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.
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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.
MACRA's 1,600 pages of new regulations increase the crushing burden of documentation without improving quality of care or reducing costs. Some of the best clinicians in my community are solo practice specialists I chose to treat me, based on my observations as a referring general internist. They have all complained to me that they have already been hit with substantial Medicare fines for non-compliance with the electronic health record (EHR) mandate, and now, MACRA. One of my doctors steadfastly refuses to abandon her neat, legible and well-organized paper charts. Another specialist made an expensive investment in an EHR, only to find that it was burdensome, interfered with patient care, distracted him from concentrating on important issues and was too costly. After one year, he fired his IT consultant and tossed the whole system out of his office. His brilliant and astute clinical care is not being assessed accurately by CMS. He will retire earlier than he had planned, because MACRA fines have cut his already thin operating margins.
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When CMS Administrator Seema Verma was recently told by clinicians that her agency's regulations are too burdensome, her reassuring reply was that MACRA will ease that burden when it is fully implemented. Only a bureaucratic zealot could believe that adding 1,600 pages of regulations will relieve regulatory burden.
The most significant improvement introduced in this year's MACRA update is that more clinicians will be exempted from its mandates. By that metric, MACRA can achieve its maximal improvement by exempting all clinicians from its regulations, I concur.
We are told that an ever-increasing portion of each clinician's pay will be based on how low they can drive their average spending per Medicare beneficiary. That approach will definitely reduce the cost of the Medicare program, but I do not want to be treated by any doctor who is incentivized to reduce spending on tests and treatments. I do not want to be treated by a doctor whose hidden agenda is to save money on my care. I want to be treated by doctors who will offer me the most beneficial interventions for my condition, and my doctors should derive neither profit nor loss from the interventions they order.
Traditional Medicare incentivizes medical testing, in certain situations where a practice owns a lab or imaging facility. Again, doctors should never be financially rewarded or punished for the cost of care they provide. The cost of a patient's care should have an entirely neutral effect on physician income. Doesn't it make sense to get rid of rules that let doctors profit from ordering tests, before we adopt rules that levy fines on doctors for ordering tests?
The fatal bias of patient satisfaction scores
Let me close by condemning MACRA's reliance on patient satisfaction surveys as a factor in physician compensation. The fact that a clinician retains a patient who is free to choose a different clinician tells you everything you need to know about patient satisfaction. Patients vote with their feet, and they do not hesitate to vote themselves a new doctor if their needs are not being satisfied. Traditional Medicare allows patients to switch doctors freely, a freedom which may exact some cost in continuity of care, but which increases satisfaction for patients and doctors alike.
Surveys are fatally biased by the fact that angry patients are much more motivated to fill out a survey than are satisfied patients. Read the handwritten comments by the patients and ignore the standardized rating numbers they circled. The comments tell the true story:
• The patient had to wait for over an hour (because their stingy HMO forces the doctor to overbook to pay the overhead).
• The doctor's medical assistant was nasty to the patient (because most doctors today have no control over the hiring and firing of ancillary staff).
• The billing department turned their account over to collections (because the front desk staff failed to contact the patient when their bills were "returned to sender" by the post office).
• The doctor refused to refer the patient for acupuncture or to prescribe medical marijuana (for a condition lacking evidence of benefit of either treatment).
Doctors prefer to satisfy their patients as much as possible, but there must be limits.
David L. Keller, MD is a retired internist who resides in Lomita, California.