Is Dr. Halamka Right When He Says that MDs Might Leave Practice over Health System Reform?

Oct. 4, 2016
When Dr. John Halamka says that excessive complexity in the required measures under the proposed new rule issued by CMS could cause him to leave medical practice, federal healthcare officials might want to pause to consider

Anyone who hasn’t been living in a cave for the past few years already knows this: the U.S. healthcare system is changing rapidly—so rapidly that it’s becoming difficult for healthcare professionals of all types to keep up. Simply keeping abreast of new policy developments alone is becoming a challenge these days.

So it should come as no surprise to many that the release on April 27 of a proposed rule on the part of the Department of Health and Human Services (HHS) that has many moving parts to it, is probably taking many practicing physicians in this country a bit unawares.

As we reported in a news article on that date, “In a dramatic policy move, federal healthcare officials announced on Wednesday afternoon, Apr. 27, that the Centers for Medicare & Medicaid Services (CMS) is introducing a new program that will replace the meaningful use program under the HITECH (Health Information Technology for Economic and Clinical Health) Act, for physicians participating in the Medicare program (for the moment, hospitals will be unaffected). The new program, called Advancing Care Information (ACI), was introduced Wednesday as a Notice of Proposed Rulemaking by the Department of Health and Human Services (HHS), under the terms of the Medicare Access and CHIP Reauthorization Act (MACRA). The new program,” we noted, “with its associated changes, was announced on the CMS website, and via two succeeding press conferences, the first one involving Andy Slavitt, Acting CMS Administrator, and Patrick Conway, M.D., Deputy Administrator for Innovation & Quality and Chief Medical Officer for the agency, and the second one involving Slavitt and Karen DeSalvo, M.D., National Coordinator for Health IT, along with Kate Goodrich, M.D., Director of the Center for Clinical Standards and Quality at CMS.”

While the announcement could not be said to have been totally unexpected, it is important to note that, with all the recent developments in so many areas, only those paying very close attention could probably have anticipated the Apr. 27 announcement very specifically and planfully.

So, it happened, and for the most part, most commentators, including John Halamka, M.D., CIO at Boston’s Beth Israel Deaconess Medical Center, expressed general support of the new proposed rule’s focus on quality and outcomes, on the day of the rule’s release. But then on Thursday, May 5, after having analyzed the rule’s details, Dr. Halamka made a different kind of statement, in his blog, as we reported.

Before he editorializes extensively about it, Dr. Halamka, in his blog, explains a great deal about the proposed rule, going into some detail to explain the measures contained in the proposed Advancing Care Information program that will replace current meaningful use requirements for physicians, and explaining what physicians and other eligible clinicians (“ECs”—the term replaces the term “eligible providers,” or “EPs,” that has been used under the meaningful use program). There is a lot that is very much worth reading, and Dr. Halamka has done everyone a service by reading through and analyzing the full 962-page proposed rule.

Now, here are the editorializing comments from the full blog itself, entitled, “A Deep Dive on the MACRA NPRM,” that I found fascinating:

“After spending 20 hours reading the MACRA NPRM, I had one overwhelming thought.  Sometimes when you remodel a house, there is a point when additional improvements are impossible and you need to start again with a new structure.  The 962 pages of MACRA are so overwhelmingly complex,” Dr. Halamka writes, “that no mere human will be able to understand them.  Above, I have only covered the HIT related concepts, which are a small subset of all the changes to payment processes.  This may sound cynical, but there are probably only two rational choices for clinicians going forward –become a salaried employee delivering clinical care or become a hospital-based clinician exempted from the madness.”

What’s more, Dr. Halamka writes, “The folks at CMS are very smart and well meaning, but it’s hard for me to imagine implementing the NPRM as written in the timeframes suggested.  I will watch closely for comments from organizations such as the AMA, AHA, and clinician practices.   I’m guessing that many will see the ONC Surveillance provisions as overly intrusive and the "advancing care information" requirements as creating more burden without enhancing workflow.   Maybe the upcoming Presidential transition (whoever is elected) will give us time to pause and reflect on what we’ve done to ourselves.    As a practicing clinician for 30 years, I can honestly say that it’s time to leave the profession if we stay on the current trajectory.”

So, let’s unpack some of this, shall we?

Let’s start with the fact that Medicare officials, with this move, have taken yet one more step to make it clear that they mean business. They are putting the agency’s conceptual foot to the conceptual metal here, and leveraging the MACRA law to rework federal physician reimbursement incentives, big-time. Essentially, Medicare-accepting physicians will have two options: to participate in an alternative payment model, post-haste, or to participate in MIPS, with its evolving requirements. Dr. Halamka essentially seems to support that move.

