In regards to the passage of the doc fix bill (known now by the acronym MACRA) John Goodwin said it well: " it locks in Obamacare's vision of the relationship between physicians and the state." ... Now, doctors and patients will have to get used to a new reality where the federal government and beltway lobbyists’ priorities are more deeply embedded in physicians’ offices than ever."
Further the exact details and degree of the embedding will not be made known until phase three of new payments system. Remember we have to pass the bill to see what is in it?
The changes made in physicians payments are in three phases and from the years 2015 -2020 there will be a 0.5% increase in physician CMS fees and from 2020 -2026 the increase will be zero.
Phase 1 is the "lull-docs-to-sleep" phase in which all physicians will "enjoy" increases in the payment schedule (that do not keep pace with inflation) and for a while not worry about the always impending threat of a SGR imposed fee cut. This is the deal that is too- good- to -pass-up phase which typically occurs in the early stages of a scam.This phase runs from 2015 to 2019.Docs who are part of an APM )(see below) will receive an extra 5%.
Phase 2 is what I call the the devil is in the details phase.Physicians will be reimbursed based on a formula that takes into account four buzz word filled metrics.The categories of metrics are 1)quality 2)resource utilization 3)meaningful use of electronic health record. 4) clinical practice improvements. This phase runs from 2019 through 2025 and the overarching buzz word is MIPS (Merit based incentive payment system).
CMS will play the major role is setting physician payment.Note the meaningful use requirement will likely have more teeth and there is reason to believe that the much reviled MOC has received more statutory authority,although there are conflicting claims as to whether MOC is explicitly in Doc Fix or if it was already part of ACA or not in either.The National Quality Forum (NQF) is contracted by CMS for three years to provide advice and make suggestions regarding quality issues.It should not go unnoticed that the CEO of the NQF is the same Christine Cassel who was CEO of ABIM during the time that MOC was implemented and the Choosing Wisely Campaign was launched.
Whoever the rule makers will be will be targeted by
Phase 3 is the everyone-work- for- the-man final phase in which physician pay will be dictated by their involvement in a "alternative payment model", examples of which would be an ACO or a medical home or some sort of scheme involving large vertically integrated health behemoths.This phase begins in 2026.
Medical decisions will be shifted even more than they are now to Washington and the wishes of Don Berwick and Troyen Brennan that they expressed in their book New Rules are much closer to being realized. I quote from their writing:
"Today, this isolated relationship[ he is speaking of the physician patient relationship] is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care...Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority...Health care is being rationalized through critical pathways and guidelines."
The Doc Fix also moves forward the recommendation of Dr. Robert Berenson that he and a co-author made in a 1998 Annals of Internal Medicine Article ( p 395-402):
"We propose that devotion to the best interests of each individual be replaced with an ethic of devotion to the best interests of the group for which the physician is personally responsible."
MACRA will go a long way to achieving that proposal.