Thursday, August 25, 2016


Is MACRA the Final Blow for Small Independent Practices?
The following article is from Kaiser Health News?   It raises this fundamental  question -  does MACRA(The Medicare Access and CHIP Reauthorization Act) – which discourage fee-for-service and encourages ACOs (Accountable Care Organizations  and APMs (Alternative Payment Models ) spell the end of small private practices which depend on Medicare patients for their existence?
Doctors Raise Concerns For Small Practices In Medicare’s New Payment System
By Steven Findlay August 25, 2016
“We’re struggling to survive,” Gross, 47, said. “Our kind of practice is dying in this country, and medicine itself is changing so rapidly that doctors everywhere seem to be burning out.”
Indeed, in their professional journals, at conferences, on social media and health care blogs, and in comments to federal regulators, the nation’s doctors are expressing growing anger and frustration.
The focal point of their angst is a 2015 federal law that changes the way Medicare pays doctors.logo washingtonpost110
The Medicare Access & CHIP Reauthorization Act — is Congress’ boldest step since the 2010 Affordable Care Act to push the health care system to reward quality over quantity. It replaces a reimbursement system that was widely criticized by doctors and regularly ran into budget problems on Capitol Hill.
“This is a big change, we know,” said Tim Gronniger, deputy chief of staff at the Centers for Medicare & Medicaid Services. But, he added, “the current way we pay doctors incentivizes them in bad ways — to waste resources, for example.”
The law has bipartisan support and does not come with the political tension of the ACA. Still, the Obamacare battles have shown that broadly reshaping health care is no easy task.
Poor and wasteful care accounts for a quarter to a third of all health care spending, according to the National Academy of Sciences’ Institute of Medicine.
That would total between $875 billion to $1.1 trillion of the $3.5 trillion expected to be spent on health care in the U.S. in 2016.
The law sets up two payment tracks. All doctors must choose one, except for those who see too few Medicare patients or whose income from Medicare is too low.)
On one track, doctors whose performance and quality of care exceeds benchmarks get bonuses up to 4 percent of their total Medicare reimbursements. Those will start in 2019, based on evaluations of care delivered in 2017, and will rise a maximum of 9 percent by 2022. By the same token, physicians who score poorly on quality benchmarks — which include requirements for the use of electronic health records — face penalties at the same levels.
The amount the government spends on the bonuses — estimated at $833 million for 2019 — must be balanced by the penalties, keeping the program “budget neutral.” However, Congress also authorized an extra $500 million a year bonus pool through 2024 for doctors judged “exceptional.”
On the other path, doctors choose to join larger practices or organizations — called “alternative payment models” — that would be held accountable for the quality of care delivered by all the doctors in the organization.
Congress’ intent, experts say, was to push doctors to join such larger organizations, which generally are considered better equipped to manage and coordinate care, improve quality and lower costs than are solo or small groups of doctors.
Doctors get a 5 percent annual bonus between 2019 and 2024 if they join an alternative payment organization, along with any bonuses or penalties the organization chooses to mete out.  Starting in 2026, doctors in such organizations will continue to get a small annual payment adjustment from Medicare that’s larger than doctors who don’t choose the alternative path — 0.75 percent versus 0.25 percent.
Physicians’ concern is that the new payment system — laid out in a 962-page proposed regulation in April — will put doctors in solo or small practices at high risk of incurring payment penalties and will push thousands into larger practices and alternative payment organizations.
“The ways it’s structured now, the large practices will do well and the small practices will do badly,” said Paul Ginsburg, director of the Center for Health Policy at the Brookings Institution.
During a public comment period, the American Medical Association and dozens of other physician trade organizations and every state medical association said the system needs to be simplified and must “accommodate the needs of physicians in rural, solo, or small practices in order to enhance their opportunities for success and avoid unintended consequences.”
One of those unintended consequences, the AMA says, is that penalized doctors would limit the number of Medicare patients they see, or drop Medicare.
“I have no idea what I’m going to do yet,” says Dr. Jean Antonucci, a primary care physician who has a solo practice in Farmington, Maine. Half her patients are covered by Medicare. “If I’m going to lose money, I’ll have to see what my options are. I don’t want to limit how many Medicare patients I see."
“I don’t want to spend the bulk of my time doing paperwork or collecting data on my patients,” said Jean Antonucci. (Courtesy of Jean Antonucci)
Antonucci and Gross say they want to preserve their small practices. “I don’t want to spend the bulk of my time doing paperwork or collecting data on my patients,” said Antonucci. “That’s what the doctors in my community who are employed [in larger groups] seem to spend most of their time doing.”
Some experts agree that the burden to report quality-of-care to the government is significant.\
“We don’t yet have a good system to measure the performance of individual physicians,” says Robert Berenson, a physician and fellow at the Urban Institute and former director of Medicare payment policy for the federal government. “And yet we are going to peg billions of dollars in payment to such measurement. It’s a little crazy.”
A study published in March in the journal Health Affairs calculated the scope of that data collection now. It found physicians and their staffs spend $40,000 per doctor per year — $15.4 billion nationwide — collecting and reporting information about their care to Medicare, private insurers and others.
Gronniger says CMS has, in the proposed rule, scaled back the number of measures doctors must report. “We are eager to work through the issues doctors’ groups have raised,” Gronniger said.
Even so, the AMA and other physician groups are pushing CMS to delay the start for collecting quality-of-care information from  next January until at least July. Medicare administrators have pledged to issue final regulations by Nov. 1.
“This is all very complex,” said AMA President Andrew Gurman. “A lot of doctors are very frustrated … but we are committed to trying to make the new law work.

