I have been one of the people trying to rally the knowledgeable people in our Country to wake up to the total government control of the healthcare system. Consider that last year, Congress passed the MACRA (Medicare Access Reauthorization CHIP Act) bill into law ending their ill-devised SGR (Sustainable Growth Rate) formula.  Basically, this was a formula to decide how to reimburse health care providers but they miscalculated, just as they have miscalculating the sustainability of the Affordable Care Act/ACA. It never worked from the onset and after a decade, MACRA was devised to “fix” it.  When MACRA was rolled out, the requirements were, not again, just like the ACA, thereby putting into law a bill that its components were yet unknown.

On April 27, 2016, CMS released the components of this new bill.  While it does set out to balance the budget, it does so at the expense of physician reimbursements. There are bonuses for some and negative adjustments for others. But, those hit hardest will be solo doctors and those in small practices. So, as a solo practitioner, I will probably have to close up shop, unable to afford to keep my practice open.

Over the past decade or so, our reimbursements did not increase despite soaring overhead costs.  Yet, data released by CMS suggests that solo doctors will face negative adjustments to the tune of $300 million. We simply cannot afford that. Additionally, of solo practices, 87% will suffer negative adjustments, as CMS refers to it.

Negative adjustments may not sound that bad but let’s call it what it is: pay cuts, for the same work. In what other profession would this be acceptable? Yet, doctors are not allowed to collectively bargain or strike, we can just bear the rules shoved down our throats. Unbelievable!!

Large practices stand to gain under the new healthcare ecosystem.  In fact, practices with more than 100 doctors will enjoy the largest positive adjustments. It is estimated that more than 80% of practices of this size will see pay increases.

Where is the quality incentive when reimbursements are based on practice size? Small practices just cannot compete on the same level nor should we be expected to. I see my patients and try to give them the best medical care. Yet, CMS apparently is extolling assembly line medicine and patients will be the biggest losers here.

By passing these regulations, lawmakers effectively killed private practices and many wonder why. But, many doctors see the over-reach of the government in the exam room every day. We know this is a step in the direction of single-payer government run healthcare. The private practice doctors are continually burdened with the weight of useless and ridiculous mandates on our shoulders. We now have the noose around our necks and Congress is pulling the knot.

The US is an economy that thrives on capitalism. Yet, in medicine, those who want to provide quality care for patients are being driven out of business. Many look to the example of Marcus Welby, MD as the kind of doctor they want. Well, he is now dead and the government has killed him and the government wants to kill the rest of the solo practitioners.

The future of healthcare in the U.S. has been drawn out. Americans will only be able to seek care in large practices. Don’t expect personalized care. The government doesn’t care about you, only your numbers. Do we really want those who mismanaged Medicare running our medical system?

As a doctor in the US, I cannot strike like the Junior doctors in the UK are now doing. It is illegal for doctors to do so. We cannot change the policies lawmakers issue for their own political agendas. We can opt-out and stop taking Medicare and perhaps the time to talk with our feet has arrived. And the big mega-practices can pick up where we left off. The death bell of private and solo practice rang and we can only watch in despair.

The new rules are over 900 pages long and the AMA admits they have not gone through all of them thoroughly.

They are estimates by CMS, Similar to a CBO (Congressional Budget Office ) score. Page 676 Table #64 from CMS final rule for MACRA shows CMS’ estimates of how practices will be affected, sorted by size.

87% of solo practices will likely get cut by MIPS (Merit Budget Incentive Payment System) and 70% of practices of 2-9 clinicians will see cuts.

Here is a brief summary of how physicians will be scored on these categories, and what work it will require on the part of the physician, according to a CMS fact sheet:

Quality: This is essentially a modified PQRS. Physician would choose six quality measures to report on from a list of options tailored to specialty and practices. Currently PQRS (a whole bunch of benchmarks for running your practice and treating patients) requires physicians to report on nine quality measures.

Advanced care information: This is meaningful use, but with some new flexibility. Under the new program, physicians will get 50% credit simply for attesting. The rest of the score (in fact physicians can exceed the maximum score) will be based on performance on measures that cover categories such as patient electronic access to health information, care coordination and patient engagement and electronic exchange of health information.

Clinical practice improvement activities: Physicians will need a score of 60 points in this section by participating in programs to improve their practices in the areas of care coordination, patient engagement and patient safety. Activities are worth either 20 points or 10 points, with higher-weighted activities contributing to those that support the PCMH model or practice transformation. There are more than 90 choices for physicians to pick from, in these 9 categories:

Expanded patient access

Patient engagement

Achieving health equity

Population management

Patient safety and practice assessment

Emergency preparedness and response care coordination participating in an APM, including a PCMH integrated behavioral and mental health

Cost: This replaces the value-based modifier. The good news is that there is no extra work for physicians; CMS will calculate these scores based on Medicare claims.

