One year ago, I wrote to you about my concerns for the future of my practice in light of upcoming changes to the Medicare system. I explained my anxiety about the Medicare Access and CHIPS Reauthorization Act (MACRA), a change in fee structure from fee-for-service (I treat you in the office, submit the bill to Medicare, and they pay the bill), to “value-based” payment (I treat you in the office, submit the bill to Medicare, and they decide if my care provided adequate value to warrant payment).
This payment change guarantees to financially penalize 50 percent of Medicare providers, mostly solo and small practice doctors, just by nature of design. It works like this: Medicare allots a set pool of money to pay doctors. Payment occurs on a scale, with the “best” doctors (those who provide the best value, per Medicare) getting paid more, while the remainder are penalized with less money. “Value” is determined by physician reporting of various data points, like diabetes control and cholesterol medicine use. Doctors must either do this extra reporting during their free time, or hire additional staff to act as data entry clerks, just to avoid a financial penalty.
In addition to data reporting, physicians are graded by the dauntingly vague concept of “resource utilization.” This means that doctors will become accountable for patient outcomes, with financial penalties if their patients end up in the emergency room or readmitted to the hospital. Somehow, doctors are now responsible for ensuring that patients make the right choices, like smoking cessation and taking their medications, all the while attempting to maintain the highest patient satisfaction scores, since patient “experience” also contributes to the payment/penalty calculation.
This additional reporting and superhuman level of expectation demanded by MACRA just adds to the growing burden of administrative responsibilities faced by physicians. The increase in bureaucracy , often coming from the demands of insurance companies and Medicare, is a major cause of physician burnout, causing many doctors to contemplate leaving the practice of medicine entirely.
And I get this urge to leave clinical medicine. As I spent hours reviewing Medicare’s 2400-page final ruling on MACRA, set to begin just a few short months from the release of the report, I felt a sense of hopelessness and despair. How could I ever comply with the ever-growing list of requirements demanded of me, on top of the time that I needed to spend with my patients?
And so I made a difficult decision. I have decided to opt-out of Medicare, acknowledging that I can no longer play a game that is rigged against me; one that I can never win because of constantly changing rules, and one where the stakes include fines and even potential jail time.
And in leaving the current broken system, I will take my chances in a brave new world that hopes to return to the foundation of medicine: the physician-patient relationship.
I am returning to a time before insurance companies and Medicare, when doctors wrote their notes for themselves rather than for bean-counters. And while I will be using an electronic record rather than a 5 x 8-inch index card as many old-school physicians once did, my notes will be succinct and differential diagnosis-based, not cluttered by meaningless information entered merely to earn a payment bonus or avoid a penalty.
I am getting back to a time when medical decisions were made between the patient and the doctor, rather than by third-party mandates. And in eliminating those third-party payers, I am recreating a system that allows doctors the time they need, face-to-face with patients, to make those important health decisions. I will no longer require hours of time on needless paperwork, or have to pay an entire team of staff to handle the minutiae while I maintain a breakneck 7-minute-per-patient visit schedule, just so I can pay my overhead.
As of January 1, 2017, I am no longer a part of the conventional Medicare system. And as hard as this transition may be, it’s a no-brainer when compared with the option of staying in a system that has led to catastrophic levels of burn out, depression, and physician suicide. I am taking back control. I am direct care.