Wednesday, August 24, 2016

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.

Tuesday, August 23, 2016

Media Moral Outrage and Donald Trump
The elitist media cannot contain itself.   Although the mainstream media  portrays itself  as dispassionate ,  fair-minded,  and compassionate, it cannot help itself when it comes to labeling Donald Trump as a moral degenerate, a lowly demagogue,  an outright bigot,  a flaming racist, and an egocentric narcissist. 
Cokie Roberts

Cokie Roberts, who has been called the mother of NPR,  has gone as far as to say his supporters are immoral.  Trump is one of the least qualified candidates ever to make a serious run for the presidency." Roberts wrote late last month in a syndicated column with her husband, the journalist Steven Roberts. "If he is nominated by a major party — let alone elected — the reputation of the United States would suffer a devastating blow around the world."
Roberts  also is an commentator for ABC news, which along with CBS, NBC,  MSNBC,  the Washington Post, and the New York Times  is one of the pillars of the mainstream media.
New York Times

-- In his left column front-page piece,  the headline reads “Trump’s Empire: A Maze of Debts and Opaque Ties; U.S. Holdings Examined;  At Least $65 Million  is Owed by Republican Nominee’s Firms.”   The gall of the guy, “The success of his empire depends on his ability to get credit, to get loans extended to his business entities,  and we simply don’t know a lot about his financial dealings, here or around the world.” The obvious implication of the articles is that there’s something rotten in the Trump Tower of Debt.
Sunday Review Section

--In the Sunday Review section of the August 23  New York Times, the paper threw all pretense of objectivity,  either by its writer, reporters, columnists, or editorial board. Its editorial bore these headlines, “Can America Recover from Donald Trump” and  “Mr. Trump and the Damage Done” and concludes,  “Trump supporters have now been promise a nation where non-natives, and their children are locked outside the borders forever…The challenge to responsible leaders o any political party will be to separate the economic discontents form the bigotry and paranoia that the key to the Trump phenomenon.
--The front page of the Sunday Review  has this headline, “Donald Trump Takes Aim,” and asserts “his message resonates with voters who feel guns are all they have.”
--A column  “Low and Lower” contains 18 quotes from various sources on how low Trump has sunk (example” Trump’s groundless assertions  his a new low last week, as the mass shooting in Orlando, when he repeatedly suggested that President Obama secretly supports the Islamic state.
--And Maureen Dowd, in her column “Open Letter from Mr. T rump,”   commenting on Trump’s speech saying he was sorry if this remarks had offended anybody,  lists 15 reasons Trumps should feel sorry about his sorry performance.  Each reason oozes with sarcasm and contempt over why Trump should feel sorry.   “Most of all, “ she ends, quoting Trump, “I’m sorry that I’m not really sorry.”

Friday, August 19, 2016

Trump’s  Apology and Humbleness Speech
I listened closely last night to Donald Trump’s  scripted speech last night. 
Trump apologized for past blunt or harsh statements,  appealed directly to Afro-Americans for their support,  said he was a law and order candidate, and gave a bleak assessment of what the future would look like under a President Hillary Clinton.     That same night Paul Manafort, his campaign manager, resigned.   Today Trump visited Baton Rouge to show he cared more about flood-ravaged people than President Obama who was playing golf at Martha's Vineyard among the Democratic swells.
Will this new scripted Trump change the trajectory of the current  political campaign,  which at the moment,  is decidedly and decisively in favor of Hillary Clinton if you believe the Real Clear Politics average of polls, which should Clinton ahead in 7 or the 9  states Trump needs to win?
Can Trump convert this into a “change election,” based on a discontent with the economy,  ISIS “radical Islam” threats,  bias against  police,  unhappiness with a dysfunctional health law, and a populist revolt against the establishment on both sides of the political aisle.
Can Trump,  like Harry Truman before him, come from  behind as a political underdog to win in  a late season political surge?
Can Trump neutralize a powerful mainstream and social media to win the hearts and minds of enough women, college graduates, and millenials  to squeak  out a political victory?
Is Hillary Clinton like a modern-day ship like the Queen Mary, impossible to turn around on a dime?  
Will some technological revolution,  like jet plans making the Queen Mary obsolete or further email scandals, change the political chemistry
Can she just sit on her lead and her Democratic assets,  which includes 98% of the black vote,  70% of the Hispanic vote, and at least 60% of the women’s and youth vote.
Will some catastrophic event,  like a 9/11 attack or a shopping mall massacre,  or large scale terrorist happenings in Europe,    change the political equation?   Will more email revelations  of Hillary perjuries , change peoples’ minds?  
None of these things seem likely.

