Leadership
Health Care Under Trump

A Memo to the Brilliant

Article · October 18, 2017

In an election in which a few thousand votes made the real difference, the vote of physicians mattered. For several years now, these physicians have been condescendingly told that their valued independence is a threat to patient care, that their autonomy should be given up in the name of the common good, and that the ever-increasing requirements from the federal government are designed to make them better at their profession. In other words, they’ve been told to trust those who have invented the rules of the game — for they are brilliant, they are enlightened, and they hold the truth.

Two proposed rules were the final straws for physicians — one might have caused them to permanently break away from the policies of the current Administration, and another that was purported to outline the future of alternative payments, despite lack of evidence.

The first rule, on MACRA, told all the physicians of this country that they could suffer the wrath of bureaucratic hell if they stayed in MIPS, or finally surrender to their local ACO. No other option of alternative payment models was given to the tens of thousands of specialists who care for patients every day. It’s an ACO or MIPS — pick your poison.

The second rule, on CMS’s mandatory cardiac bundles, told all cardiologists that their financial future was going to be decided by hospitals, whether they liked it or not. The rule did admit that the proposed models were flawed because they were facility-centric and lacked appropriate severity adjustment, but that would be dealt with another day, by another Administration. We’re reminded that when the original rule on Bundled Payments for Care Improvement (BPCI) was released, CMMI made it a point to outline that condition-focused bundled payments would be next, and also asked for input on potential models. That, of course, turned out to be fiction because the Innovation Center and much of CMS was imbued with the Brilliant’s belief that all but a few procedural episodes belong squarely in ACOs.

Claims of regulatory overreach have been echoed not just by more than 100 members of Congress, including the members of the physician caucus, but have also been reprised by Big Pharma and others who are now trying to stop the proposed reforms on Medicare Part B. Much is now in jeopardy, and it may have been completely avoidable.

So here we are. The election results are in, and 11,000 votes flipped Michigan to red, 15,000 votes in Wisconsin, and 30,000 in Pennsylvania. Note that there are 45,000 physicians and 200,000 nurses in Pennsylvania, more than enough to have made a difference. The Brilliant woke up with horror, but only because they had been blinded by their own light.

Fortunately, the movement away from fee-for-service and toward alternative payment models will continue, fueled by MACRA and the Medicaid reforms going on in dozens of states across the country. But the future of CMMI is in serious question, along with the pilots it has launched. The regime change will lead to a clean sweep of all those in charge today, and their replacements will have a tough task. We can guess, however, that their approach will be more collaborative, because such had been the hallmark of prior administrations. The new leaders of HHS and CMS will likely reach out to the private sector instead of the ivory towers, and look for what’s working in the field instead of what a few minds had worked up in their heads. They will likely scrap mandates and, if we’re lucky, expand the number of experiments.

Because here’s the reality of payment reform in the United States in 2016: we know very little about what works. We must continue to learn — broadly, deeply, and quickly. Physicians of all stripes, as well as hospital leaders, must be brought into a collegial discussion about the pains of the transition away from volume-based payments. Specialists must be engaged in crafting alternative payment models that will work for them. CMS must significantly upgrade the operational infrastructure of its administrative contractors. And nothing should be anointed as the solution based on a set of textbook beliefs.

 

This post originally appeared in NEJM Catalyst on November 15, 2016.

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