ObamaCare Endgame:  Achieve Savings by Redistributing Income from Specialists to Primary Care Physicians

 MACRA (Medicare Access and CHIP Reauthorization Act of 2015) which shifts traditional Medicare patients into risk-based reimbursement  by giving doctors incentives to join with hospitals to form  Accountable Care Organizations to share “savings” with hospitals and  to join organizations that employ primary care organizations  in order to achieve savings by reaching  measurable quality goals by reducing the specialty care referrals.

According to Robert Kocher, MD, and Anuraag Chigurapati, MS, at policy institutes at the University of California, Stanford, and Harvard,  the MACRA endgame  is designed to redistribute income to primary care physicians from specialists ("The Coming Battle over Shared Savings - Primary Care versus Specialists,"  New England Journal of Medicine,  July 14, 2016,)  In a sample chart in their article, the authors project MACRA could reduce incomes for diagnostic radiologists by $35,000 and cardiologists by $25,000,   thereby narrowing the average incomes of $284,000 of specialists versus $195,000 for primary care physicians. 

Will this MACRA scenario work in the real world?

Specialty care is by far the most expensive cost Medicare has to bear.    In the minds of CMS officials and progressive elistists,  at least 30% of  Medicare costs are unnecessary and can be traced to physician and hospital greed, which depend on specialty referrals as their major sources of revenue.  By curtailing specialty referrals,  theoretically one could save money by reducing hospital  days,  ER visits, lengths  of stay in skilled nursing facilities, and intensity of diagnostic testing and procedures  performed by specialties.

To accomplish the goals envisioned by CMS,   one simply needs to  measure the outcomes of Medicare populations  by measuring  “population health”,  by shifting risks to primary care physicians,  and by preaching the gospels of evidence-based medicine and “value” health , both of which are loosely defined as outcomes and quality control per doctors expended. 

The basic belief system here rests on a fundamental thesis of management,  “In God we trust, all others use data.”  If you impose enough regulations  and impose enough documentation rules,  somehow, somewhere, somehow,  government “savings” will be achieved.   Unfortunately,  Government bureaucracies have no history of achieving savings, and trust in government has reached  an all time low.

ACRA requires a leap of faith in government experts to do the job of reform, on the ability o0f government experts to analyze complex systems,  on sophisticated technocratic analysis, and government rule-writing on the most equitable solution to social  inequities.   

I am profoundly skeptical about MACRA.  It’s hard to understand, rests on non-commonsensical assumptions, and its bloated bureaucratic rules will raise costs.   Pitting primary care doctors against specialists will be psychological offensive t many doctors,  and it won’t raise quality since many consumers  regard specialty essential in many instances.