Curbside Consult with Dr. Jayne 5/2/16

Since the release of the proposed rule for MACRA, many of my colleagues have been heads down trying to digest the content and figure out how to operationalize the requirements. While some organizations are taking the proposed rule and running with it, others are adopting a “wait and see” approach given the anticipated volume of negative comments from the public. They’re hoping that things will change prior to it becoming final, which is always a possibility given this crazy environment in which we all now operate.

Although CMS talking heads have said MU is dead, it must be zombie-dead. It’s just been reinvented as “Advancing Care Information,” which although more flexible than MU, is still too daunting for many practices. Physicians will not be accountable for cost category measures from claims data as well as being pushed towards further tracking and reporting on PQRS.

There are two tracks for physicians, with CMS expecting that most providers will be in the MIPS track vs. Alternative Payment Models. The numbers I saw estimated were 700,000 vs. 60,000, respectively. Unfortunately, providers will have to decide wither to submit under MIPS before they know whether they qualify for the APM track. Many organizations will be doing a belt and suspenders approach.

Several of my friends that work at vendors are extremely stressed out, realizing that federal requirements will dominate development efforts over the rest of the year. Just when they had breathing room to work on usability and customer-requested enhancements, they’re going to be forced back to the grindstone to crank out code that may or may not be what their customers want or need. Vendors have to walk a fine line between speculating on what will be dropped from the final rule and running full speed to get it all done.

Some vendors will start working on the requirements whether or not they think they’ll be modified. Given the way the last few rulemaking cycles have gone, even if a particular element gets taken out of the final rule, it will likely rear its head in a subsequent rule or in another program, so this might be a wise approach. On the other hand, if the rule is substantially modified, there is a risk of significant wasted development efforts. Once the comment period closes, it will be several months before we have a final rule. My friends with crystal balls tell me we’ll have the final rule in October with it taking effect in January. If that timeline holds, there won’t be much time for vendors to shift gears if the modifications are significant.

In the provider space, there is a tremendous amount of chatter about this being the last straw for small or independent practices. The requirements are daunting, especially for practices who haven’t been at the forefront of payment reform efforts. Just trying to read and understand all the rules and keep track of all the FAQs we’ll undoubtedly see could be a full-time job. As CMS goes, so go the commercial payers, and I expect we’ll see them ratcheting down on physicians as well. I’m still trying to fully absorb how this will affect my own practice given that we opted out of MU and haven’t looked back.

One of my colleagues brought up a good point. Although providers may not be ready to go to a direct model practice or all the way to a concierge / retainer model, providers have been slowly transitioning out of Medicare. It’s tricky for these non-participating providers when they want to continue to care for Medicare beneficiaries. Another option is to opt out of Medicare entirely. The complexity of the choices make it difficult for providers to consider leaving, especially when they consider that commercial payers will have matching requirements of their own that the providers will still have to deal with. The seemingly-onerous nature of the proposed rules might be a catalyst for providers to consider moving to direct models.

When you think about it, direct payment models would go nicely with some of the goals of all these efforts. If the goal is to put the patient at the center of their own care and to engage them, what better way to engage them than with their pocket books? Patients who start to see the true cost of care (rather than being shielded by their co-pays) might start choosing their therapies more wisely. Perhaps the generic drug that’s been around forever but doesn’t have sexy marketing will start looking more attractive.

We’ve experimented with that to some degree with tiered co-pays and that has driven patients to ask about cheaper alternatives. I’ve seen some patients question their hospital-employed physicians when the patients start getting bills from both the provider and the facility through provider-based billing arrangements. A couple of organizations in my region have done away with the practice based on negative community feedback.

Understanding the cost of care may encourage patients and families to make end-of-life choices that are ultimately more compassionate – choosing palliative care or hospice rather than expensive interventions that may not prolong life and may even damage the quality of life. Patients may begin to analyze whether the expensive (and life-altering) cancer treatments that may only extend life a few months are really worth it for them or for their families. Maybe we’ll stop ordering CT scans for things that really could be diagnosed with a good history and physical exam.

Of course, this wouldn’t solve all our problems. The cost of care is still prohibitively high for many treatments. Patients would still need insurance against catastrophic medical bills and we would still need safety net facilities and arrangements for patients who have limited ability to pay.

It also doesn’t address the real origins of healthcare costs. Lifestyle and behavior-related factors are 40 percent of the pie compared to medical care, which is a mere 10 percent. Human biology is 30 percent, with social determinants of health at 15 percent and environmental factors at 5 percent. Although patient engagement may help the lifestyle and behavior-related category, there’s still much more work to be done.

I still have several hundred more pages to get through, but I’m not sure I’ll make it. It’s too depressing.

Have you finished the proposed rule? What do you think? Email me.

Email Dr. Jayne.