Kip Sullivan submitted the following comment on CMS’s proposed MACRA rule.
I am not a doctor. Nor was I trained in establishment health policy ideology by a graduate school of economics or health policy. I state that I am not a doctor not because I hold the condescending view of doctors held by CMS and those who enacted MACRA, but because I want to make it clear I cannot be accused of having the bias that CMS and other MACRA proponents allege that doctors have. I have spent the last quarter-century studying and teaching health policy for non-profit citizen organizations.
I have described the most important defects in the proposed MACRA rule in three articles I posted on The Heath Care Blog (see links below). Those defects are (1) CMS’s inability to measure cost or quality of medical services accurately, which means “value” cannot be measured accurately, and (2) the failure of ACOs and “medical homes” (the “advanced APMs” that CMS relies on to make the APM program work) to save money for Medicare. These defects guarantee CMS’s MACRA rule will fail.
Exactly how it will fail is difficult to say because it is so complex. It may fail by raising Medicare’s costs; by raising physician and hospital costs so high providers avoid APMs or Medicare patients; by damaging quality of care for patients whose care is not measured because doctors “teach to the test” (that is, they move time and resources from patients whose care is not measured to patients whose care is measured); by worsening physician burnout; by worsening health disparities as those doctors who treat sicker and poorer patients are punished by CMS’s crude attribution and risk-adjustment algorithms; and/or by accelerating the consolidation of the health care system and thereby making it even less likely that either competition or regulation can hold physicians and hospitals “accountable” for anything.
But MACRA’s failure is certain. Failure is guaranteed by this simple fact: For feedback to be useful, it must be accurate and intelligible. The feedback CMS will give doctors under MACRA – the financial feedback and the periodic reports CMS proposes to send to doctors – will be grossly inaccurate and unintelligible. CMS’s feedback will be grossly inaccurate because neither CMS nor any other group of human beings can “attribute” patients accurately to most doctors, and, even assuming the attribution problem could be fixed, neither CMS nor any other group of human beings can adjust physician cost and quality scores for factors outside physician control with anything resembling accuracy (with the possible exception of simple and condescending process measures, such as, Did Dr. X advise Patient Y to stop smoking?). CMS’s feedback will be unintelligible not only because it will be inaccurate, but because the composite score will consist of many bits of noisy data arbitrarily crammed into a single score.
CMS’s inability to attribute patients accurately and to risk-adjust accurately are in turn major factors in the failure of CMS’s ACO and “medical home” demos to work as advertised.
CMS should acknowledge its inability to measure cost and quality accurately. Instead CMS whistles past the graveyard. CMS and Congress pretend CMS’s measurement systems are ready for prime time when they are not. CMS and Congress do a profound disservice to America’s doctors and patients by taking such a cavalier attitude toward these fundamental and intractable issues. CMS should tell Congress MACRA must be postponed so that CMS, MedPAC and others can evaluate honestly and thoroughly the stew of “value-based purchasing” programs CMS has already implemented (PQRS, ACO, “medical home,” etc), none of which are working well. To drop MACRA on the nation’s doctors now given what we know already from the numerous “value-based purchasing” experiments CMS has conducted, not to mention commonsense, would be irresponsible.
Kip Sullivan, J.D. is a health policy expert and frequent blogger living in Minnesota. His articles have appeared in The New York Times, The Nation, The New England Journal of Medicine, Health Affairs, the Journal of Health Politics, Policy and Law, and the Los Angeles Times.