MACRA…An Open Letter to Andy Slavitt

I am not a physician, so have no credentials to be telling the Centers for Medicare and Medicaid Services (CMS) how to run hospitals, much less physicians how to treat patients. However, as part of a clinic struggling to get reasonable reimbursement for the care we provide, I can speak directly to the issues about reimbursement. It’s beyond draconian. It’s beyond the seventh level of Hades. And to most stakeholders in healthcare, it appears to be invisible. Even, I suspect, to most CMS wonks.

CMS Has an Attitude Problem

Mr. Slavitt, you have brought a large measure of humanity and openness to the ongoing discussion of the development of MACRA. Before your time at CMS, the meanness and downright hatefulness towards physicians was palpable. Doctors were assumed to be out to scam the system any way they could, and by jingo, every bit of fraud was going to be ballyhooed from one end of the country to the other. This perverse attitude has turned the practice of medicine into a battlefield much like the finger-pointing, rabble-rousing, often less than honest comments from the recent election.

Never mind that the vast majority of physicians really just want to take care of their patients to the best of their abilities. They have gone to school for more years than most professionals, they have proven their competence with medical licensing, boarding, and continuing education throughout their careers. Many have practiced long enough to know how to read patients who do not present with the standard set of symptoms. In other words, they know when evidenced-based medicine and the standard of care miss the underlying problem.

Although ostensibly about Facebook and how technology has destroyed democracy, Tobias Stockwell’s article  makes some good points about how members of large communities tend to protect their beliefs by isolating themselves with people of similar beliefs. Think government bureaucracy. Think CMS. Many large government departments have lost all ability to empathize, work with, or understand anything outside their narrow view of how they think the world should work.

Mr. Slavitt, you have brought a breath of fresh air to the discussions about MACRA. But punishing health care providers by cutting their reimbursement when unproven—beta versions of—programs fail puts CMS in that narrowly populated room of like-minded thinkers. No reasonable person should accept these kinds of ugly, nasty, punitive ways to punish failed beta-testing results over which the victims have no control. Physicians are no exception.

The Food and Drug Administration tests new products for years to be sure a given drug won’t kill patients. CMS should be held to the same level of accountability for the results of their untested schemes. Patients die from the end results of bad policy as well as bad drugs. Trust me. I’ve seen it. When CMS punishes hospitals for patient readmissions in less than 30 days, the sick patients wind up in a different hospital with the physicians from the first hospital refusing to acknowledge they had anything to do with the patient’s current condition. This hardly improves the quality of care and it certainly doesn’t save money.

The only thing health care providers can count on is that the punishments will continue to be dispensed even though the results have little to do with either the quality of the health care they provide or with saving money.

Cost of Participating in MACRA

CMS gives no thought to provider cost to participate in Meaningful Use, PQRS, or MACRA. Dr. Rocky Bilhartz describes the need for many consultants just to help him be sure he can adjust his practice procedures to meet the ever-increasing reporting requirements.

Indeed, many practitioners have decided that it costs more to hire the people necessary to be sure these requirements are met than the lost reimbursement for penalties. Would our clinic miss 4% of a $40 Medicaid reimbursement for a 20-minute visit? Or 4% of Medicare’s $60 reimbursement?

It’s hard enough to get reimbursed for providing care as it is. By the time a clinic receives $40 for an office visit, there’s not much left over to hire consultants to be sure the clinic meets meaningful use, PQRS, or the 900+ pages of MACRA requirements.

The proposed solution bandied about by critics for those opting out of MACRA? Make the penalties much greater.

Punishment is the only modality CMS understands. Corporal punishment has been denigrated for years, but CMS evidently hasn’t noticed. Just get a bigger stick.

Physicians Provide Unnecessary Services

CMS thinks physicians should be paid based upon the quality of the care they provide patients. The assumption is that with the old “fee-for-service” model that physicians have been “gaming” CMS to increase their reimbursements by providing unnecessary services.

The numbers don’t support this assumption, at least in our office. If our clinic physician orders a non-microscopic urine test, we will bill $15 on the 1500 form. Our reimbursement? Medicare will pay us $3.48 for this test, but subtracts another .07 cents for sequestration (CMS accuses physicians of gaming the system?). The $3.41 will just about cover the cost of the test material and supplies.

It’s true, Mr. Slavitt, you have worked hard to bring some less onerous requirements to small practices, but the minor concessions made to small primary practices, the very kind of practices needed to keep patients healthy, are not enough. I suspect the real bias against independent physicians is that they are hard to control. Many are independent precisely for the reason that they do not want to work under corporate rule, which often isn’t any more sensible than CMS rule. And anyway, independents can easily jump ship to Direct Primary Care.

Mr. Slavitt, none of the loosened up restrictions in MACRA for small practices is going to fix this problem. Honest pay for honest work used to mean something.

CMS needs to reimburse primary care physicians more, not less. It’s as simple as that.

No Way to Measure Physician Value

Reimbursing physicians based upon the value of the services provided is a nice thought. While fevered attempts to collect Big Data can certainly capture some elements of quality care, computers can’t capture the art of medicine, which is where the real quality—and the art— resides. As Stuart and Hubert Dreyfus say in their many writings, expert systems can provide rules and heuristics, but a big collection of data does not an expert make:

…no amount of rules and facts can capture the knowledge an expert has when he has stored his experience of the actual outcomes of tens of thousands of situations.

