Physicians have pledged to retire or leave Medicare as a result of burdens placed on them by the recently finalized payment rule. That could spur Republicans, soon to be fully in charge of the government, to slow federal value-based payment efforts.
But the Medicare Access and CHIP Reauthorization Act, or MACRA, was a bipartisan policy change, making it unclear if the GOP would want to dial back a law that has received wide approval.
Last month, CMS finalized the rule that implements MACRA. To avoid penalties under the law, physicians will participate in one of two reimbursement tracks: a quality-based system or advanced alternative payment models.
In the Merit-based Incentive Payment System, known as MIPS, physicians' Medicare pay will be based on success in four performance categories: quality, resource use, clinical practice improvement and “advancing care information,” which is based on the meaningful-use program the government has used to decide whether doctors should be rewarded for using electronic health records.
If physicians opt out of the MIPS track, they could participate in an alternative payment model, such as an accountable care organization or patient-centered medical home, which align doctors, hospitals and post-acute providers to coordinate care.
Despite finalizing the rule, the CMS left it open for comment, and complaints are pouring in from providers who say they are at wit's end.
Dr. Joseph Morgan, an allergist in Oregon, hoped to practice another four or five years before retiring. However, he said coping with the new ICD-10 coding system and EHR rules has cut his productivity and added a minimum of at least two hours to an already long work day, therefore “destroying” family time and social life. Now with the final rule in place, he wrote he has been pushed over the edge.
“With the prospect of adding MACRA's impossible requirements, I will retire shortly after the first of the year,” Morgan said in a comment to the CMS.
Dr. Kenneth Luckay, a family physician in Virginia, had a different response to MACRA. Instead of retiring, he will no longer take Medicare reimbursement.
“I am one of the increasing number of experienced physicians who have opted out of Medicare due to MACRA,” Luckay said in a comment letter. “One upside of this exodus will be the desired cost containment for Medicare, but at a great cost to those patients who will be affected by the lack of healthcare availability.”
The CMS' final rule is “causing the biggest brain drain in the best medical system in the world,” Dr. Marc Swerdloff, a Florida-based neurologist, commented. “You will reap the whirlwind you have sown. I would have never thought the central government would have so little regard for its patients and doctors.”
Experts are mixed about whether those sentiments would be enough to get the Republican-led Congress and the incoming Donald Trump administration to slow Medicare's march away from fee-for-service medicine to a value-based system.
With the nation already facing a physician shortage, it is likely Congress will take these comments seriously, said Kristen Valdes, a former vice president at UnitedHealthcare who founded b.well, a Baltimore-based digital health startup. Congress may choose to slow implementation of MACRA until they can assess how many physicians would leave Medicare or the profession because of the law, she said.
Grace-Marie Turner, president of the Galen Institute, a conservative research group, agreed. But she said the likelihood of slowing the MACRA rollout will rely heavily on how aggressively doctors lobby. The American Medical Association has called for flexibility with the MACRA payment tracks and was supportive of many of the changes made in the final rule.
Others were doubtful the provider concerns would have much impact. MACRA passed a GOP-controlled House and Senate, which could mean legislators will be unlikely to revisit the law, said Dr. Jane Orient, an internist and executive director of the Association of American Physicians and Surgeons, a far-right provider group.
Many in the industry also agree value-based care models will survive regardless of which party is in power. “This is not an area that is up for debate,” said Blair Childs, senior vice president of public affairs at Premier. “It's clear that value is the new health economy and measures are the currency.”
Some policy experts believe doctors could be crying wolf. “Physicians have threatened to retire or leave Medicare many times,” said Gail Wilensky, a health economist who was the Medicare administrator under President George H.W. Bush. “I haven't heard anything to suggest it's likely.”
Michael Cannon, director of health policy studies at the libertarian Cato Institute, noted there may be more seriousness in the physician comments CMS is receiving. “There is reason to think they may mean it this time,” he said. “These are more sweeping changes. It's not just a change in payments. It's a change in what they need to do to get paid.”
