2 Major Problems with MACRA

Everyone’s started to dive into the 10 million page MACRA (that might be an exaggeration, but it feels about that long) and over the next months we’ll be sure to talk about the details a lot more. However, I know that many healthcare organizations are tired of going through incredibly lengthy regulations before they’re final. Makes sense that people don’t want to go through all the details just for them to change.

As I look at MACRA from a very high level, I see at least two major problems with how MACRA will impact healthcare.

Loss of EHR Innovation
First, much like meaningful use and EHR certification, MACRA is going to suck the life out of EHR development teams. For 2-3 years, EHR roadmaps have been nothing but basically conforming to meaningful use and EHR certification. Throw in ICD-10 development for good measure and EHR development teams have basically had to be coding their application to a government standard instead of customer requests and unique innovations.

Just today I heard the Founder of SOAPware, Randall Oates, MD, say “I’m grieving MACRA to a great degree.” He’s grieving because he knows that for many months his company won’t be able to focus on innovation, but will instead focus on meeting government requirements. In fact, he said as much when he said, “We don’t have the liberty to be innovative and creative.” And no, meeting government regulations in an innovative way doesn’t meet that desire.

I remember going to lunch with a very small EHR vendor a year or so ago. I first met him pre-meaningful use and he loved being able to develop a unique EHR platform that made a doctor more efficient. He kept his customer base small so that he could focus on the needs of a small group of doctors. Fast forward to our lunch a year or so ago. He’d chosen to become a certified EHR and make it so his customers could attest to meaningful use. Meaningful use made it so he hated his EHR development process and he had lost all the fire he’d had to really create something beautiful for doctors.

The MACRA requirements will continue to suck the innovation out of EHR vendors.

New Layers of Work With No Relief
When you look at MACRA, we have all of these new regulations and requirements, but don’t see any real relief from the old models. It’s great to speak hypothetically about the move to value based reimbursement, but we’re only dipping our toe in those waters and so we can’t replace all of the old reimbursement requirements. In some ways it makes sense why CMS would take a cautious approach to entering the value based world. However, MACRA does very little to reduce the burden on the backs of physicians and healthcare organizations. In fact, in many ways it adds to their reporting burden.

Yes, there was some relief offered when it comes to meaningful use moving from the all or nothing approach and a small reduction in the number of measures. However, when it comes to value based reimbursement, MACRA seems to just be adding more reporting burdens on doctors without removing any of the old fashioned fee for service requirements.

MACRA is not like ICD-10. Once ICD-10 was implemented you could see how ICD-9 and the skills required for that coding set will eventually be fully replaced and you won’t need that skill or capability anymore. The same doesn’t seem to be true with value based care. There’s no sign that value based care will be a full replacement of anything. Instead, it just adds another layer of complexity, regulation, and reporting to an already highly regulated healthcare economic system.

This is why it’s no surprise that many are saying that MACRA will be the end of small practices. At scale, they’re onerous. Without scale, these regulations can be the death of a practice. It’s not like you can stop doing something else and learn the new MACRA regulations. No, MACRA is mostly additive without removing a healthcare organization’s previous burdens. Watch for more practices to leave Medicare. Although, even that may not be a long term solution since most commercial payers seem to follow Medicare’s lead.

While I think that CMS and the people that work there have their hearts in the right place, these two problems have me really afraid for what’s to come in health IT. EHR vendors the past few months were finally feeling some freedom to listen to their customers and develop something new and unique. I was excited to see how EHR vendors would make their software more efficient and provide better care. MACRA will likely hijack those efforts.

On the other side of the fence, doctors are getting more and more burnt out. These new MACRA regulations just add one more burden to their backs without removing any of the ones that bothered them before. Both of these problems don’t paint a pretty picture for the future of healthcare.

The great part is that MACRA is currently just a proposed rule. CMS has the opportunity to fix these problems. However, it will require them to take a big picture look at the regulation as opposed to just looking at the impact of an individual piece. If they’re willing to focus MACRA on the big wins and cut out the parts with questionable or limited benefits, then we could get somewhere. I’m just not sure if Andy Slavitt and company are ready to say “Scalpel!” and start cutting.

About the author

John Lynn

John Lynn

John Lynn is the Founder of the HealthcareScene.com, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference, EXPO.health, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.

3 Comments

  • God Bless You John,
    As you know I am a front line provider, in a small single specialty group. You are RIGHT on target with MACRA. Its more of the same with adding even more complexity and a Clinical Practice Improvement Activity module that someone thinks is a good idea, on top of 3 other modules, 2 of which are cutely renamed, like we really didn’t notice. As I said to you before, its like we are punched in the face 18 times a day and now they just want to make it 11 times, shouldn’t we be happy? Sheesh. Its truly the definition of insanity to keep doing the same thing over and over and expect a different result. I have no idea how CMS and ONC really thinks that its all the doctor’s fault for healthcare costs. Second, why dont we just test AAPM’s or MIPS with practices and see if they are the lowest cost and/or highest quality. Don’t penalize us for an experiment. Why don’t EHR vendors have to have their own MACRA, that the physicians make up, that they have to attest and count and prove that they are usable, efficient safe and secure, or CMS have some practice improvement activity and then dock their pay. Or my patient refuses to stop smoking, how about we charge them more? Or Big Pharma have some price controls? Or IT have some price controls? Why is it always me that gets price controlled. I really think the blowback from this is going to be big loud angry and stunning to those in the box in DC that think they did something better. They just don’t get it. Stop penalizing physicians, stop burdening us, we are depressed, demoralized, and frankly at our wits end.

  • I’m one of those who tend to believe that without the government pushing, some things would never progress. For instance, we’d still only have a small percentage of providers on EHR, or eprescribe or ICD10 unless there was enough pressure from government (and perhaps the insurance industry). But once in a while we need to step back and get that mile high view as to where we are, what is working, and what isn’t. As I recall, back during the Clinton presidential years, Al Gore led an effort to clean out government waste and excessive regulation. Maybe we need some variation of that once again; in fact, maybe we should have such once every so many years.

    Ron

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