Less is More: take the deductions for MACRA non-compliance

Friend of IP4PI, Jane Hughes, MD writes in:


Read this BS sent to us by our “professional” organization whose mission is to preserve the profession, etc etc. For the love of God I cannot understand why any physician can’t see by now that this is a fool’s errand and meant to be. Our clarion call should be to all doctors: Take the deductions for non-compliance because: you will save in essence $40,000/yr in compliance costs that would take $430,000 in Medicare payments at the 9% top reward to equal your $40,000 reimbursement before you see a penny in increased payments. More importantly, you can proudly state that you are saving the government (taxpayers) money at the same time. And the best, wait for it- it would go away because no one would be doing it.

This is not to say I have given up on reform. But, to change Medicare we have to straighten out the private sector, and then, with insolvency looming, we can give Medicare ppl a choice- defined monthly contribution (i.e. check like Social Security) or continued traditional Medicare, which would also be a fast disappearing institution with the current costs to “beneficiaries.” Gee, HSAs with no networks, Medicare as catastrophic, and cash pricing versus what we have now… pipe dream worth fighting for. As you can see I almost came off the rails reading this stuff.

Warm regards,

MIPS Math: a losing equation for physicians and patients

Dr. Jane L. Hughes reacts to the latest offer for MIPS “training”: http://conta.cc/2ps7YTq

I will bet that in their course they will not mention that “the physician must [participate in MIPS]” is not true. The physician chooses to comply in the hope of getting that 9% increase in Medicare payment. CMS says 47% of physicians will lose the zero sum game of MIPS. Weill Cornel Medical college estimates the cost of compliance with EMR, PQRS, etc to be $40,000/physician/year. As I’ve said before, do the math. You would have to clear $430,000 at a 9% return (if you are in the elite compliers) to reimburse yourself for your compliance costs. Hey, then you’d be rolling in reward money…What a thinly veiled process to gather the data to justify real time treatment dictates. I know of no other profession that would give up their privileged communication without a tooth and nail, knock down drag out fight, except the medical profession. If only because of the disastrous treatment implications of not being able to candidly talk and privately record medical and surgical encounters, it would seem to me that all physicians, in spite of the many compliance courses, should choose to just say no, at least to “interoperable EMR with 24/7 unfettered access” by HHS and CMS, as dictated in the MACRA law.

Best regards,


MACRA does not measure physician quality nor improve patient care

Dr. Jane Hughes writes in with a summary of pages 100-200 of CMS’ proposed rules to implement MIPS & APMs.  

Submit your comments to CMS before June 27!: https://www.regulations.gov/#!submitComment;D=CMS-2016-0060-0068

Here are the most telling and salient points for pages 100-200.

  • All reporting has to go through EMR/Questionaires CMS approves
  • The requirements are going to increase for reporting outcome measures over next several years as more outcome measures become available
  • High priority measures to be rated are a. Outcome b. Appropriate use (not defined nor not specified who decides “appropriate use”) c.Patient safety d. Patient experience e. Care coordination quality measures
  • CMS believes MIPS “Appropriate use will minimize overuse of services, treatments or related ancillary testing that may promote overuse of services and treatments.”
  • CMS decides “underuse” of specific services that reflect “overuse” of alternate treatments that are not evidenced based or supported by clinical guidelines. CMS assures that they will seek input from various “stakeholders” as to evidenced based treatments and clinical care guidelines.
  • CMS plans to develop a.Care episode groups b. Patient condition groups c. Patient relationship groups with codes for all.
  • CMS plans to update definition of primary care services, and thinks MIPS survey will closely align with PQRS, but they state they do not know yet.
  • Doctors will bear the cost of contracting with CMS approved survey vendors to administrate the required MIPS surveys.
  • In future years there will be bonus points, girls and boys, for patient experience reports. CMS may expand patient experience measures to all payers so that everyone can be be included.
  • CMS expands reporting to non-Medicare patients to “ensure completeness” for the broadest group of patients possible. If submitting via qualified registries or EMR must report on 90% of patients. If using Medicare Claims must report on 80% patients. KEY: CMS thinks this gives a more complete picture of each MIPS eligible clinician’s scope of practice and more access to data not currently captured on PQRS.
  • CMS plans on increasing data requirements in the future.
  • Global population based measures and global outcome measures may be used by the Secretary for purposes of defining quality performance. Will use Agency for Healthcare Research and Quality (AHRQ) and Prevention Quality Indicators (PQI)in calculating total MIPS score.
  • Secretary will publish annual list of quality measures which may change from the previous year. If performance on a measure becomes so high that meaningful improvement is not possible, it will be eliminated.
  • There’s more of the same, with promises of even more rules to come.

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We Must be the Paradigm Shift and Mount an Innovative Goliath Offense

Guest Post from Kris Held, MD

After spending the last 7 years treading water naively and optimistically waiting for things to be repealed and fixed and after countless trips to DC and across the country trying to cry from the wilderness of the practice of medicine from the trenches with many of you and our organizations, I am convinced this is beyond repair and will never be repealed by those in power.

The Philosophy of the architects of the current system we are floundering in is the antithesis of Hippocratic medicine and in fact works to undermine and dismantle it. Just take innovation- look at Ezekiel Emanuel’s own words on this- he believes innovation is too expensive and the taxes in Obamacare reflect this opinion. He also is an ethicist whose roots stem from his area of expertise which is dying with dignity and systems of rationing like the complete lives system. Continue reading