The deadline for public comment on the MACRA proposed rule is June 27, 2016 at 11:59 PM ET.  This is the most comprehensive healthcare legislation enacted since Obamacare (ACA) and it will have a significant impact on all actors within our healthcare system for years to come. Since commercial payers tend to take CMS’ lead, this will be true for everyone whether or not they participate in Medicare. Given that, I hope all of you will consider commenting individually here or by contributing to the joint #hcbiz comment by participating in this week’s episode (details below).

In #hcbiz 12, we attempted to find opportunity in the proposed rule.  I was joined on air by Dr. Mike Koriwchak and Dr. Randall Oates. Rather than opportunity, we mostly discussed the uncertainty that these two long-time doctors were seeing. As always our goal for the show was to identify some immediately actionable advice. Koriwchak and Oates agreed that the only thing to do was to learn as much as you could about the proposed rule and submit your comments to CMS.

In a recent episode of The Doctor’s Lounge (The Obamacare Shell Game), Dr. Mike Koriwchak walked us through his process for evaluating the rule and developing his own comments. In doing so, he demonstrated how one might gain enough understanding to comment intelligently even if you don’t understand every part of the 962-page proposed rule.  Additionally, he identified a few crucial points that are worth your consideration before the comment period closes.

How did we get here?

The first key point that Koriwchak makes is that he narrative of healthcare reform has shifted. It’s a kind of creeping normalcy, where each day doesn’t seem so different form the last, but when you look back to the beginning you see that we’ve crossed a huge chasm.  The original conversation surrounded two very important issues that most of us would agree on: Cost and Access.  Clearly costs are growing uncontrollably:

And the uninsured rate was hovering around 17.5% when the ACA was passed in 2012.

 The issues of cost and access are clear, understandable and most importantly, measurable (as depicted above).  Today the narrative is around two related, but very different issues: Quality and Value.  In the headlines this doesn’t seem much different, but there’s a crucial distinction:  No one can agree on how to define or measure quality or value.  Consider the definitions from Google Dictionary:

Quality – the standard of something as measured against other things of a similar kind; the degree of excellence of something.

Value – the regard that something is held to deserve; the importance, worth, or usefulness of something.

Both of these definitions leave much to interpretation and mean something different to every individual. For quality and value, what do we measure against? Patient satisfaction? Longevity? Quality of life? Cost? Where one person wants to extend their time on earth by any means regardless of quality of life, another might pass on intervention once they can no longer do the things they love. These two people will place a very different value on the care they receive based on their preferences and circumstances. Further, a one size fits all standard for quality may prevent one or both of these individuals from getting what’s right for them.

Simply put, there’s no year-over-year measure of quality or value that we can refer to and see how we’re doing.  It’s largely an academic exercise to try and define these things and while that may provide some inspiration for what we do, it should never dictate it.

Don’t believe the Hype

The most common argument for the need to address Quality and Value can be summed up with this chart:

On the surface that looks pretty damning.  Clearly, we’re spending way more than everyone else and our “results” are relatively poor.  But we have to ask ourselves, is life expectancy a good measure of the performance of our healthcare system?

Koriwchak points out that much of the quality/value argument is supported by data from the World Health Report 2000.  But Philip Musgrove, who was the editor-in-chief for the study wrote this in 2010:

This is not simply a problem of incomplete, inaccurate, or noncomparable data; there are also sound reasons to mistrust the conceptual framework behind the estimates, since it presupposes a production function for health system outcomes that depends only on a country’s expenditure on health and its level of schooling, ignoring all cultural, geographic, and historical factors.

And specifically in reference to the US being ranked 37th in the world:

It is long past time for this zombie number to disappear from circulation.

Koriwchak offers another interesting example: people from Japan who move to the U.S. (and use our seeming crappy healthcare system) have similar life expectancy as those that stay in Japan (and use their seemingly superior healthcare system). In the other direction, this article points out that foreigners moving to Japan from other countries don’t suddenly get the Japanese longevity.  It’s not Japanese healthcare that keeps folks alive longer; it’s their lifestyle.

To further this point, James Marks, SVP of the RJWF Health Group told us Why Your Zip Code May Be More Important to Your Health Than Your Genetic Code. In it he opened with a beautifully relevant quote:

“How you see a problem drives how you create the solution.” 

Looking at healthcare reform from the quality/value perspective leads to the large top-down rule-making that we’ve become accustomed to (a la MACRA). What Koriwchak refers to as “the shell game”. Looking at it from a cost/access issue forces us to think more about the social determinants of health (SDOH).  Here are a few salient points from the article:

  • Evidence now suggests that medical care accounts for only 10 to 15 percent of preventable early deaths.
  • Some Americans will die 20 years earlier than others who live just a few miles away because of differences in education, income, race, ethnicity and where and how they live.
  • College graduates can expect to live five years longer than those who do not complete high school.
  • Middle-income people can expect to live shorter lives than higher income people, even if they are insured.
  • And people who are poor are three times more like to suffer physical limitations from a chronic illness.

