Dr. Darren Meyer’s Dissent on the CMS proposed MACRA rule

A courageous Texan physician colleague, Darren Meyer, MD, shared his comments to CMS with me. Please, take heed of his comments and share yours with CMS before the deadline,  June 27, 2016. I personally have submitted a series of 8 Daily Dissents to CMS and have yet to see them posted, while others are posted within a day of submission and since the submission of mine. Please, read my previous posts and take heed of my comments as well. Then post yours. Thank you Dr. Meyer for allowing me to share your comments. You are a blessing to your patients and our profession. Here are Dr. Meyer’s comments:

Darren Meyer, MD

McKinney, Texas

Memorial Day

May 30th, 2016

 

As I tried for formulate some of my thoughts about why I am opposed to the implementation of the MACRA, my initial thoughts were that the whole idea and the assumptions on which it is based are so demonstrably false that trying to address particular concerns about how this or that item is scored or reported is pointless.

My concerns are based in part on the current situation with the VA’s health system. Despite what may be $65 billion in VA healthcare funding in 2017, tens of thousands of administrative positions, and a massive data collection and reporting system, the VA cannot generate accurate quality data that translates into meaningful benefits for veterans seeking care. Consider the following excerpt from the VA’s investigation of alleged manipulated wait times in the North Florida/South Georgia Veteran’s Health Center. This report was issued in 2008 regarding events from years prior:

“We substantiated the allegation that when schedulers created appointments for some new

patients, the use of non count clinics prevented the patients’ actual waiting time from

being accurately assessed.”

 

“Although the Director’s Fiscal Year (FY) 2008 Performance

Plan included patient waiting times as a performance measure, it was not a “mission

critical” measure and only accounted for 5 percent of the Director’s rating. Therefore,

the understatement of waiting times that occurred from creating new patient

appointments in non count clinics did not significantly affect his performance appraisal.”

(VA OIG Report No. 08-03327-35 December 4, 2008.)

 

This points out several systemic flaws in medical performance data collection, reporting, and evaluation:

1) If the people entering the data are not telling the truth, or even just making honest data entry errors, everything that follows is useless. In many systems, employees are pressured to make the numbers look good so their managers look good. It’s human nature, and forced implementation of the MACRA will just create more pressure on the data collectors to enter the “right” data. Even if there is no deliberate manipulation of the data, the volume of data entry the MACRA requires in order to be a compliant, quality provider is so burdensome that it is certain to fall short of the accuracy it will claim to possess.

2) Decisions about what is “mission critical” determine the value of the reports generated. In this example, patient waiting times were not considered critical. I am certain the veterans waiting for care would feel otherwise.

3) How different evaluation criteria are weighed also determines the conclusions one makes, such as the scoring system of bonus points and such built into the MACRA. Again, whoever decides what items count for how much determines the reported outcome more than the real outcome. In the above example, since wait times were given so little value, the Director came out looking like he was doing a great job, when that was not the case. The MACRA is going to do the same thing. And no amount of changing the weighting of this item or that will ever take enough bias out to make the collected data have much relevance to real-world patient care. Patients care about getting well, not getting cut up into data points.

Now recall that this VA investigation and report was back in 2008. Sadly for our veterans, their situation has not changed despite one report and investigation after another. I’ll spare us both the references to all the current challenges veterans face in trying to access healthcare in a timely manner. Veterans Affairs Secretary Bob McDonald himself still brushes off wait times, comparing the “experience” of waiting for health care to Disneyland guests waiting for a ride:

“The days to an appointment is really not what we should be measuring. What we should be measuring is the veteran’s satisfaction,” McDonald said. “What really counts is how does the veteran feel about their encounter with the VA? When you go to Disney, do they measure the number of hours you wait in line? What is important is, what is your satisfaction with the experience.”   Unless a veteran died in line, of course. Then that insignificant 5% of the total score was 100% fatal.

(http://www.csmonitor.com/USA/Politics/monitor_breakfast/2016/0523/Quality-care-for-vets-more-important-than-wait-times-says-VA-secretary)

I am concerned that with the further expansion of the Federal government into our healthcare system through the MACRA, everyone’s healthcare is going to end up like the VA healthcare system, where the wait does not matter, and your “experience” only exists as it was administratively recorded, entered, weighed, and scored under an arbitrary accounting system that is almost completely disconnected from the real-life encounters that patients have with their doctor.

One partial solution was to give veterans the option to go outside the VA system for care under The Veterans Access, Choice and Accountability Act of 2014 (https://www.gpo.gov/fdsys/pkg/BILLS-113hr3230enr/pdf/BILLS-113hr3230enr.pdf). That has proven to be an administrative failure as well. As currently structured, doctors have to file so many forms and requests to receive authorization to provide care, and then another set to get paid, that few participate.

The same 2014 act referenced above also created the Commission on Care “to examine veterans’ access to Department of Veterans Affairs health care and to examine strategically how best to organize the Veterans Health Administration (VHA), locate health resources, and deliver health care to veterans during the next 20 years” (https://commissiononcare.sites.usa.gov/). Their preliminary conclusion? Scrap the whole system over the next 10 to 20 years and transition veteran’s care to the private sector. (https://commissiononcare.sites.usa.gov/files/2016/03/2016.3.18-Proposed-Strawman-Assessment-and-Recommendations.pdf). So while there still is a private healthcare sector, and while we still have a chance to not make practicing medicine so much more administratively oppressive, I urge delay in the implantation of the MACRA. As currently written, the MACRA will only serve to accelerate the push of the private healthcare system in America toward a VA-like system, just as the patients trapped in the VA system are trying to get out.

Darren Meyer, MD

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