June 15, 2016
My name is Darren Meyer, MD, and I am in a two-physician psychiatric practice in McKinney, Texas. I am currently both a TriCare and a Medicare provider. I have read through much of MACRA and I must say again, as I had posted earlier, that I am not in favor of implementing this Act. A particular concern I have is how quality of care and outcomes are to be measured and reported. Let me share two recent clinical cases to illustrate my belief that the recommended quality measures and reporting mechanisms cannot be relied upon as accurate indicators of quality of care, and should not be used to determine physician reimbursement.
A middle-aged female patient of mine who has been under my care for years returned for a follow-up visit a few weeks ago. She was clearly not feeling well. She had recently had back surgery and had spine films taken the day before. Those x-rays showed bilateral patchy infiltrates as an incidental finding to her intact spinal hardware. Her orthopedic surgeon recommended she take that report to her primary care physician. She was there this morning, and saw the nurse practitioner. The nurse practitioner told her she needed to go to her pulmonologist. She called her pulmonologist, and was told they would get back with her with an appointment time. My patient has limited mobility and is not able to drive. Getting to and from all of these other appointments is extremely difficult for her. I have a nurse who works with me in my office. You should know I had to hire her two years ago to help me keep up with my attempt to be EHR-compliant, an endeavor I soon abandoned as one additional staff member was all we could afford to hire. I had my nurse check my patient’s vital signs, and we found she had a temperature of 100.1°F and an oxygen saturation of 92%. Her son was with her, and we advised them to go to the emergency room. She called the next day to tell me that she had been admitted with bilateral pneumonia, and she thanked me for sending her to the hospital right away. Now keep in mind, I am a psychiatrist. But I have not forgotten my medical training. I know her other physicians practice in large groups and they have marvelous IT staff and they generate very pretty electronic records so I assume they would score quite well in their management of this woman’s case. But I find no means under MACRA for me to receive adequate credit for the time that I spent to listen to her concerns, to perform what was largely a non-psychiatric evaluation, and to make a potentially lifesaving referral. I am the type of physician who will be penalized under MACRA, while the box–checkers will be rewarded.
I had a similar outcome earlier today. There is a gentleman who has seen me for years who has had chronic recurring infections that have not responded to multiple rounds of antibiotics. He has been to an excellent dermatologist and an infectious disease specialist. I have received progress notes from those practitioners. They are clearly computer–generated records, and very likely would pass every MACRA quality review. But it was me, the psychiatrist, who suspected that he had some type of immunodeficiency syndrome and referred him to an immunologist. My suspicions turned out to be correct, and he will likely begin gammaglobulin infusions soon. I don’t find a checkbox under MACRA’s psychiatric quality measures that would credit me for anything other than documenting that he has continued to take his antidepressant medications routinely. And I’m by no means unique. There are thousands of doctors who take the time to listen to their patients, who truly care for them, who try their best to help them, and who are at their wits end with more forms to fill out or reports to file when all they want to do is take better care of their patients, not chase brownie points on an EHR.
So from MACRA, this is what I see in one of the tables:
28374 Federal Register / Vol. 81, No. 89 / Monday, May 9, 2016 / Proposed Rule
Percent with negative pay adjustment: 68.8%
Percent with positive pay adjustment: 31.1%
Aggregate negative impact: -$29 mil.
Aggregate positive impact: +$8 mil.
At a time when it is clear that mental health services need to be expanded, why are you proposing a net negative reimbursement to psychiatry? According to CMS data as reported in Modern Healthcare, “Among adults aged 18 through 64 with Medicaid coverage, approximately 9.6% have a serious mental illness, 30.5% have any mental illness, and 11.9 % have a substance use disorder.” (http://www.modernhealthcare.com/article/20160329/NEWS/160329877) When those adults turn 65, or at an earlier age if they are determined to be disabled, they are all going on Medicare. Who is going to be there to take care of them?
And as reported in Modern Healthcare by Maria Castellucci on June 15, 2016,
“A House committee Wednesday voted unanimously in favor of advancing a sweeping mental health reform bill. The Helping Families in Mental Health Crisis Act passed 53-0 in the House Energy and Commerce Committee and is now going to the full House floor. “
(http://www.modernhealthcare.com/article/20160615/NEWS/160619939) Again I have the same question: If just as laws are being proposed to expand mental health treatment, why is CMS considering cutting reimbursement to two-thirds of the few psychiatrists who still accept Medicare assignment? And for the third who might receive a small increase, don’t you see that the measures proposed to decide who is rewarded and who is punished are only minimally indicative of what actually happens in real clinical encounters between patients and physicians? You are not collecting meaningful data, and therefore cannot come to accurate conclusions as a basis for payment. You will reward large impersonal corporate practices with the dollars you withhold from physicians like me, who have chosen to spend more time listening and less time typing. That makes no sense and it’s wrong on all counts, so I ask that MACRA not be implemented at all until these and so many other intrinsic flaws are corrected.
Darren Meyer, MD