Health Care’s Ominous Transformation under MIPS: An Orwellian twist to the push for Quality and Value, Part I.
May 29, 2016
A year ago HHS Secretary Sylvia Burwell announced that Medicare would be dramatically altering the way doctors are paid. She stated that starting in 2019 physician and NP salaries will be based on Quality and Value, a very noble proclamation that, on the surface, sparkles of a transformative change in the landscape of health care. At the time of her announcement I wrote an op-ed in the Baltimore Sun (CLICK HERE for a link to the article) questioning how CMS intended to define the words Quality and Value. Now that Medicare has introduced its product in a 900 page memo, the meaning of quality and Value has been delineated. And in a page out of George Orwell’s 1984, the two seemingly innocuous words are the very epitome of double speak, likely to usher in a tidal wave of change that is the antithesis of the Quality and Value they purport to advocate. MIPS (Merit-based Incentive Payment System) will be tracking physician behavior starting in 2017 and handing out its first rewards and punishments two years later. Every doctor/practitioner and patient will be impacted by this seemingly minor rule change, even if the press and organized medicine have largely leaped on board CMS’s Orwellian script.
In Part II and III of this blog we will delve more deeply into how Quality and Value are defined, and what that means to both primary care doctors/practitioners and their patients. Medical practitioners will receive bonuses and penalties depending on a complex 4-pronged report card that CMS will be handing out to based on their clinical activities two years prior. The penalty/bonus will be 4% in 2019 based on what transpires in 2017, and go up to 9% by 2022. A 9% penalty is enough to decimate a primary care practice, and thus many practices will fall prey to the new rules. MIPS will be revenue neutral; CMS will be handing out as many penalties as bonuses. It is estimated, due to the way the report card will be tabulated, that 70% of small primary care practices (and 87% of solo practices) will receive substantial Penalties under MIPS, while 81% of large corporate and hospital run groups will receive Bonuses. Because of this stark bias against small primary care groups like mine, 76% of doctors in a recent Medscape survey estimate that most primary care practices will either be forced to give up Medicare or merge into a larger group. Already hospitals are buying up small practices with very unfortunate consequences (SEE MY BLOG), and that trend will be accentuated by MIPS.
How does MIPS work, and how will CMS generate its report card and determine the winners and losers in this new system? Of course, a 900 page memo is not easy to translate, and likely there are many snags hidden in the pages that most unsuspecting small practice docs will not be able to navigate. CMS has offered webinars and summary pages, while many private organizations have provided similar information both gratis and for a fee. The report is preliminary, and a final report will be presented in October, just two months before practices will have to reorganize their staff/computers/schedules to comply with the very demanding program. Until then, both patients and practitioners can offer suggestions and criticisms to CMS through a formal website up until June 27th atCOMMENT MIPS, and I encourage everyone to sign in and make their wishes known, especially after reading this 3 part blog. CLICK HERE for a quick-version CMS summary of MIPS. Basically the report card for practices is broken down into 4 parts:
QUALITY INDICATORS: This part of the report card represents 50% of a practice’s final grade. It is similar to a current CMS mandate called PQRS where practices must track several pre-defined health categories (preventive health, heart health, dementia, diabetes, ect) for their patients and measure outcomes. If the outcomes correspond to what CMS has slated to be appropriate, then practices will pass all or some of the measures and be deemed to have been providing “quality” care. As we will discuss, much of how doctors/nps prove that they provide “quality care” is based on their adhering to clinical practice guidelines, or protocols, which offer generically artificial definitions of what constitutes normal. For instance, patients must have a blood pressure or sugar below a specified number that CMS has declared to be “normal” for everyone; be on a specified set of medicines that are considered to be standard of care for everyone with certain illnesses (statins, beta blockers, aspirin, Coumadin, ect); or receive specified groups of tests, labs, specialist visits, ect, for everyone with certain diagnoses. All of these “quality” outcome measures are defined by CMS with minimal flexibility, are mandated even if the patient does not want them or if they may be inappropriate or even dangerous for any particular patient, do not allow for shared decision making between doctor and patient, are often based on poorly accepted data, and have to be tracked by the MD/NP in a way that is acceptable to CMS even if logistically difficult for a practice. But more on this later….
