-Collection from all-payers:

“In addition, we are finalizing our approach of including all-payer data for the QCDR, qualified registry, and EHR submission mechanisms because we believe this approach provides a more complete picture of each MIPS eligible clinician’s scope of practice and provides more access to data about specialties and subspecialties not currently captured in PQRS” (page 468)

“We desire all-payer data for all submission mechanisms, to create a more comprehensive picture of the practice performance. Section 1848(q)(5)(H) of the Act authorizes the Secretary to include, for purposes of quality measurement and performance analysis, data submitted by MIPS eligible clinicians with respect to items and services furnished to individuals who are not Medicare beneficiaries. As discussed in section II.E.5.b. of this final rule with comment period, we are finalizing our proposal to require MIPS eligible clinicians to report allpayer data on quality measures where possible.” (pg1396)

CMS will be accepting comments for 60 days, however the online comment portal is not yet open as far as we can determine.  Stay tuned!

Be heard in Congress on MACRA – Submit testimony to Senate Finance Committee

On, July 13, 2016, The U.S. Senate Committee on Finance held a hearing on MACRA implementation, with Andrew Slavitt testifying.

Any individual or organization wanting to present their views for inclusion in the hearing record should submit a typewritten, single-spaced statement, not exceeding 10 pages in length. Title and date of the hearing, and the full name and address of the individual or organization must appear on the first page of the statement. Statements must be received no later than two weeks following the conclusion of the hearing.

Statements should be mailed (not faxed) to:

Senate Committee on Finance
Attn. Editorial and Document Section
Rm. SD-219
Dirksen Senate Office Bldg.
Washington, DC 20510-6200

Eliminating the six degrees of patient-physician separation

By Craig M. Wax, DO

Parties and special interests within the US federal government have been trying to passively and actively control the health and welfare of its citizens for a century. With the War Labor Board’s wage and price controls instituted in 1943 during WWII, the US federal government first warped both the employer/employee workplace and healthcare by firmly establishing health insurance as a employee “benefit” in lieu of salary. The premiums were paid with pretax dollars by a combination of the employer and employee.

This gave the employer the power to choose the coverage based on the employer’s needs and wants, not the end user employees needs and wants. This was the first degree of separation.

The insurance premium was used as a bet against the employee getting sick. Today, the insurance companies and other third parties make money by denying the healthcare payment for services, studies, tests and medications. After the insurance company processes healthcare provider claims, they make restrictive and sometimes arbitrary decisions about whether to fund the care, tests and medications. This leaves the patient on the hook for associated costs, despite the insurance premium already paid. This is the second degree of separation. Continue reading

A Tool for Patients to Bypass MACRA Rationing and Privacy Intrusion?

Could the below HHS regulation be a potential tool to help patients do an end run around MACRA privacy intrusions and rationing guidelinesMedicare patients CAN refuse to authorize the filing of a Medicare claim and pay cash as outlined below.
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In 2013 HHS updated HIPAA regulations giving cash-paying patients greater ability to restrict the disclosure of health information.  Here’s what the final rule states about Medicarepatients’ ability to assert this right:

Continue reading

MACRA: CMS Policy Nerd #Fail

One aspect perhaps not getting enough attention is how MACRA doubles down on price fixing for Medicare services. It’s price fixing coupled with increasingly complicated hoops to jump through; hoops that determine if a physician will get a small percentage more or less than the fixed price. But the costs and risks of jumping through the hoops far outweighs any potential gain for a solo physician. (It’s not really about paying physicians more anyhow but controlling costs under the guise of paying for quality.)

The CMS self-styled “innovation center policy nerds” think they are smarter than the free market at determining prices. They think they can create algorithms that somehow replace free market mechanisms to tie payment to value. The problem is that decades of Medicare payment policy developed by Medicare policy experts has resulted in one failure after another; flopped Medicare policies are actually responsible for divorcing payment from value. Why should we expect they are getting it right this time?

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