The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is not going to hold down the increasing cost of Medicare by adding over 1,600 pages of new regulations to the program. Instead, the Centers for Medicare & Medicaid Services (CMS) should have reduced the cost of traditional Medicare by eliminating the requirement for detailed documentation of evaluation and management (E/M) charges.
Physicians are hard-pressed to examine and treat each patient, plus provide detailed E/M billing documentation, while keeping up with patient flow. Doctors type furiously during the entire office visit, focusing attention on the computer instead of the patient. The chart should be a concise record of important findings, results and conclusions, for clinical use only by physicians, not a compendium of details intended to support billing. Payment should be based on the time spent treating the patient, and the services rendered, as attested to by the physician. The reduction in the time spent on justifying E/M billing would reduce the cost of traditional Medicare, and reduce the amount of typing required. Instead, CMS will retain the requirement for full E/M documentation, and then pile onto that the additional documentation burdens of MACRA, which will require even more typing during the office visit.
Can doctors be trusted to self-assess the value of each patient encounter? Who is better qualified? It is insulting and ridiculous for a doctor's progress note to have its "complexity of medical decision-making" downgraded by a CMS auditor who has a high-school diploma and 6 months of training in CPT billing. Rather than requiring each note to be free-standing proof of the level of work performed, let the doctor bill based on the time spent treating the patient, and the complexity of the patient's problems. CMS can also add up the estimated time for every appointment, and check that the total does not exceed the doctor's recorded office hours that day. The patient's complaints, ICD-10 codes and medication list can be used to determine complexity.
Costly quality improvement
We are told that MACRA will save money by improving the quality of care. Evidently, someone at CMS imagines that improving the quality of medical care can make it less expensive. Improving quality is a worthy goal, but one that generally requires increased spending.
FURTHER READING: 10 things physicians need to know about MACRA in 2018
Consider the example of screening postmenopausal women for osteoporosis, and treating osteoporosis with bisphosphonates to prevent fractures. Most good doctors do this already, but the bad doctors who don't are probably saving money for Medicare by not ordering all those DEXA scans and bisphosphonates. The patients of bad doctors require more hip replacement surgeries in later years, but this does not raise the cost of bad care enough to make preventative DEXA screening and treatment pay for itself. That is why the estimated cost per quality-adjusted life year (QALY) for DEXA screening is about $50,000. Good medical care is generally more expensive than bad care. Even taking low-dose aspirin, for secondary prevention of myocardial infarction, has an estimated cost of $11,000 per QALY.