ADVANCING CARE INFORMATION, or, in the old lingo, meaningful use of electronic medical records. This part of the report card represents 25% of a practice’s final grade. Practices will have to prove that they are using their computerized records in ways that CMS considers meaningful. We have been doing this already, and although I spend about an hour a day plugging in information to prove I am using the computer correctly, I have failed meaningful use the past two years and have been hit with a 1% penalty for that sin. Under the new program, practices can get partial credit, but of course the penalty for mistakes could be much larger. Docs and nps will be spending a lot of time and effort clicking information into the computer that may or may not be of any relevance to their patients, making sure all office visits comply with the script of meaningful use, and carrying out absurd and meaningless activities (for instance, hours after I see patients at assisted living facilities, which is when I do my notes, I have to log onto my computer to check the patients in and out of the “office” and print instructional information for them that they will never see) that squander time and help no one. Office visits will be dominated by practitioners making sure that the note is in compliance with CMS rules and that all appropriate boxes have been checked; a doctor staring at a screen and not listening to his/her patients is the inevitable result of this bizarre mandate, as most patients already know. Meaningful Use has been widely criticized by many groups and physicians, has never been shown to save money or improve quality as I show in my book, and is one of the most cited causes of physician burnout and patient dissatisfaction; CLICK HERE to see my prior blog about burnout. But since this is considered a significant part of the Quality and Value report card, practices and patients will have to comply with its rules. We will talk more about this in part 2.
COST OF CARE: This part of the report card represents 10% of a practice’s final grade, and is the crux of what CMS defines as Value. Essentially, practices will be graded by how much their patients cost the system. Thus if patients are hospitalized more and squander more Medicare resources, practices will fail this measure, even if the doctors have no control over that cost. For instance, if a cardiologist performs an unnecessary stent, or if a patient cannot afford to stay home with her illness and decides to go to the hospital, or if a surgeon sends a patient to the emergency room for something that could have been resolved in a doctor’s office, the primary care practice will be penalized for those actions. More about this in part 3 of the blog.
CLINICAL PRACTICE IMPROVEMENT ACTIVITIES: This part of the report card represents 15% of a practice’s final grade. Essentially practices will have to participate in several activities selected from a menu of 90 options and carry out those activities throughout the year. In the end, practices will have to prove that the activity helped enhance the quality of their patient care. Likely to be a very time consuming chore tossed on top of the usual hours of administrative duties, phone calls, and paperwork that practices now are drowning in, these activities will just be another burden dropped on the laps of burnt out doctors and nps. There is no evidence that such activities actually improve the quality or value of patient care. And most likely their implementation will be so complex and nuanced that passing the measures will be difficult for small practices.
Based on the scores tabulated by these four parts of MIPS, a final report card will be issued for every practice. As mentioned, the plan is revenue neutral, so as many practices will be hit by fines as greeted with bonuses; thus even if a practice scores well, it may not be well enough; MIPS is graded on a curve. What is already very clear is that the vast majority of practices that will be getting bonuses are large hospital and corporate based practices where doctors are employees and overhead is typically high. Classically in such institutions bonus money never trickles down to the doctors and nurse practitioners; it tends to disappear after bouncing around the pockets of the executives and corporate managers of the practice. And with such harsh penalties being inflicted upon independent primary care practices, those practices will likely disappear; most patients in Medicare’s future will be getting their health care in large corporate structures that are protocol driven, where visits are shorter, and where individualized care evaporates amidst generic rules and regulations. Doctors will be employees following orders, patients will be generic entities expected to similarly follow orders; the script is being written by MIPS. That is why this seemingly innocuous and beneficent program will transform the health care landscape much more profoundly than anyone seems to realize.
Also, as we will see in the next two blogs, this program will likely lead to worse Quality and Value for doctors, patients, and Medicare. It is the classic Orwellian ruse; Big Brother telling us what to do, using words like Quality and Value to create a system that promotes just the opposite, as doctors and patients are buried in a soulless medical landscape that has lost all allegiance to an individual patient’s wants and needs. In chapter 6 of my newest version of Curing Medicare, published this month by Cornell, I discuss how Medicare reforms like MIPS are taking us down a dangerous and costly path, while I demonstrate a far simpler way forward that does not have to be so complicated and costly. It is called common sense. And we will talk about that in the next two blogs.