Rethinking MACRA, a Follow Up by John Halamka

John D. HalamkaIn my blog posts, I speak from the heart without a specific political or economic motivation. Although I’ve not written about highly controversial subjects such as religion, gun control, or reproductive policy, some of the topics in my posts can be polarizing. Such as was the case with MACRA. Some agreed with my initial analysis that clinicians will have a hard time translating complex MACRA payment processes into altered clinical behavior. Others felt I was overharsh, negative and inappropriate. It’s never my intent to criticize people, instead I want encourage dialog about ideas. In that spirit, here’s my opinion on how we should evolve from fee for service to pay for value/outcomes.

1) Humans can never really focus on more than 3 things at a time. Although we sometimes believe multi-tasking is efficient, in reality we do work faster with less quality. Instead of 6 or 8 dimensions of Meaningful Use performance combined with a large number of quality indicators, why not delegate each medical specialty the task of choosing 3 highly desirable outcomes to focus on each year, then reward those outcomes?  

For example, I have glaucoma. Asking my opthalmologist to record my smoking status or engage in secure messaging with me is probably less important than ensuring my intraocular pressures are measured, appropriate medications are given, and my visual field does not significantly worsen. The cost to society of my blindness would be significant. Keeping my sight intact represents value. Care Management software could ensure I’m scheduled for pressure check appointments, given medications, and have my visual field checked once per year. Some percentage of reimbursement could be withheld until those outcomes are achieved. How software does that is not important and innovative workflow would be left to the marketplace where clinicians will choose applications based on usability, cost, and time savings instead of regulatory oversight.

2) Care coordination is important and there is a role for government to drive consensus around standards selection. Certification could be limited to an application’s ability to perform a few key interoperability functions such as

• Look up a recipient address from a national provider directory and send a clinical summary of care (transition, referral request, consult note) to that address securely.
• Query a record locator service/master patient index and retrieve a list of electronic addresses where patient data is stored, then be able to retrieve a small common data set from those locations (problems, meds, allergies, labs, notes).
• Be able to send a clinical summary of care to a patient provided electronic address.
• Be able to send a small number of data elements to a relevant registry.
• Be able to participate in a prescription drug monitoring program.

Each of these functions would use a single standards implementation guide without significant optionality, tested in the marketplace and deemed mature enough for use. How these transactions are implemented in workflow would be up to each vendor. Certification would test nothing more than successful transactions against a publicly available test bed.

3) All other Meaningful Use criteria and quality measures would be eliminated so that clinicians can focus on just the three goals per year relevant to their specialty while working in an environment that thrives on the simple information exchanges listed above.

We need to avoid unnecessary burden for clinicians, hospitals and software developers.   Think about all the effort (and dollars) spent during the Meaningful Use Stage 1 and 2 processes to report quality measurements, which were never used for anything. Think about all the certification done that was not related to health policy goals or outcomes. Think of all the data entry required which resulted in clinicians  spending time practicing below the top of their licenses.  

Focusing on 3 outcomes per specialty which are easily measurable, while radically focusing certfication on a few key interoperability transactions is likely to be acceptable to provider and developer stakeholders. The big question - would it satisfy CMS goals for MACRA based on Congressional mandates? I hope to have that dialog in several forums over the next few weeks.