The more I read federal healthcare law and the rules promulgated thereof, the more I realize how insane the law is and how bizarre it is that we the people dutifully implement and comply with the insanity. I first read the Medicare Access and CHIP Reauthorization Act (MACRA) just after the House of Representatives passed it in March of 2015. I tried to alert the public and stop the Senate from passing it. Only eight Senators had the wisdom and fortitude to vote against it. I then read and dissented to the proposed MACRA rule and went so far as to travel to DC to personally meet with then head of CMS (formerly Executive VP of United Optum), Andy Slavitt, to point out the dangers and suggest solutions. While professing to listen, hear, and modify the rule accordingly, the CMS bureaucrats made revisions to the proposed rule that did virtually nothing but provide lip service to the people and cover to the most egregious, transformational law in US history.
MACRA’s Merit Based Incentive Payment System (MIPS) is a top down totalitarian, Chinese-government-style rubric crafted by progressive politicians of both parties and applied by progressive bureaucrats of the deep state to all physicians and patients of America in a one-size-fits-all fashion. It is the template for the transformation to socialized medicine, replete with assigning scores from 0 to 100 in grade-school and Communist-China fashion to individual Americans in association with monetary rewards and penalties based on how obediently “eligible professionals” dole out limited amounts of government approved medical goods and services to “beneficiaries.”
CMS acknowledged per the government’s own analysis, that MACRA will harm small medical practices and put them out of business in short order. The infamous Table 64 from the original proposed rule projected that 87% of “Eligible Clinicians” who are solo practitioners will receive a negative payment adjustment, as will 70% of those in practices of two to nine physicians. Combined, 73% of physicians in practices with fewer that 25 physicians and 60% of all eligible clinicians in groups of less than 100 will be penalized with a cut in payments. Loss of these practices will shatter care. According to the Texas Medical Association (TMA), more than 60% of Texas physicians practice in groups of one to three. These patients will lose their doctors and access to medical care under MACRA MIPS.
In response, CMS created exemptions for small practices from MIPS and self-congratulated shamelessly. The current 2017 MIPS policy allows exclusions for individual MIPS eligible physicians or groups with less than or equal to $30,000 in Part B allowed charges OR less than or equal to 100 Part B beneficiaries for the year. The proposed 2018 rule increases the threshold for exclusion from MIPS to less than or equal to $90,000 in Part B allowed charges or less than or equal to 200 Part B beneficiaries. Before they hurt their backs patting them, let’s see what they have in fact done.
For my medical surgical practice of ophthalmology, the one-size-fits-all law is a nightmare, and the exemption from it is a farce. A typical ophthalmology practice is composed of largely Medicare aged patients, because most medical conditions that require eye surgery and ophthalmologic evaluation and treatment occur in patients 65 and older. Cataract, glaucoma, age-related macular degeneration, retinal detachment, diabetic retinopathy, complications of cardiovascular disease, and other potentially blinding diseases occur in the Medicare age population. Most people fear blindness more than death. Ophthalmologists work to prevent and treat blindness in this increasing segment of the population. According to the AARP Fact Sheet: “Currently, 44 million beneficiaries—some 15% of the U.S. population– are enrolled in the Medicare program. Enrollment is expected to rise to 79 million by 2030.” Using the 2017 CMS MIPS exclusion, I can only see only 2 Medicare patients per week over the course of the year if I want to avoid the MIPS monetary penalty and stay in business. I cannot perform even one cataract operation per week on a Medicare patient if I want to avoid penalty. The 2018 proposal does little to improve on this- I could see 4 Medicare patients per week but not operate on even 2 Medicare patients each week if I choose to avoid MIPS participation. According to Richard Lindstrom, M.D. in the March 2015 Review of Ophthalmology , Thoughts on Cataract Surgery: 2015 (the same month MACRA was passed in the House): “Cataract surgery is the most common procedure performed by the ophthalmic surgeon. This year 3.6 million cataract procedures will be performed in the United States… In the United States, there are approximately 18,000 ophthalmologists, of whom 9,000 perform cataract surgery regularly. Thus, a typical surgeon might anticipate a surgical volume of about 400 eyes per year. “ Under current MACRA law, a surgeon who does even 10% of what is truly needed currently will be penalized. The insanity is blinding, literally. Who needs to see when they’re 65 or older anyway? What Health and Human Services Secretary Price should do is advise CMS to exempt all practices with less than 10 physicians from MACRA MIPS altogether and allow Medicare beneficiaries to see private-contracted Medicare physicians if they so choose, but this is not what is proposed.
I am dumbfounded that MACRA is law and more so that physicians implement and comply. Of serious concern, is that MACRA’s “All-Payer Model” rolls out in 2018, a few short months from now. This new government payment model subjects all payers, commercial insurance companies and Medicare and Medicaid, and all patients, those with commercial insurance and those with Medicare and Medicaid, to this flawed template for government command and control of their medical care- AKA socialized medicine and its inherent rationing of care. Thus far, I see little difference in how this is being handled under GOP control from the handling under Democrat control. The government agencies’ focus is on making it easier for physicians to comply not making it actually work. That physicians acquiesce, albeit begrudgingly, is tragic.
If we would refuse to comply with such insanity, the law would fail. But as a profession, we are too busy to pay attention or too weak to do anything but run for the cooler corner of the hot box. Because of such totalitarian laws (which completely violate what was set forth when Medicare and Medicaid were created), I can no longer ethically enter into any agreements with 3rd party- commercial or government insurers. My agreement is solely with my patient. Heartbreakingly, national healthcare law is making it increasingly difficult for patients to see physicians like me who won’t play the game and facilitate the fundamental transformation to socialized medicine. I pray Americans, particularly our physicians, will wake up and stand up. I am discouraged, but surrender is not an option. So, I keep reading the ludicrous laws they pass and the ridiculous rules they write and trying to forge ways to practice Hippocratic medicine in spite of them . Insanity reigns. We must dethrone it.
Start by commenting to CMS on the proposed MACRA rule changes by tomorrow.