Thursday, May 19, 2016

The Heart and Soul of MACRA

Ms. Jeannie is a 65 years old woman, slightly overweight with mild hypertension that is perfectly controlled. Ms. Jeannie is the office manager at Dr. Abrams, the pediatrician down the hall, who’s been taking care of your kids since you moved here. Ms. Jeannie called earlier because her allergies are killing her today and she’s out of refills for her blood pressure meds anyway. After an uneventful 15 minutes, and a brief chat in the hallway, Ms. Jeannie pays her $15 copay and heads back to work. Medicare will pay you another $60 in a few weeks. On to Bob Burns who is here for his DOT physical and his BP is through the roof… again…

Somewhere in our nation’s capital, someone has decided that when you go about your day like this, you’re doing a lousy job, because you provide very little bang for the buck they pay you. Maybe Jeannie could have seen your nurse instead of wasting your time with trivial things. Maybe she could have just stayed at her desk in Dr. Abrams’ office and talked to your nurse over Skype or email. And why is it that you can’t get a grip on Bob’s blood pressure and make him take his meds and understand that driving a truck is not a form of exercise? You need to provide value, instead of just counting volumes and volumes of expensive visits that may or may not work. This is wasteful. You need to learn how to do better with less money.

This is the heart and soul of MACRA. This is what 962 pages of gibberish are trying to elucidate for those who have the time to read 962 pages of government regulations on a Wednesday morning. You can certainly try to set aside time to pore over the intricacies of how Medicare plans to not pay you the $60 it owes you for seeing Jeannie, but if you have twenty to forty hours to read, I’d suggest taking another shot at Ulysses which may be a more rewarding and less frustrating choice. In Medicare’s defense though, it’s not that they don’t want to pay you anything for seeing Jeannie. No, that would be dumb. The 962 pages of labyrinthine regulations are about $3 that Medicare may be withholding from or adding to your $60 remittance for similar visits with Ms. Jeannie in 2019.

There are plenty of good summaries of MACRA out there (here is a great one), so I’m not going to repeat any of that here, because frankly, it doesn’t really matter. First, the SGR formula which MACRA is supposedly replacing was never implemented. Chances are good that the furious mathematics at the fraying edges of medicine described in the latest notice of proposed rulemaking will suffer a similar fate. Second, even if Medicare spends the prerequisite billions of dollars to implement a national mechanism for withholding your $3, booking one more patient per day will completely neutralize any effects on your practice and your personal income. Alternatively, and particularly if you are “of a certain age” this may be a great opportunity to spruce up your golf game, as Dr. Halamka himself is suggesting.

The Doctor Whisperers

Have you ever trained your pooch to walk nicely on a leash, to sit and stay and rollover whenever you tell him to? If so, chances are that you used those little bits of liver treats to reward good behavior. You don’t reward your pup in training with huge T-bones because he will ignore you for the next hour or two as he enjoys his bone. For obedience training, you use cheap, tiny morsels over and over again, along with profuse words of encouragement, until Rover gets the idea, and then you replace the liver bits with a pat on the head, and then you just assume that the dog is conditioned to always do what you want him to do, without rewards. And that’s how Rover becomes a good dog. The $3 Medicare incentive is your liver bit. Using it repeatedly, every 15 minutes or so, all day every day, is how you will be trained to become a good doctor.

The people who run programs like the MACRA are not stupid. They know, and the math is pretty straightforward, that the $3 training morsels won’t make any difference in Medicare finances, but at the end of the day you will learn to always pay attention to the handlers and respond to nonverbal cues in a reliably consistent manner. For example, many EMRs today have special markings for data fields that must be captured for Meaningful Use or PQRS. Some are color coded, others are marked with little stars and practically all have lists of items that were “satisfied” or not. Those are equivalent to yanking Rover’s choke collar, quickly, gently and ever so slightly. Nobody wants to hurt their “best friend”. We train docs for their own good, because well trained, obedient dogs are happy dogs.

Unfortunately, not all dogs are created equal. Great Pyrenees for example were bred for centuries to work independently, mostly alone, mostly at night, to protect their sheep from big bad wolves. Having shared my home with a few great ones over the years, I can tell you that they find fetching sticks a rather uninteresting proposition. Buried deep in the bowels of the 962 pages is a cute little table forecasting whose chain will be yanked and who will be getting those $3 bits most of the time (page 676). As you would expect, 9 out of 10 solo docs and 7 in 10 docs practicing in groups of less than 10 will be penalized, while over 80% of those working in very large systems, or rather their employers, will get rewarded. The heart and soul of MACRA has no room for independent doctors. They either submit themselves to employment in the service of big corporations, or go their separate way.

