Monday, June 6, 2016


A MACRA-scopic View of Federal Acronyms
The federal government has a fetish for acronyms.
This fetish began in 1933 when Franklin Delano Roosevelt (FDR) unleashed a  series of government programs that helped lift America out of the depression:
--Emergency Banking Act (EBA)
--Economy Act (EA)
--Civilian Conservation Corps (CCC)
--Federal Emergency Relief Act (FERA)
--Agricultural Adjustment Act (AAA)
--Emergency Farm Mortgage Act (EFMA)
--Tennessee Valley Authority (TVA)
--Truth-in Securities Act (TISA)
--Home Owners’ Loan Act (HOLA)
--National Industrial Recovery Act (NIRA)
--Glass-Steagall Banking Act (GSBA)
--Farm Credit Act (FCA)
4,298 Federal Acronyms
At last count, the federal government  has 4,298 acronyms for God- knows-how-many federal agencies (GKHMFA).
CMS Acronyms
At Centers for Medicare and Medicaid (CMS) acronym-making has become an art form.  Among other health care acronyms  are these – Patient Protection and Affordable Care Act (PPACA),  Centers for Medicare and Medicaid Innovation (CMSMI),  Patient-Centered Medical Homes (PCMH),   Accountable Care Organizations (ACOs), Alternative Payment Model (APM),  Merit-Based Incentive Payment System (MIPS),   Pay-for-Performance (P4P),   Fee-for-Service (FFS),  and that mind-stretching  acronym MACRA (Medical Access and CHIP Reauthorization Act of 2015).
Basic MACRA Idea
The basic idea behind MACRA is to drive physicians who use FFS into coordinated care models in which physicians assume the risk of caring for Medicare patients using a fixed budget.  CMS is hell-bent for rewarding and punished physicians in Physician Group Practices (PGP) for providing Evidence –Based-Medicine (EBM), also known as Value-Based Medicine (VBM),  for Medicare patients who belong to PGPs.
Three MACRA Problems
There are three problems with MACRA.
One, Medicare patients do not “belong to” or are owned by physicians or PGP.   Patients are free to go to the physician whom they like or prefer, even if that physician is outside the PGP.
Two, in short physicians are not “attributable “to any specific physician or PGP.     This goes by the name of the Attribution  Problem (AP).
Three, It is extremely difficult, if not impossible. to measure physician risk or performance  when patients seek care outside the PGP in emergency rooms, urgent care centers, concierge practices, retail clinics,  or when the average Medicare patient with chronic disease seeks or shops for care from 6 different physicians, usually a specialist, who may not be in a PGP or ACO.  This is called the RAP (Risk Adjustment Problem).
MACRA Unworkable
Creating acronyms to herd physicians into APMs Alternative Payment Models (APMs) to facilitate rewarding of punishing physicians is an exercise in bureaucratic futility.    It may be politically correct (PC), but it does not work, if, for no other reason, it turns physician off because it raises the cost of physicians to enter data or to track where patients go outside the physician’s office and sphere of influence.
As Kip Sullivan,  a Minnesota health care analyst , after reading the 962 page MACRA document,   explained in “Sloppy Risk Adjustment and Attributable  Guaranteed  MACRA Won’t Work” (June 5, The Health Care Blog):
“CMS’s inability to determine accurately which patients ‘belong’ to which doctors (the attribution problem), and CMS’s inability to adjust costs and quality scores outside physician control(the risk adjustment problem) are a lethal one-two punch to the fantasy that CMS or anybody else  can measure the ‘value’ of the vast majority of physicians accurately.”

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