By Sally C. Pipes and Michael Koriwchak
If you have visited the doctor recently, you probably noticed a new instrument in the examination room. It is a computer running an electronic medical records system, or EMR, that has been lauded by federal agencies as bringing a revolution to health care. But to patients, the computer has proven to be a nuisance rather than a blessing. It is hard to get quality health care when a patient must compete with the computer for his or her doctor’s attention.
Rest assured, most doctors do not like the computer coming between them and their patient either. Multiple studies demonstrate that roughly two-thirds of physicians are dissatisfied with their EMRs and do not think that they improve quality of care.1, 2, 3, 4
For physicians, the computer has become the instrument of obedience to a senseless body of regulations that directs not only the technology itself but also its use as a vehicle to “improve quality of care.” If your doctor pays attention to you instead of entering data, he or she will be penalized by Medicare regulations that reduce physicians to data-entry clerks.
The use of information technology as a Trojan horse for government-driven health care began with a part of the 2009 federal Stimulus Bill called Meaningful Use, or MU. Through a system of incentives and penalties, the architects of MU masterminded a major digital revolution of our health care infrastructure within five short years.
The developers of this system also force-fed physicians the unproven practice of using information technology to improve quality. Despite the mandated implementation of EMRs under MU, they have failed to deliver on any of the promises made in 2009, including a higher quality of care.5 By the end of the five-year program, doctors’ support for MU was waning.
MU would have disappeared quietly had it not been for a unique set of circumstances and timing related to Medicare, the federal healthcare program for seniors. The formula used to calculate Medicare payments to physicians — called SGR, or the Sustainable Growth Rate — had for several years dictated payment cuts of 20-30 percent.
Every year from 2003 to 2014, Congress had to act under duress to override SGR and pass a temporary “fix.” When Members of Congress became desperate for a permanent solution, the architects of MU seized an opportunity to re-brand their unpopular program by offering the repeal of SGR as part of a bill called MACRA — the Medicare Access and CHIP Reauthorization Act of 2015.
The MU program found a safe haven within MACRA. Its proponents even changed its name to camouflage it. Congress passed MACRA in April 2015, mere hours before another SGR-mandated payment cut was to go into effect.
The implications were not clear until the Centers for Medicare and Medicaid Services issued the MACRA regulations the following year. The centerpiece of the rule is a draconian compliance scoring system that pits small medical practices against large healthcare institutions to compete for a place on the upper half of the MACRA compliance bell curve. Physicians on the lower half of the bell curve who do not meet the requirements must pay penalties to cover the incentives paid to physicians in the upper half who meet more of the requirements.
CMS’s own data predicts that 87 percent of solo practices and 70 percent of practices with 2-10 physicians will receive penalties under MACRA.6
Physicians in independent practices cannot compete, so they are being driven to become employees of large hospitals. It is inevitable that costs will increase as these large institutions gain market share. Quality will suffer as care is depersonalized and unproven “value based reporting” consumes resources formerly directed towards patients.
Physician burnout will continue to increase as doctors must spend more evenings and weekend time on data entry.7,8 And the information technology itself, designed first and foremost to comply with MU certification requirements, will remain useless relative to the needs of individual patients and the doctors who care for them.
The irony is that quality of care was not the original problem. The healthcare reform narrative that began in 2008 was based on legitimate issues regarding cost and access. But the architects soon realized that their agenda would be better served by pivoting the discussion to quality and value.
Cost and access are easy to measure; the latter two are not because they lack well-established definitions. It is impossible within a quality/value paradigm to measure the performance of any program and judge its merits.
The cost of quality reporting alone has been estimated at $15.4 billion per year, according to a March 2016 study published in Health Affairs.9 The total cost of MACRA will significantly exceed that figure.
Reporting quality data to CMS has never been shown to improve outcomes. At a time when cost and access are the real problems facing our healthcare system, our limited resources would be more wisely directed to cost and access problems.
Is there a politician or a bureaucrat that has the chutzpah to face several million Americans and tell them we can’t afford their health care because of our devotion to a program whose benefits are completely unproven?
It is time to make participation in MACRA voluntary. Dropping the penalties and preserving the incentives will allow MACRA devotees to continue their work while unshackling other doctors from unproven quality measures and EMR mandates. Every physician, MACRA supporter or not, will be free to pursue his or her own vision of health information technology — the one that is best for patients.
Understanding exactly how MACRA was passed makes clear that it did not and does not enjoy “bipartisan” support and protection. A new administration should have the incentive to promote and introduce legislation that would make effective changes.
Sally C. Pipes is President, CEO, and Thomas W. Smith Fellow in Health Care Policy at the Pacific Research Institute. Dr. Michael Koriwchak is an ENT physician in Atlanta, co-host of “The Doctors Lounge” radio show, and Vice President of the Docs4PatientCare Foundation.
1Medical Economics and MPI Group. EHR Survey 2013.
2Medical Economics. 2016 EHR Report.
3Deloitte Center for Health Solutions. 2016 Survey of U.S. Physicians.
4American EHR Partners and the American Medical Association. Physician Use of EHR Systems 2014.
5Kellermann, AL and Jones, SS. What It Will Take to Achieve the As-Yet-Unfulfilled Promises of Health Information Technology. Health Affairs 32(1) 2013: pp 63-68
6Proposed Rule, The Medicare Access and CHIPS Reauthorization Act of 2015, Table 64, April 2016
7Shanafelt, TD; Dyrbre, LN et al. Relationship Between Clerical Burden and Characteristics of the Electronic Environment with Physician Burnout and Professional Satisfaction. Mayo Clinic Proceedings 2016; 91(7) 836-848.
8Shanafelt, TD; Hasan, O et al. Changes in Burnout and Satisfaction with Work-Life Balance in Physicians and the General U.S. Working Population Between 2011 and 2014. Mayo Clinic Proceedings 2015; 90(12): 1600-1613.
9Casalino, LP; Gans, D et al. U.S. Physician Practices Spend more than $15.4 Billion Annually to Report Quality Measures. Health Affairs 35(3), March 2016.