Other People’s Money

A century ago, under similar circumstances as we are experiencing today, Louis D. Brandeis railed against the "curse of bigness", and particularly the bigness of bankers who used “other people’s money” to exert undue influence (control) over the nation’s economy solely for their personal benefit and with complete disregard for the welfare of the people. To be sure, Justice Brandeis, as Thomas Jefferson before him, was disgusted with big corporations and big government as much as he was appalled by big banks. Both before and after his Supreme Court appointment, Brandeis experienced significant success in his crusade against bigness, but a century of American politics as usual managed to destroy practically everything he achieved, and to add insult to injury, today it’s not just the big banks that get to play games with other people’s money.

The 962 pages (with more to come) of MACRA regulations are how big government is creating a set of financial instruments that nobody understands (including the authors) to affect 20% of the American economy, not to mention the lives of 300 million people, using other people’s money to benefit the bottom lines of big corporations and for the personal aggrandizement of political appointees. I may be wrong, but I believe Justice Brandeis would be irate at the mere thought that the Federal government is proposing to award 7.5 cents to medical doctors who are “registered for a minimum of 6 months as a volunteer for domestic or international humanitarian volunteer work”. Thomas Jefferson would probably observe that our tree of liberty is long overdue for some refreshments, but I digress.

From its inception, health care reform has been focused on diverting physicians’ attention from patient care, which comes naturally to most of them, to counting things supposedly representing patient care. First came counting scripts sent electronically to pharmacies, then came counting the number of times the mammogram box was checked, the number of times the Pacific Islander box was ticked, the number of times one glanced at this or that list, culminating with the number of dollars patients are costing the insurance company. The MACRA is just the next step in the succession of incremental steps designed to transition Medicare to a Medicount program.  The problem with this strategy is that you are counting other people’s money.

Every dime the Federal government spends on obedience training (or culling) for doctors, is our money. Every nickel Medicare is spending on managing the largest accounting exercise known to mankind, is our money. Every penny commercial insurers spend on adopting the Medicount method, is our money. We are the true risk bearers for this experimentation, and so far we are seeing nothing but downside. Public health expenditures are going up. Private insurance premiums are going way up. Out of pocket expenses are going up. Our life expectancy is going down. Suicide rates are up. Addiction rates are up. Mental distress levels in general are up. And yet we are all compelled by taxation laws to fund our own demise without honest representation, without informed consent and without any legal recourse.

Maybe not this summer, and maybe not this fall, but what do you think comes next?

Monday, May 9, 2016

Health Care is Not a System

The Merriam-Webster dictionary has many definitions for the term system, but the most straightforward, and arguably the most applicable to our health care conversation is “a regularly interacting or interdependent group of items forming a unified whole”. The common wisdom is that our health care system is broken and hence our government is vigorously attempting to fix it for us through legislation, reformation and transformation. We usually work ourselves into a frenzy arguing how the government should go about fixing the system, but I would like to take a step back and question the assumption that health care is, or should be, a system. This is not about splitting the hairs of semantics. This is about proper definition of the problem we wish to solve.

You could argue that we use the term system loosely to refer to everything and there are no nefarious implications to calling health care a system. We have a transportation system, an education system, a legal system, a financial system, a water system, a political system and so forth. Note however that we rarely talk about our food system or auto system, fashion system, hospitality system, etc. We call those industries. Starting to see a difference here? Good. Our government obviously regulates both systems and industries, but it regulates them differently. And systems have distinct characteristics that industries seldom have, such as built-in (systemic) mechanisms for discrimination, and institutionalized (yep, systemic) corruption aplenty.

When we begin by assuming that health care is a system, we assume that health care should possess those same characteristics. We assume that health care in Beverly Hills will be, by design, different than health care in Flint, Michigan. We assume that health care delivered in private settings will be different than health care accessed in public settings. We assume that some areas will have sprawling, on demand health care hubs, while others will have none. We assume that public engagement in health care is for show only, while the billionaire class and its carefully constructed echo chamber get to make all our health care decisions. We assume that health care is, and always will be, rigged. And based on these assumptions, we proceed to fix our health care “system”.

You may be tempted to dismiss these thoughts as specious demagoguery, strawmen, soapbox arguments or just plain exaggerations. After all, health care system fixing includes such socially beneficent endeavors as expanding “coverage” for the poor (Medicaid expansion), subsidizing insurance for the less poor (Obamacare exchanges), granting insurance to the sick (preexisting conditions), and a steady drumbeat of accountability, measurement and reduction in “disparities” for “vulnerable populations”. To that I would respond by pointing you to several recent utterings from public figures empowered to effect health care reforms.

