MACRA, Physician Reimbursement, and Moving beyond MIPS

Dr. Gail R. Wilensky, Ph.D has just wrote a thought provoking perspective in the New England Journal of Medicine. ("Will MACRA Improve Physician Reimbursement?" April 5, 2018)

Tracking the journey from Resource based relative value scale (RBRVS) and Sustainable growth rate formula (SGR) which was not really a value based system, to current MIPS portion of MACRA (Medicare Access and CHIP Reauthorization Act); it becomes clearly evident that it is still work in progress. 

MedPAC March 2018 Report to Congress - Monkey Wrench

While agreeing with the initial goal of MIPS, MedPAC has thrown a monkey wrench, claiming that MIPS is a burden along with the claim that it's goal will not be accomplished.

MedPAC shares Congress’ goal, expressed in MIPS, of having a value component for clinician services in
traditional Medicare that promotes high-quality care. However, the Commission believes that MIPS will not
fulfill this goal and therefore should be eliminated.
— MedPAC March 2018 Report

They are making two recommendations:

  1. Eliminate MIPS as it is today.
  2. Establish a new 'Voluntary' value program in fee-for-service.

As Dr. Wilensky points out, 'Under the MedPAC proposal, physicians would have 2% of their fee-for-service payments withheld. To get the withheld money back, physicians would have to join an A-APM or be part of a (real or virtual) group that is evaluated on population-level performance measures such as mortality and readmission rates, potentially preventable admissions, and patient experience. MedPAC also proposes that the measures be based on claims, which would mean that the burden would be on CMS rather than clinicians to provide the relevant data. Clinicians who do not participate would lose the 2% that was withheld.'

Even if we agree with MedPAC's assessment that MIPS has flaws, I'm not sure if anyone has the answer. MedPAC has an alternative proposal, but dumping MIPS altogether is probably not wise, until CMS tests and tries the MedPAC proposal. Dr. Wilensky proposes that CMS should test it under its Innovation Center (CMMI).

In either case, we are certainly making progress. This is such a huge issue that we must test and try various models. There is no silver bullet. While Practicing Physicians will encounter a bumpy road, we must all pitch in to make our views known and heard.



Procrastination - Just One thing to do

I have suffered from Procrastination all my life. I guess who hasn't - to some extent, some more than others. 

I am 55 now and I don't say I have fully overcome it, I don't think I ever will, but I have to a large extent controlled it.

I recognized this is a huge issue when things started suffering. Work got delayed both at home and office. I kept pushing things off to the point of no return. I then started reading about it, seeking self-help books and articles. When I read them, I resolved to get better, and I procrastinated on those resolutions. 

There was a lot of theory. Here is what one article said:

Follow these steps to deal with and control procrastination:

Step 1: Recognize That You're Procrastinating. If you're honest with yourself, you probably know when you're procrastinating. ...

Step 2: Work Out WHY You're Procrastinating. This can depend on both you and the task. ...

Step 3: Adopt Anti-Procrastination Strategies.

Here's another article: If you're looking for effective ways to beat procrastination and finish your tasks timely, these 8 tips are for you.

  1. Eliminate distractions.
  2. Use your strongest sensation to memorise things.
  3. Set yourself deadlines. ...
  4. Work when you feel most alert and efficient.
  5. Don't stress too much.
  6. Eat healthy & exercise.

...and on and on...

My wife is the exact opposite. She is always on top and never procrastinates, and that's not an exaggeration. I observed her. I noticed and started implementing just one simple thing.

Just Do It!

When something comes to top of mind that needs/should be done, just do it right now. I initially felt - I'll do it as soon as... or 'I'll do it later'. We know what happens. Then, I realized if I stop what I am doing, and just get that thing done, it is not going to disrupt anything at all, because most of the time, what I am in the middle of, is never that urgent.

That's all - no long theories, no steps, Just Do It.

Best Way to Evaluate any Product - Ask - "And Then What Happens?"

Seth Godin's blog below got me thinking. This is how we should evaluate software and technology products.

A simple dialog can turn opinions into plans (or perhaps, into less tightly held opinions).

We ask, "and then what happens?"

Flesh it out. Tell us step by step. The more detail the better.

No miracles allowed. And it helps if each step is a step that's worked before, somewhere and sometime else. The other question that helps with this is, "has that step ever worked before?"

We don't have a shortage of loud and strongly held points of view about business, culture, or technology. But it may be that finding the time to draw a map helps us get to where we want to go (or to realize that we need a new map). 

What does all this have to do with Product/Software Evaluation?

When doctors buy EMR software, majority of them make the mistake of doing an improper evaluation and testing before buying. This leads to dissatisfaction and practice inefficiencies. Medical clinics have a lot of moving parts and workflows. Doctors will evaluate from the clinical perspective. Office managers and billing staff evaluate the systems from their own workflow point of view.

Where it gets complicated is that they focus on inefficiencies and dissatisfaction with their previous software. They assume that other parts of the system work fine. The evaluation needs to happen as if you are buying a system for the first time.

Every step of the process must be evaluated independently.

Do your homework.

This requires a lot of homework. Start by documenting every step of the process. This is more difficult than it sounds, because you have been doing things for a long time and you take things for granted. You don't do not feel the necessity to document simple steps. Once all the steps and workflow have been documented, this is where you need to ask the vendor, 'then what happens?' Keep on asking this question until you know the exact steps that you have to take in that software to do your job - everyone's job.

There is another side benefit of doing this. It will prevent future finger-pointing. In majority of the cases many unspoken things lead to discontent. How many times have I heard, "I thought you said...", Or, ... "You never told me this..."

Do yourself a favor, and keep on asking "and then what happens?". Spend as much time as necessary with the vendor evaluating the product.