From Socrates to Expert Systems:
The Limits and Dangers of Calculative Rationality


The data CMS is feverishly collecting, then, is basically public health information. CMS now has a pretty good idea how many patients smoke or how many use street drugs (although who really self-reports this kind of stuff). The art of medicine will not be found in a checklist, or even an expert system. That data has no real relationship to physician expertise:

We can see now that a beginner calculates using rules and facts just like a heuristically programmed computer, but that with talent and a great deal of involved experience, the beginner develops into an expert who intuitively sees what to do without recourse to rules.…normally an expert does not calculate. He does not solve problems. He does not even think. He just does what normally works and, of course, it normally works.

From Socrates to Expert Systems:
The Limits and Dangers of Calculative Rationality

Tests—what are essentially beta tests—of the success of CMSs checklists for quality clearly demonstrate that they fail miserably. CMS, if it were reasonable, would invite health care groups to participate in the beta testing and reward the few who actually do manage to meet the qualifications, and refrain from punishing those who showed how ineffective CMS’s scheme had really been.

And then CMS should go back to the drawing board and figure out how better to represent the quality of care provided by physicians. If CMS would admit its failures and go back to the drawing board with each failure, there would be some hope that CMS would eventually realize that the art of physician care cannot be reduced to checklists.

But no. The failed program is wrapped up with various other attempts to reduce physician payments in a much larger untested program to reduce costs, MACRA. Do you see the pattern here? It doesn’t matter if the data doesn’t indicate quality. CMS simply rolls the failed program into a much bigger and more complicated scheme to reduce physician reimbursement—once again with unproven markers.

The bottom line: CMS has no real way to measure the fundamental value of the care physicians provide patients.

CMS needs to stop pretending that quality of care has anything to do with its primary focus, to pay physicians less and less for the care they provide.

Misuse of Electronic Medical Records (EMRs)

The government has spent billions of dollars getting the health care sector to adopt medical records. Don’t get me started on the miserable excuses for EMRs that health care workers everywhere are forced to work with. They are kludgy, organized for the convenience of the programmers, and actually prevent physicians from doing their job.

But there is a more crucial problem with EMRs. The physician, by having to attend to typing in data, loses the connection with his or her expertise. Attending to keystrokes pushes the physician back to the level of the novice, concentrating on rules rather than expertise. Remember, Stuart and Hubert Dreyfus note that the art of medicine, the expertise of physicians, is destroyed by having to pay attention to entering data into a computer:

In each of these areas and many more, calculative rationality, which is sought for good reasons, means a loss of expertise. But in facing the complex issues before us we need all the wisdom we can find. Therefore, society must clearly distinguish its members who have intuitive expertise from those who have only calculative rationality.

From Socrates to Expert Systems:
The Limits and Dangers of Calculative Rationality


CMS’s real interest in EMRs is data collection. Data collection which someone in the CMS circle of like thinkers believes can be made to measure “quality” so reimbursements to providers can be decreased.

In each area where there are experts with years of experience, the computer can do better than the beginner, and can even exhibit useful competence, but it cannot rival the very experts whose facts and supposed heuristics it is processing with incredible speed and unerring accuracy.

From Socrates to Expert Systems:
The Limits and Dangers of Calculative Rationality


Research shows—yes, evidence-based research—that EMRs will never be able to capture data on the quality of physician care that really counts, the experienced physician’s gestalt of all the patients he or she has treated over time.

CMS Pays Billions for Electronic Toys

The billions CMS pays the makers of EMRs, outsourcing oversight of physicians to RACs, outsourcing prescription monitoring to Medicare Part D pharmacies and insurance companies, and the most horrendously bad outsourcing, to Medicare Advantage plans, could fund reasonable pay for physicians and health care organizations many times over. Plus provide real universal healthcare to patients, something any number of other countries do well.

MACRA and the associated EMRs do collect data on public health issues, but no EMR Review of Systems data or Physical Exam data is going to be stored in a physician’s gestalt. That information is in patient story.

Let’s face it, Mr. Slavitt. The data computers are capable of collecting are in EMRs. But that is not the data that reflects the physician’s quality of care, the results of physician expertise. In fact, having to type and pull down menus to decide what data to save actually interferes with the physicians’ ability to use their hard-earned expertise.

In each of these areas and many more, calculative rationality, which is sought for good reasons, means a loss of expertise. But in facing the complex issues before us we need all the wisdom we can find. Therefore, society must clearly distinguish its members who have intuitive expertise from those who have only calculative rationality.

From Socrates to Expert Systems:
The Limits and Dangers of Calculative Rationality


Mr. Slavitt, in my humble opinion, EMRs are a travesty to quality health care and seriously impede physicians in the use of their expertise in providing that quality care which eludes CMS.

Reset the MACRA Machine to 0

MACRA doesn’t do what it purports to do and can’t because of its rule-based structure. Big Data analysts understand the workings of complex problems. It is known any change in a program, however minor, can have catastrophic results in unexpected places. Chaos theory. No matter how deterministic MACRA attempts to be, outcomes will be unpredictable.

MACRA is doomed to failure, and that failure will fall squarely on the backs of physicians, physicians CMS clearly believes are not needed or CMS would refrain from its continued attempts to reduce physician reimbursements.

CMS should instead be concerned that physicians are paid an honest wage for honest work. And acknowledge that the art of medicine is beyond CMS’s grasp.

…at least one thing is clear: if you don’t understand what expertise is and what tacit knowledge is, you can’t even discuss the social, political, labor movement issues, power issues, etc. intelligently.

Bent Flyvbjerg, p. 71

Mr. Slavitt, it’s time to abandon MACRA.

Charon awaits.




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