Medicaid for America

Let’s begin with the all-powerful Acting Administrator at the Centers for Medicare and Medicaid, Mr. Andrew Slavitt. The “acting” prefix is there, because for some reason, Mr. Slavitt is running the largest (taxpayer financed) health care insurance entity in the country without proper Congress confirmation. In a recent string of tweets, Mr. Slavitt refers to our “beloved modern Medicaid program” as “America’s healthplan”, proudly reminding us that Medicaid is 72 million strong (“Working people, families, majority white...”) and growing. I think it’s safe to assume that Mr. Slavitt himself is not receiving his medical care through "America’s healthplan", and neither does anybody he associates with.  It is also safe to assume that an accomplished executive like Mr. Slavitt, who is Harvard and Wharton educated, understands all too well that the size of Medicaid is inversely proportional to the prosperity of the American people. If the sheer notion of a senior political appointee in the Obama administration being ostentatiously proud to see working families forced to beg for public charity is not triggering a fire alarm in your head, then I don’t know what will.

One could argue that since Obamacare expanded Medicaid to people above official poverty levels, perhaps a bigger Medicaid does not necessarily imply more poor people, but a more generous society. One could make such argument, if federal poverty levels were a realistic measure of poverty, or if we didn’t have other sources of information. The grim reality is that even middle class Americans are now lacking the ability to purchase decent medical care, or insurance instruments for the same, and hence the Obamacare exchange subsidies for cheap insurance, which is marginally better than Medicaid in some ways, and substantially worse in other ways.

In another insightful tweet, Mr. Slavitt observes that “In exchanges, consumers vote with their feet and with their feet they say unaffordable care is a deal breaker”. Note how elegantly, inability to pay for nice things due to being destitute in general, is now framed as a preference, something you vote for with your feet. This is precisely how establishment henchmen convinced us that we vote with our feet when we shop at Walmart while decently paying jobs are being vacuumed from underneath our very same feet. Being poor and unable to afford eclectic amenities prized by the elites is a consumer preference, one very short step away from arguing that being on food stamps or sleeping under a bridge are merely choices some consumers make.

Health care in America is expensive. Expensive, though, is a relative term, and if America’s working class didn’t see its income consistently go down the 1% drain, perhaps health care would seem more affordable. But American health care is also expensive in absolute terms. Mostly it is expensive because each service and each item is priced higher than anywhere else in the world. Tackling the pricing problem is guaranteed to upset the masters of establishment henchmen, so they worked hard and found a couple of other alternatives to generate cheapness, just in case the voting with feet thingy blows up in their face (as it seems to be the case right now). The trick is to deflect scrutiny from real issues, and assign responsibility (blame) to doctors and the people in general.

The Return of the Broccoli

I’ve written compulsively about the apparent war on doctors in the past, and I am certain I will be writing more, but the war on people is a much more intricate subject. It’s relatively easy to separate a quarter of one percent of people from the herd, paint them as for-profit mass murderers and sic the hungry mobs on them. But then how do you subdue the mobs? For that, my friend, we have government. We have behavioral economics. We have the experts and pundits in that echo chamber. And we have the righteous souls who innocently light the fuse of every calamity.

I’m old enough to remember the debates preceding the Obamacare litigation in front of the Supreme Court, culminating with both Justice Scalia and Chief Justice Roberts pondering whether the government has it within its enumerated powers to make you buy broccoli. Before the broccoli debacle, the same libertarian lunatic fringe wondered if government can order Americans to lose weight, or if the government can mandate that we buy certain products from certain manufacturers. Of course Obamacare and its mandate to buy health insurance or be penalized by the IRS survived these outlandish challenges, and the IRS is doing its best to rake in those penalties. It must be doing a great job too, because it sounds like IRS services for mankind could be drastically expanded.

Steven Findlay is an expert health care policy journalist, with an illustrious record working for the Consumers Union, and one of the handpicked advisors who shaped the Meaningful Use program. Mr. Findlay recently commented on The Health Care Blog, making the following statement: “Hell, I’d support tax breaks for people who quit smoking and/or can document to the IRS that they exercise 3 times a week for an hour each time!” Hell, indeed! But if the IRS can collect penalties for failure to purchase insurance, and grant tax credits for buying Pella windows, why not offer tax breaks for making your body more productive and more efficient?

Was Mr. Findlay writing in jest? Perhaps, but note that Obamacare is already empowering health insurers and employers to offer “incentives” and “discounts” for a variety of wellness schemes, which are essentially paycheck penalties on sick and “non-compliant” people. And note also that these types of shell games are only effective if you are poor enough and forced to vote with your feet every time someone reaches for your empty wallet. I wonder if voting with your feet would be an IRS approved form of exercise…
This is the glorious power of systems. This is the power of a “regularly interacting or interdependent group of items forming a unified whole”. This is why health care must become a system where the “items” regularly interact in formulaic pathways. This is why free range actors randomly affecting the system cannot be tolerated by the centrally installed array of levers and signaling networks.

This is why independent medical practice must die, small hospitals must be euthanized, and managed population health must encompass the entire nation (minus the elite caretakers) down to the minutest detail. This is why each one of us must be systematically tagged, numbered and catalogued in the vast repositories of “precision medicine”. And this is precisely why health care must never be allowed to become a system.