A Ransom Is a Ransom by Any Other Name
I am enjoying  the State Department’s and Obama administration’s explanation of why the $400 million  given in exchange for the release of 4 American Iranian held prisoners was not a ransom.
Instead the $400 million in cold hard cash which arrived by plane while the prisoners waited for their release was a “highly leveraged contingency” mechanism springing them loose from their imprisonment.   The $400 million was an installment on  $1.7 billion deal that  had been negotiated years before in a court at the Hague in 1981, 
 The $400 million was not “ransom,” but a move calculated  to save American taxpayers interest on an internationally agreed up deal.  The fact that the plans landed on the same day was strictly “ coincidental ,”  and had nothing to do with the prisoners’ release, unless you factor in the current State Department admission  about the release  being “highly leveraged” to spring the hostages.
It may not make any difference who is right here.   The point is that  the money and the prisoner release were closely related and are viewed by political opponents,  the Iranians,  and the world at large as a ransom, which is defined at the release of a prisoner or kidnapped person for a price paid or demanded.  In other words,  if it looks like a ransom,  works like a ransom, smells like a ransom, and releases prisoners like a ransom,  it’s a ransom and can used a precedent for future ransoms.

Thursday, August 18, 2016

Who Are You Going to Believe:  Insurance Actuaries of ObamaCare  Visionaries?
Who are you going to believe, me or your lying eyes?
Groucho Marx (1895-1977)
Following the lead of other major health insurers, Aetna has withdrawn from 536 of 778 ObamaCare health exchange markets.     This abrupt withdrawal reminds me of a Groucho Marx story.
When his wife caught him in bed with another woman, Groucho denied any wrong doing.  He asked his wife,”Who are going to believe me or your lying eyes?

In my blog title, I use the word “betrayal” because President Obama promised consumers they could keep their plans, doctors,  hospitals,  while keeping their premiums low.   Instead, of course, consumers have found few of these promises apply to them.   The old phrase “finders keepers” apparently does not apply to ObamaCare.
In the case of health insurance,  health actuaries are the “lying eyes,” and “me” is the government who is telling them what they are experiencing isn’t reality.   Actuaries are financial experts hire to calculate  the “actual “ reality-based risks.    The government policy people are promissory visionaries of what they think might happen.
Who to Believe?

Who are you going to believe  independent actuaries  calculating risk who are predicting insurers must increase premiums by an average of 18% to 23% across multiple markets or government officials, who are saying don’t believe your eyes, things will get better.  

Doug Badger and Marilyn Travenenar, former CMS and government officials,  now working on the anti-Obama side of the ledger say CMS is “cooking the books” to hide heavy losses and to present a falsely-positive view of the future  ( “Adjusting ObamaCare Reality,” National Review Online,  August 16. 2016). Travenner notes,  “Insurers,  unlike government spin doctors, understand  that, while one can adjust the numbers,  one cannot adjust reality.  For insurers to participate in ObamaCare – as well as consumers and taxpayers, who bear the brunt of the law’s costs and dislocations, the reality isn’t good.”

Don’t worry say ObamaCare advocates, we’re from the government and you can trust us. Every comprehensive government program has hiccups (Jeff Spross, “ObamaCare Is Not Doomed “,  August 16,  The Week, and “Editorial Board, “ObamaCare Will Survive,” New York Times, August 18, 2016).
Government and ObamaCare can always print money, incur debt, and stay in business by increasing subsidies,  having taxpayers bail them out, passing a Public Option, and offering Medicare to  everybody over 55,  Never mind that enrollment in exchanges have been flat, at 11 million half of what was predicted,  that there is too much “churn” as enrollment drop out after receiving care, and that exchange polices are not attractive to health people.
Could it be that highly compensated  conservative  actuaries are lousy at math?  Could it be that ObamaCare is simply designed by pie—in-the-sky theorists who have no concept of risk and profit and who dedicated to the proposition that failures will lead to universal care if we only wait long enough to come to our senses?