When Medicare and Medicaid were created, the government promised not to interfere in the practice of medicine whatsoever. President Lyndon Johnson signed the Act into law on July 30, 1965, ironically in Independence, MO. The Act established Medicare, a health insurance program for the elderly, and Medicaid, a health insurance program for the poor.
Nothing in this title shall be construed to authorize any Federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided, or over the selection, tenure, or compensation of any officer, or employee, or any institution, agency or person providing health care services… or to exercise any supervision or control over the administration or operation of any such [health-care] institution, agency, or person. Section 1801, Medicare Act, 1965
Fifty years later, in flagrant violation of this prohibition clause, stands the 2015 Medicare Access and CHIP Reauthorization Act (MACRA), replete with the Merit-Based Incentive Payment System (MIPS). MIPS is a rubric the federal government uses to grade physicians and assign each a score of 0 to 100. The Composite Performance Score (CPS) is used to financially incentivize or penalize physicians, and then the scores are posted on a public website for all to see. I contend MIPS constitutes deliberate government extortion of our nation’s physician, and at the core lies the ultimate conflict of interest- the very lives and well-being of America’s patients vs. the money and power of the medico-industrial complex run by a small group of insider elites, implemented and micro managed by entrenched, faceless deep state bureaucrats. At the heart of the matter, begs the question of physicians, who do you serve? Are you a physician in the tradition of Hippocrates, who believed the physician works on behalf of the patient, not for the good of the state, or are you a physician like Plato, who urged that doctors refrain from curing the weak and infirm to improve society? Do you serve the patient or the state?
I further contend that implementing and complying with MIPS is ethically untenable for those who sacrifice and devote our lives to serving patients, and that physicians who do engage in MIPS either don’t understand it or are forsaking their virtue and morality under threat of bankruptcy and continued abuse from an over-aggressive government no longer controlled by the people but by a powerful cartel of self-serving third party bosses.
MIPS consists of four categories upon which physician are graded: quality (outcomes), advancing care information, improvement activities, and cost. Earning a high score often requires doing what government says instead of what is best for the patient. Doing what is best for the patient often results in a low score, loss of income, and public humiliation on the public website.
- While this sounds great, the “quality indicators” and “outcome measures” chosen may be harmful for patients or deter physicians from taking on the most difficult and challenging patients. For example, one measure of outcome is how many patients under a physicians’ care achieve a blood glucose level under a certain number. One of my patients told me she has passed out twice, sustaining injuries, since her PA put her on two diabetic medications to get her blood sugar below the government number. Imagine if she had been driving or been alone at home in her bathtub. She stopped taking the medications and has yet to return to her physician for care. Since I have refused to participate in MIPS and the likes, I am “out of network” for all insurance plans including Medicare and Medicaid. Ironically, I am seeing an influx of patients with what I call “3rd world cataracts” seeking my care. One that comes to mind could see light only when he sought my care. He is 60 years old with severe cardiovascular disease that presents a higher than normal surgical risk, but his quality of life is unnecessarily negatively impacted because he can only see light, not even hand motion. I did what was best for the patient, operated on him, and he is now 20/20. The surgery was more difficult, because in the government medicine shuffle with the risk of a poor outcome, he had been avoided by several surgeons trying to play the MIPS game to the point his cataracts were like granite rocks floating in bags of milk, making visibility and removal difficult. The physicians earning the highest “quality” or “outcomes” score might be inflicting undue danger on their patients or avoiding the most difficult, sickest, weakest patients altogether.
- Advancing Care Information (ACI). This used to be called “Meaningful Use Electronic Health Records”, but Advancing Care Information sounds so much friendlier that MACRA changed the term in Orwellian fashion. MACRA sets law and rules in motion that mandate that government have full, unblocked access to patients’ records, including their protected health information (PHI) without their permission. PHI includes all personal identifying data including all demographics and all medical history, past and present, including all medications ever taken. This is not just a violation of the Hippocratic Oath and sacrosanct patient-physician relationship, but this is a blatant violation of the 4th Amendment. Government will gather all data, not just MIPS data, on all patients, not just Medicare patients, and from all insurers- commercial too, not just Medicare. This data will be sold by government to entities the federal government itself chooses. On a personal note, when I was hospitalized after breast cancer surgery in 2012, an elderly male patient’s medication list was errantly entered into my electronic health record. Had I not been a physician, the error could have gone unnoticed, and I could have been severely injured if not killed. EHR’s have been implemented at warp speed without proper testing. Those seeking high MIPS scores facilitate this, thus, endangering patients and violating their rights. I believe it is my duty to keep my patients’ private information from government not transmit it to government.
- Improvement Activities. This is a sneaky one. This is a category where government hopes to, in their own words, “drive physician behavior,” like by having us engage in “education” activities that government deems important- like learning about the emerging “palliative care” movement, replete with educational material glorifying “aid in dying”- formerly know as “physician assisted suicide,” the little sister of euthanasia. This also links the Maintenance of Certification (MOC) issue to government scoring, and financial penalty or reward, and is the mechanism for control of physicians by hospitals, insurance companies, and groups working toward nationalized, if not international, medical licensure.
- Formerly known as Resource Use, this category is beyond worrisome. The sample grade chart itself shows that physicians who spend the most on their patients get 0 to 2 points while those that spend the least get 8 to 10 points. In other words, doctors get more money for withholding care and resources from patients and are penalized for delivering care and resources. Need I say more?
There can be no denying, MIPS is a top down, command and control grading system based on perverse incentives whereby government rewards physicians who do government bidding and penalizes physicians who serve their patients first. MIPS is more like a Marxist grading system used by China on their citizens than a grading system imposed on America’s physicians. Don’t shrug and think this doesn’t affect you. To make matters worse, government has redefined the definition of physician to include everyone from audiologists, dieticians, and speech pathologists to Nurse practitioners, Physicians Assistants, Nurse Midwives, clinical nurse specialists, psychologists, and so on. We are all now lumped into a group called “Eligible Clinicians” or “Eligible Professionals”- that subjects virtually everyone at all associated with health care to MACRA and its perverse MIPS. Read the law for yourself.
In the fifty years since Government vowed not to interfere with medicine whatsoever, government has completely taken us over. It is no wonder physician suicide is epidemic and life expectancy in the US is not increasing, but declining for the first time in history. Ask yourself; do you serve the patient or the state? Do not violate your oath, your ethics, and your conscience to get a higher Composite Performance Score and a positive payment modifier- AKA a payoff. I don’t know whether this is extortion, bribery or both, but I do know- I won’t do it. And neither should you. If physicians would not comply, this perverse system would die. Patients can help by understanding what is going on and realizing that physicians with the highest scores may not necessarily have their best interests in mind, while those of us who refuse to play this most dangerous game wear our Scarlet Zeroes proudly and deserve a second look rather than a premeditated shun.