What type of payment adjustments are we talking about?

The law requires MIPS to be budget neutral. Therefore, clinicians’ MIPS scores would be used to compute a positive, negative, or neutral adjustment to their Medicare Part B payments.

In the first year, depending on the variation of MIPS scores, adjustments are calculated so that negative adjustments can be no more than 4 percent, and positive adjustments are generally up to 4 percent. The positive adjustments will be scaled up or down to achieve budget neutrality, meaning that the maximum positive adjustment could be lower or higher than 4 percent.

Per the law, both positive and negative adjustments would increase over time. Additionally, in the first five payment years of the program, the law allows for $500 million in an additional performance bonus that is exempt from budget neutrality for exceptional performance. This exceptional performance bonus will provide high performers a gradually increasing adjustment based on their MIPS score that can be no higher than an additional 10 percent.

As specified under the statute, negative adjustments would increase over time, and positive adjustments would correspond.

The MACRA incentives are supposed to be revenue neutral. In other words, the total taken in penalties will be equaled by incentives given.

So this is a redistribution of physician compensation, ostensibly from those who practice low quality care to those who practice high quality care.

But from the outset, CMS has given up the pretense that this is about quality; before they even release the rules, they tell us that the redistribution is ACTUALLY from small groups/solo docs (who will be penalized) to big groups (who will be paid more).

“Among practices with two to nine eligible MIPS clinicians, only 29.8 percent are expected to receive a positive adjustment, but this number increases to 81.3 percent for practices with 100 or more. ”

Who are these practices that employ 100 or more? They are nearly all hospital owned.

This is simple, folks: CMS is very clearly stating that (even more) of physician payments will be directed AWAY FROM the independent docs and TOWARDS the hospitals and their employees.

I agree with all who have stated that the overall plan is to drive doctors into larger, and frequently hospital-controlled, practices. Add pay cuts to the regulatory burdens requiring the hiring of too many paper-pushers for solo or small practices to sustain, and the goal is obvious. Hospitals and large practices see this as of benefit to them and, therefore, support it.

But does anyone think that, once everyone is consolidated into a small number of large practices, that the government- and third-party payers following in lockstep- will not then start reducing payments on these larger groups as well? If their payments are maintained, it will only be because they funnel a goodly part of it back into Democrat campaign coffers. So their day will come, too.

However, none of this is likely to reach full fruition, as the whole financial system with its burden of overextended credit and no remaining markets to sell into is about to collapse. If this does, indeed, happen, all the large crony companies, and the government, will collapse. Only people who have the equivalent of real money- gold or goods top barter at first, eventually a “new dollar” based on gold- will be able to pay for medical care, and only solo practitioners will be in a place to provide it. Of course, you may then have to carry a small arsenal to protect you and your assets from the save-nothing masses who will go to any lengths to take it from you.

Remember that this all began with LBJ in 1967 after Medicare became law and went into effect. At first, it was subtle and quietly done, by forcing physicians who accepted Medicare to accept ‘usual and customary fees’. The rest is history. Now, there are no attempts to avoid offending physicians, not any attempts to pay fairly. The system is failing, as all Ponzi schemes fail when there are no longer adequate numbers of ‘new’ investors to pay off the ‘older’. Likewise Social Security, Disability, and all of assorted Marxist programs passed to buy votes for the Democrats.

It is only a matter of time before CMS tries to dictate to physicians their specialty, their locale, and their workplace, using medical schools, residencies, state licensing boards, and perhaps a national licensing board. It has actually started in a number of States who are trying to dictate that if a physician doesn’t accept ACA, Medicaid, etc. patients, that their licenses will either be restricted of not renewed.

None of the above are pleasant prospects. Eventually, it’ll all settle out into some sort of a system, but the transition is going to be hell and, depending on the nature of the new system which arises, it may not be much better, either.

Not pleasant, but don’t say I didn’t warn you. Take steps now to insure your physical, financial, and most importantly mental, survival.

The handwriting was on the wall years ago. Do we really doubt that all government programs are inefficient, costly, and never fulfill their goals or even their intent? When the program fails, the response is to enlarge the program, add more clerks and administrators, make it more “cost effective” (cut reimbursement, increase paperwork) and generally screw it up even worse.