If you buy into this narrative, it seems less effective to spend money trying to create and track artificial quality measures than it would to build some grocery stores or deploy some mobile clinics to under-served areas.

What’s being proposed?

MACRA brings us a complex attempt at defining and measuring quality and value.  I believe the intention is that by addressing these issues costs will come down and access will be improved.  Unfortunately, that’s not how it tends to work.  Complexity pushed down from the top brings with it costs in the form of administrative overhead, mistakes and fragility in the system.

Providers accepting Medicare will fall into 1 of 2 buckets. Most doctors (at least at first) will stay in traditional Fee For Service and have their payment modified up or down by the MIPS program.  The remainder of doctors will participate in Advanced Alternative Payment Models (APM) such as Accountable Care Organizations (ACO), Medical Homes or the Comprehensive Primary Care Plus model (CPC+). CMS plans to develop new APMs as time goes on, but that is largely undefined today.

MIPS will be measured and paid against 4 quality measure groups:

  1. Quality (50%) – A measure of how the doctors perform against 6 measures of their choosing from a menu of 475 available measures.
  2.  Advancing Care Information (25%) – this replaces Meaningful Use and requires that physicians not block CMS form measuring quality, respond to patient requests for data in a reasonable time frame, etc.
  3. Clinical Practice Improvement (15%)
  4. Resource Use (10%)

Each of these measures will require their own combination of workflow changes, tools, consultants, auditors, etc. It’ll require a veritable army of people to make it go. While I do believe that you can “expect what you inspect” and therefore measurement is good, I wonder how much money we’re willing to throw at it when there’s so much doubt in our ability to measure the right thing.

Finally, the infamous Table 64 from the proposed rule indicates that small practices will be hit hard:

Andy Slavitt has stated that this may not be the reality and we can expect updated projections in the final rule, but if it holds true at all it means more consolidation and that means higher prices. So the original goal is to address Cost/Access, but we shift to focus on Value/Quality and we drive up cost!

Crafting a Response

Koriwchak closed out his show by sharing the current version of his own comments on the rule.  I agree with many of them and my comments are italicized):

  1. Reduce the number of Quality Measures to 3. He cites supporting arguments from John Halamka and Don Burwick. I don’t know what the best number is, but I do hope that CMS defines the minimum number of requirements that allows them to satisfy the floor set by the original legislation. In this case, less is more.
  2. Quality Reporting costs us $15B annually with little to show for it.  Koriwchak believes MACRA is likely to drive that number up and argues that we could address one of the original goals, namely access, by just using this money to insure more people.
  3. Rather than enforcing a revenue neutral system where there must be winners and losers, create a system where everyone can succeed. I don’t know if this is possible under the legislation, but in concept it makes sense.  This isn’t, everyone gets a trophy, but rather set a high bar and if everyone does well there needn’t be any losers. I’ll add that if we ensure losers among the physicians, we’ll also be ensuring losers among their patients.
  4. Finally, Koriwchak’s rules for defining quality measures are born in common sense.  They should be based on demonstrable scientific method.  There should be a clearly defined plan to use the dataIt should run in the background.
  5. Certification of EMRs should happen between the feds and the vendors. Keep the doctors out of it.
  6. Don’t require back-end access to provider EMRs for CMS.

Whether you agree or disagree with any of the points made here, the important thing is that you take the time to share your comments with CMS.  As of this writing, 365 comments have been submitted. Given the monumental impact this rule will have on all of us, and all the commotion we’re making about it, I’d like to see that number go way up. Already formed your opinion? Then take 5 minutes and submit it now!

#hcbiz 17 Details

On Wednesday, June 8, 2016 the Business of Healthcare community will continue our discussion on the MACRA proposed rule. Our goal is to get a better understanding of what has been proposed and discuss the arguments surrounding the current narrative of healthcare reform so that we are all better prepared to comment on the rule by June 27th.

As noted above, I’ll take your comments from the chat and show and incorporate them into my own comments that I submit to CMS. I’ll explain where they came from and reference our community.  Is this a reasonable thing to do? Will anyone care? Who knows, but life’s one big experiment and I’m doing it 🙂

12:00 PM EST — Tweet Chat

The tweet chat will ask 3 questions in 30 minutes. Note the times below if you’d like to schedule some tweets.

Q1: Do you agree that the healthcare transformation narrative has evolved from Cost/Access to Quality/Value? What should we be focusing on? (12:03)

Q2: If we’re going down the path of Quality and Value, how should they be defined and how should we measure them? (12:12)

Q3: If you could wave a magic wand and change one thing about MACRA, what would it be (and you can’t say eliminate it)? (12:21)

(Follow the #hcbiz hashtag on Twitter or use an app like to join the conversation).

12:30 PM EST — The #Hcbiz Show! On Blab

The #hcbiz Show! Will feature Dr. Mike Koriwchak (ENT) of The Doctor’s Lounge Radio Show and The Docs 4 Patient Care Foundation. We welcome any of you to jump on with us and participate in the show.