Should Physicians “Just Say No” to MACRA? – MACRA Monday

Posted on January 9, 2017 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This post is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program.

We’d planned to start diving into MIPS this week, but I couldn’t resist commenting on a post I saw on Medical Economics where a physician makes the case that physicians should just say “No” to MACRA. The opening paragraph describes the challenges of MACRA (and its meaningful use predecessor) pretty well:

I can’t recall the exact moment I crossed over from believer in today’s version of the healthcare quality movement to skeptic. Perhaps it was when the office trash would fill with clinical summaries the staff dutifully handed out to patients to satisfy a “meaningless use” measure. Or maybe it was trying to convince a 75-year-old Mrs. Davis that we would really appreciate it if she logged on to our electronic health record (EHR) using the patient portal. To do what, she asked? I stared back at her blankly.

It’s easy to make the case that some of the meaningful use requirements are meaningless. The same could be said for MACRA. That’s particularly true if you look at specialty specific instances where certain requirements made no sense to specific specialties. In other cases, the concept is good, but the execution is poor. For example, the concept of giving patients access to their health information is good, but it was poorly executed. Providing a clinical summary after a visit doesn’t really get us there and yet that’s what doctors were required to do.

Long story short, I understand why many see meaningful use and now MACRA as a distraction and they should just say no to both. In fact, that’s the advice that the author above offers:

My advice to physicians operating in this climate is simple: Don’t participate. MACRA clearly is the law of the land, and while one may hope the implementation from a Trump-Price administration will have a much lighter touch than the Obama-Burwell administration, sustained resistance in the form of non-participation is a small but important message to send to policymakers.

It is true that opting out of MACRA would send a small message to policymakers. If doctors would opt completely out of Medicare to avoid the MACRA penalties, that would send an even stronger message. I hear some doctors talking about this as an option as well. Both actions would send a message if doctors did this in mass. The problem is this isn’t happening and I don’t think it will happen.

While it is easy for a well paid cardiologist to say in a blog post that doctors should just say no to MACRA, my experience is that the MACRA math is much more difficult for general medicine and other specialties that don’t get paid as much and have large Medicare populations. The 4% MACRA penalty is a significant penalty to many doctors and “just saying no” is a very challenging decision for them financially. In fact, I’ve talked to many that just don’t see it as an option.

The same is true for people opting out of Medicare or reducing their Medicare population so the penalties aren’t as damaging. Not only is Medicare a significant source of revenue for many practices, but opting out of Medicare would hurt many patients who would have challenge finding care without them. Indeed, choosing to accept the Medicare penalties is not as easy a decision as some like to make it seem.

If you believe MACRA will fail, then opting out wouldn’t be as hard to handle for a year at a 4 percent penalty. However, I don’t see a scenario where MACRA fails so badly that it goes away. In fact, given the budget neutral nature of the legislation and the MIPS Pick Your Pace changes, it’s easy to see how MACRA is going to be proclaimed as a successful program. It would take some really serious lobbying for MACRA to disappear and I don’t see the will in Washington to make this a reality.

Assuming MACRA sticks around, your initial 4% penalty will grow to 9%. That’s a big hit to the bottom line for many practices. Given the Pick Your Pace options and the fact that most are already doing many pieces of the MIPS program (PQRS and Meaningful Use), why would a practice just take the penalty on the chin when the penalty is easily avoided? Out of honor and principle?

In fact, if you want to minimize MACRA’s impact on your practice it might send a clearer message to Washington if everyone participated at the lowest Pick Your Pace (Test Pace) option as opposed to a few people opting out of MACRA completely. If a few people opt out of MACRA and take the penalties, that will just fuel the incentives of those that participate in MACRA. If the majority of doctors do the minimum required to avoid the penalties, then they’ll avoid the penalties and it will send a message to CMS that they need to continue at a slower pace. Plus, those that participate fully will only get a small increase because there aren’t enough penalties to pay them what MACRA could pay them.

I previously suggested that the best strategy for most practices would be to go and participate as much as possible in MIPS so that a practice doesn’t get behind. I still think getting behind is an important concept to consider when you evaluate your MACRA participation. However, given the budget neutral nature of MACRA and the way it minimizes the incentives for full participants, I’m ok with a practice that chooses to take MACRA slowly. I just think most practices with a reasonably sized Medicare population are a bit crazy to not at least avoid the MACRA penalties.

Feel free to send a small message by just saying no to MACRA, but don’t expect that strategy to achieve the goals you desire. In fact, all it will likely do is damage yourself and put you in a harder position to participate in MACRA in future years. Of course, if you’re a highly paid specialist and/or you have a small Medicare population, then you’re choice doesn’t matter much to you or them anyway.

I agree that we should make an effort to get government regulation out of the EHR world as much as possible. It’s stifled innovation, burnt out doctors, and commoditized EHR software. I dream for the day when doctors love technology because it helps them be better doctors as opposed to better medical billers and government hoop jumpers. However, “just saying no” to MACRA won’t get us there.

Be sure to check out all of our MACRA Monday blog posts where we dive into the details of the MACRA Quality Payment Program.