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It was a confusing week for physicians to figure out proposed MACRA rules and dissect the Republican plan to dismantle Obamacare. Let me help make sense of them both.
Editor’s Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Anish Koka, a cardiologist in private practice in Philadelphia. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.
Confusion reigns after a week that saw the release of the proposed 2018 rule for the law governing Medicare payment to physicians, known as the Medicare Access and CHIP Reauthorization Act (MACRA), only to be upstaged by the arrival of the latest iteration of the Republican healthcare plan for the nation: The Better Care Reconciliation Act (BCRA).
Further reading: Physicians, healthcare industry react to 2018 MACRA proposed rule
Condemnation of the BCRA is near unanimous the best I can tell. Republicans find the bill to be either not conservative enough, or too conservative and the Democrats have declared the bill poison sure to rival wars in the deaths it will cause.
It doesn't help that non-partisan analyses are difficult to find for the hapless physician who simply wants to know how this affects us and our patients, and by extension, our livelihoods. What follows are my best attempt to answer some important questions for fellow practicing physicians.
Sadly, the current administration's version of MACRA reads like it was written by the prior administration. The cat-and-mouse game between Medicare and its physicians is very much alive and well.
Avoiding a penalty in 2019 requires enrolling individually in the Merit-based Incentive Payment System (MIPS) or being a part of an Alternative Payment Model (APM). The MIPS track, as before, involves scoring points to provide value by reporting on quality measures. In the current year, a penalty may be avoided in 2019 by reporting on one quality measure for one patient to nudge physicians onto the value-based hamster wheel. There are some wrinkles to the proposed plan for 2018 (affecting 2020 payments).
Even more info: Top 8 things doctors need to know about 2018 MACRA proposed rule
The most significant is raising the low-volume threshold to $90,000 or less for Medicare Part B charges or 200 or fewer Medicare patients annually. The prior threshold was $30,000 or 100 Medicare patients. Surprisingly, only 36% of eligible clinicians cross this new threshold - though they do make up almost 60% of Part B charges. Other changes relate to bonus points for complex patients, reporting in virtual groups and easing requirements for the use of 2015 certified electronic health record (EHR) technology. In the end, these changes are not nearly enough to ease the stifling regulatory environment the current value-based regime finds itself enamored with. It puts small physician groups at a disadvantage.
The BCRA is designed to impact patients not covered by Medicare or employer-sponsored group insurance. Currently this group is divided between Medicaid patients, those on the individual marketplace and those that are still uninsured.
The Affordable Care Act (ACA) instituted an individual mandate that-under threat of financial penalty-required patients to sign up for insurance through the Obamacare insurance marketplace. Generous subsidies to insurance companies kicked in for those making <400% of the federal poverty line (FPL).
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The proponents of the BCRA envision a world where patients may choose to have health savings accounts (HSAs) funded by tax-free credits that they can use to buy insurance on the individual market. Subsidies based on age and income (less generous than the ACA) kick in at less than 350% of the FPL. The GOP has replaced the individual mandate with a penalty of its own: a freeze of six months for getting insurance for those who did not maintain continuous coverage the year before.
The New York Times recently ran a helpful table for insurance premiums for a single individual with an annual income of $26,500 purchasing a current bronze plan through the health insurance marketplace. The difference in premiums between the ACA and BCRA are significant because of the more generous subsidy support in the ACA. However, the premium comparisons listed are overly simplistic because it assumes the price of a bronze plan is static. The ACA mandated that the difference between the least expensive and most expensive plan could only vary by factor of 3, mandated generous “essential” health benefits, imposed a health insurance tax that was passed on to the consumer and had a weak individual mandate that still left millions of young healthy folks out of the marketplace. These ACA mandates were all modified in order to get those all-important patient-paid premiums to decrease, and there is widespread agreement (even from the CBO) that this will happen.
A recurring, and understandable concern, is where individuals and families with meager resources actually will get the dollars to fund HSAs or pay for care that falls under a high-deductible plan. Tax credits are a nice idea, but you need income to be able to put money into a tax free account. The GOP solution relies on the allocation of $110 billion to the State Stability and Innovation Program that is specifically meant to “Reduce out-of-pocket costs, such as copayments, coinsurance and deductibles, of individuals enrolled in plans offered in the individual market.” There is active debate about whether this is enough money, but consider that the total amount of money allocated for cost sharing subsidies (now repealed) in the ACA was $105 billion.
The intent of weakening essential health benefits was to allow for skinnier plans that would cost less. What exactly will be covered under your plan is unclear as there seems to be latitude given to states to decide on minimum health benefits (though certain popular aspects of the ACA like children being covered until age 26 were left in place). Democrats are fearful that patients may be preyed upon by insurance companies that offer plans that don't actually pay for anything. This is mildly amusing as the weighty ACA plan that I currently have pays for mental health as it is mandated to do, but leaves me with hundreds of dollars to pay for routine labs because of a high deductible.
Reasonable people can come to different conclusions about this question. The BCRA does attempt to bend the cost curve by extracting savings from Medicaid. If all one hopes to do is to take the current system and extract dollars from it, there is little question that services will be degraded.
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What is unknown, however, is if the plan to convert Medicaid to a tax credit-based system that patients can use to spend on healthcare, along with cost-sharing support for those under 350% of the Federal Poverty line will actually work. Conservatives believe, and I'm partial to the idea, that giving patients healthcare dollars directly will make them just as resistant to buying a $1,000 bag of salt water as they would be to buying a $1,000 flip phone.
Billions of dollars do flow to the truly disabled within the Medicaid program and much of the hand wringing understandably relates to cuts to services for this population. Giving states flexibility under block-grant federal funds, and capping what the federal government can spend (as opposed to the unlimited federal match states enjoy right now for each additional patient enrolled) could theoretically lead to poorer services for several patients, including the severely disabled. I find it hard to believe, though, that any politician with an interest in getting reelected would choose to do this. It is much more likely that states would go after low hanging fruit like fraud and waste, and look to incentivize able bodied patients to get off Medicaid so states could continue to pay for those who most need it.
Anish Koka is a cardiologist in private practice in Philadelphia trying not to read the writing on the wall. Follow him on twitter @anish_koka.