But the complexity of the proposed rule is itself a big issue for him—not just in itself, as some abstract characteristic, but instead, with regard to the amount of time and mental energy it will take for practicing physicians to read and interpret the information and rules involved, and to make choices on behalf of their practices.

Let’s look at a little bit of the complexity that Dr. Halamka describes. Here’s a section of the summary of the requirements under MIPS, as summarized by HHS:

“Most Medicare clinicians will initially participate in the Quality Payment Program through MIPS. The ACA moved many Medicare payment systems, including that for clinicians, towards value, and MACRA builds on that work. Consistent with the goals of the law, the proposed rule would improve the relevancy and depth Medicare’s quality-based payments and increase clinician flexibility by allowing clinicians to choose measures and activities appropriate to the type of care they provide. MIPS allows Medicare clinicians to be paid for providing high value care through success in four performance categories: Quality, Advancing Care Information, Clinical Practice Improvement Activities, and Cost.

Ø  Quality (50 percent of total score in year 1): For this category, clinicians would choose to report six measures from among a range of options that accommodate differences among specialties and practices.

Ø  Advancing Care Information (25 percent of total score in year 1): For this category, clinicians would choose to report customizable measures that reflect how they use technology in their day-to-day practice, with a particular emphasis on interoperability and information exchange. Unlike the existing reporting program, this category would not require all-or-nothing EHR measurement or redundant quality reporting.

Ø  Clinical Practice Improvement Activities (15 percent of total score in year 1): This category would reward clinical practice improvements, such as activities focused on care coordination, beneficiary engagement, and patient safety. Clinicians may select activities that match their practices’ goals from a list of more than 90 options.

Ø  Cost (10 percent of total score in year 1): For this category, the score would be based on Medicare claims, meaning no reporting requirements for clinicians. This category would use 40 episode-specific measures to account for differences among specialties.

The proposed rule seeks to streamline and reduce reporting burden across all four categories, while adding flexibility for physician practices. CMS would begin measuring performance for doctors and other clinicians through MIPS in 2017, with payments based on those measures beginning in 2019.”

And that’s a summary of requirements under MIPS; it doesn’t even address the complexity of the requirements that practicing physicians will need to address if they move forward towards participating in an alternative payment model.

And that leads us to Dr. Halamka’s key—and final—sentence—in his criticism of the new requirements. He says, “As a practicing clinician for 30 years, I can honestly say that it’s time to leave the profession if we stay on the current trajectory.”

That’s a pretty intense statement; and Dr. Halamka, one of the most thoughtful and articulate of industry leaders and thinkers, surely thought through carefully that last, gut-punch-to-the-abdomen-of-CMS, statement.

It is a statement that, taken out of context, could sound like something said by a very healthcare reform-opposing physician in solo or small-group practice, or perhaps an elected leader of the AMA (American Medical Association), rather than one of the most health system reform-progressive physician executives on the public stage. And that in itself is significant.

On the other hand, Dr. Halamka’s point is one worth pondering; and even more importantly, it’s one that would be worth having federal healthcare officials ponder. Are some of the requirements of the new healthcare too complex? Too demanding? Too difficult to fulfill? Too confusing?

The devil will really be in the details with all of this. I think what can be said is this: when one of the most respected physician and IT leaders in the country sounds an alarm, it would well be worth it for federal healthcare officials to take note, and to do what they can to mitigate unnecessary complexity in their very well-intentioned efforts to compel clinicians forward towards value in healthcare delivery. Because honestly, if Dr. Halamka threatens to quit medicine, we might all want to pause to consider any excessive complexity or rigor in proposed requirements for clinicians going forward in the new healthcare.

My own take on this? Physicians in practice who are not already salaried by hospitals, large medical groups, and integrated health systems, are going to flock to employment, hoping that their CMOs, CMIOs, CIOs, department heads, and others, will help them work through the new mazes of quality measurement participation in the new healthcare. And also that IT and informatics leaders in patient care organizations are going to be both more empowered than ever before, and under pressure as never before, to help the physicians employed by or affiliated with, their organizations, to meet these new demands.

Realistically, I don’t see massive numbers of 45-year-old physicians 15 years into practice simply giving up and moving to Belize to build wooden canoes anytime soon. But I agree that federal officials are going to need to do whatever is in their power to make this set of transitions work best for doctors in practice. That would be important, as well as the right thing to do. Stay tuned: the next year will be particularly fascinating—and I can’t wait to see how it turns out, myself.

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