Additions to the Alphabet Soup: MACRA and MIPS

Just when I thought it was going to get better with the Republican promise of fewer regulations upon business generally, the CMS bureaucracy instituted MACRA and MIPS upon the medical community.  These were signed into law (a whispered 2,000 pages) by Obama in 2015, to be unveiled in the spring of 2017.  Over the past decade, the medical community has had to adapt to electronic records, new ICD codes for all diagnoses, expansion of Medicaid with new rules, and the application of Meaningful Use for the improvement of Electronic Health Record data-keeping.  All of these unfunded but enforced regulations were paid for by the private sector.  Billions of dollars have been spent.  And physicians began to just not sign up for the next stage of Meaningful Use, renamed Meaningless Use by most physicians.

A cloud-connected system of EHRs covering the USA will certainly give to State, Federal and bureaucratic private insurance Health Plan regulators the ability to better monitor the health of the entire population and to investigate some public health issues that have been heretofore impossible.  I have seen several articles opining that 90% of the benefit of EHRs will benefit these national players, and that only 10% of the potential improvement in record-keeping will redound to benefit your local physician caring for specific patients.  The result will give the Federal government significantly more control over protocols, therapies, treatment choices, etc.  Only those therapies “approved” (i.e., the right price) will be offered to those patients on government programs.  However, the precedent set by the government soon spreads to private insurance.  All treatment will soon be under government protocols, all but for those lawmakers in Washington and their extended family of Federal employees who have exempted themselves from those treatment protocols which are mandated upon the taxpayers.

The interested bureaucracies became alarmed at physician resistance to, or rather apathy toward, Meaningful Use.  But their dream of all this command and control of the health care industry is so powerful that it cannot die.  So CMS has come up with two new and improved additions to the alphabet soup called MACRA (Medicare Access & CHIP Reauthorization) and MIPS (Merit-Based Incentive Payment System).  This law is the greatest change to Medicare since its creation in 1965.  It is perhaps the most assured way to control all of American medicine, of the patients, of the private and public payors, and of the deliverers.  

Under MIPS, CMS is going to reward “good doctors” who adopt EHRs and use them to collect information about patients that CMS wishes to know.  CMS will disseminate that information about who is good and bad back to the patients and to other health care providers.  The government is going to publish a list of these good doctors and also a list of the bad doctors who are not quite doing this information gathering the way the bureaucracies wish.  The good doctors will be rewarded by a percentage increase in their reimbursements and the bad doctors will be penalized by reduced reimbursement or dropped from Medicare payment altogether, thereby limiting access to care for Medicare-age patients substantially.  Overall, the MACRA law is supposed to keep the total expenditure for physician reimbursement stable.  And the formula by which the reward of increased reimbursement or the penalty of reduced reimbursement is to be determined is just too complicated to make public.  I have to suspect the allocation decision for monies to reimburse physicians is going to have an important political input.  There was a meeting of government and think tank philosophers in Boston several years back, in which it was floated that some 20% of hospitals needed to be closed, because there was under-utilization of medical resources.  Whether a medical facility in a small community is underutilized really depends upon whether you are a patient in that community, or end up in a serious automobile accident while traveling along a highway in that vicinity.

But I must admit that this is a subtle but powerful way to reallocate the physician population and medical resources within this country.  This is another example of the government’s iron hand inside the velvet glove.  I shudder to think of the outcome.