Jul 12, 2016

"We have deliberately set the game so that you cannot win"

Shortly before a senior Medicare official came to visit his Dallas office in late June, Texas Medical Association President Don R. Read, MD, shared with Texas Medicine his thoughts on the agency's draft rules implementing the Medicare Access and CHIP Reauthorization Act (MACRA). Dr. Read compared changing complexity of Medicare rules to a progression from a simple game of checkers to a new game no one understands, whose rules are written in Mayan hieroglyph, and which "you cannot win."

Listen to the short audio clip, or read the full transcript below.



“This is how MACRA comes across to me. With original Medicare, we were playing checkers. There were some rules we didn’t agree with, some that were truly stupid, like you couldn’t pay for a TPN outside the hospital, which was much cheaper so we had to keep them in the hospital which was much more expensive, but you pretty much understand the rules. Then with PQRS and MU, we started playing chess. Kind of easy chess, but we were starting to play chess.

“And now you say, well we’re going to change the game. It’s not checkers; it’s not chess; it’s something new. The board’s got two more columns and two more rows. Some of the chess pieces are the same, but we’ve put new ones out there. And we’ve written rules. We started to write them in Mandarin Chinese, but we figured you’d be able to get an interpreter and interpret them, so we’ve written them in Mayan hieroglyphs to make sure you don’t understand.

“But you have to start playing right away, and don’t worry about the fact that you don’t understand the rules because we have deliberately set the game so that you cannot win.

“And by the way, two years from now you’re going to get penalized because you did not win.”

Jul 1, 2016

Medicare Man Enters the Maw of MACRA Malcontent

To hear Dallas physician leaders Don Read, MD, and Rick Snyder, MD, tell it, if they can’t make it, no one can. And right now, Drs. Read and Snyder are extremely pessimistic about their practices being able to “make it” under Medicare’s proposed new quality regulations.

A top Medicare official, who made the trek to Dallas at the invitation of the Texas Medical Association, appeared to be listening.

Dr. Read: Without big changes, small practices
"are going to fail" under MACRA
“We are light years ahead of small practices, who are in survival mode all the time, in terms of reporting quality,” Dr. Read, the current TMA president, and head of a the 14-physician Texas Colon & Rectal Specialists, told Tim Gronniger, the deputy chief of staff at the Centers for Medicare & Medicaid Services (CMS).

“We are going to fail on the quality measures, which is something this practice prides itself on,” added Nancy Bowman, executive director for the practice.

Despite the practice’s large investment in health care information technology – about $300,000 on software alone in 2015 – Ms. Bowman said neither the group nor its advanced electronic health record (EHR) system vendor will be ready when it’s time to collect the new MACRA data on Jan. 1, 2017.

Dr. Read followed up with a theme that permeated TMA’s 26-page official comment letter to CMS on the proposed rules implementing the Medicare Access and CHIP Reauthorization Act (MACRA).

“All these small practices are doomed to fail under this system,” he told Mr. Gronniger. “It's not worth their spending money to participate in a system where they're going to fail.”

Tim Gronniger, deputy chief of staff,
Centers for Medicare & Medicaid Services
Mr. Gronniger acknowledged that CMS has heard that complaint from many quarters, including TMA’s official comment letter. “I hear your concern that it's too complicated,” he said “We're getting feedback that there’s too many things to think about.” He also promised that CMS would provide physicians with “bite-sized” instructions on how to comply with the MACRA requirements.

The agency is reviewing all of the feedback it has received on the draft rule, and will issue a final regulation around Nov. 1.

An hour later, Mr. Gronniger walked down the hall to hear from Dr. Snyder, whose 70-physician practice is the state’s largest independent cardiology group and one of the largest in the nation.

“We pride ourselves on being cutting edge on regulatory compliance,” Dr. Snyder told him. “There's no way in the world we are going to be ready Jan 1. Our goal is just not to lose money.”

Dr. Snyder presses Mr. Gronniger for an "independent practice pathway."
Dr. Snyder said his big-picture concern is that the rule as written will “accelerate the consolidation” of independent physician practices into hospital systems. That, he said, would increase costs to Medicare and give patients fewer choices.

“Please come up with an independent practice pathway,” Dr. Snyder told Mr. Gronniger. “Make it friendly so we can increase quality, reduce costs and remain independent, because we think that's the best model.”

Mr. Gronniger said he liked that idea and would work to modify the rule to make that happen.