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Medical Justice

Making healthcare safe for doctors



09/19/17 11:31 AM

I’ve had it with acronyms. 

SGR [Sustainable Growth Rate] was replaced by MACRA [Medicare Access and CHIP Reauthorization Act] which allows physicians to choose between two Medicare payment programs: (a) MIPS [Merit-Based Incentive Payment System; and (b) APMs [Alternative Payment Models].  

According to CMS [Center for Medicare and Medicaid Services], these changes create a QPP [Quality Payment Program].  

According to CMS, MIPS is a new program that combines parts of PQRS [Physician Quality Reporting System], the VM [Value Modifier]; and the HER [Medicare Electronic Health Record incentive program] into a single program in which EPs [Eligible Professionals] will be measured on:

  • Quality 
  • Resource Use 
  • Clinical Practice Improvement 
  • Meaningful Use of HER Technology 

Since Medicare believes most physicians who participate will opt for MIPS, I won’t dwell on APMs.  

I sat in on a lecture about prospering with MACRA. I wanted to learn more. In the auditorium I saw a few physicians. While I believe the program is well-intentioned (who would be against quality or value; it’s like Mom and Apple Pie – everyone is for it), I’m skeptical the programs will deliver value or quality.  

I was not able to understand the programs. 

If incentives are not clear, concise, and well-defined, how can any participant know how to hit their marks? 

While a few physicians attended, I mostly saw health system bureaucrats. They were there to learn the game. Yes, it’s a game. And played properly, I’m sure it can be profitable.  

These are the same bureaucrats who created what is euphemistically known as a “facility fee.” If you see a newly employed primary care doctor – or specialist, you pay a professional fee (no surprise there). Often you also pay a facility fee. That’s the surcharge the institution places for using its building. Interestingly, my accountant does not charge a facility fee. My lawyer does not charge a facility fee. Doctors in private practice don’t charge a facility fee. Only hotels charge a facility fee, because the service you receive is actual access to its facility.  

My conclusion. Large practices will participate in MACRA. Many in small or solo practices will opt out of Medicare and its acronyms.  

That does not imply small or solo practices will become extinct. On the contrary.  

I recently had lunch with a talented primary care doctor. He was previously an employee in a large healthcare system. He was tired of the rat race. He hung out a shingle with his wife, another primary care doctor. They are launching a DPC [Direct Primary Care] practice. This is one acronym worth investigating. They charge patients a modest subscription fee for essentially unlimited primary care. No waits. Patients have the doctor’s cell phone number. Labs in the office are priced at wholesale rates.  

Transitioning to a DPC model can be scary. Why? The doctor opts out of third party reimbursement. But, one’s overhead plummets. Regulatory burdens decrease. Time available to spend with patients go up.  

My only counsel to the DPC physician was to make sure he had enough of a financial runway to see the project through. I believe he and his wife will succeed. Others will likely follow. If MACRA turns out to be the stimulus for such innovation, I’m glad it passed.  

What do you think? Share your comments below.

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Posted by Medical Justice | in Legal | 4 Comments »
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All this reminds me of the outlaw shooting at the cowboys feet and telling him to dance. The government is the out law and we are the cowboys. I, and the other “providers” in my group, will not dance. We also will not to do EMRs. And will not do MOC (but we do support NBPAS). And will not do MACRA and MIPS and all those other acronyms. We will take the eventual 9% hit. I look at it as being patriotic. The government will reimburse us with a 9% discount and we are helping them reduce the national debt.… Read more »


All of these acronyms are the government’s attempt to ostensibly improve quality and decrease costs. Very few patients would say that healthcare has improved. Now physicians type into a computer screen and don’t interact with patients in the older normal conversational way. This may fit perfectly into the video game generation, but physicians don’t like it, and patients hate it. Quality of care with all of the ballyhoo has not improved. Costs have gone up and not down. Now we as a country are prepared to throw more taxpayer confiscated money at the problem. Meanwhile the bureaucracy chews up more… Read more »


Dr Jeff Segal is one of the brightest minds I’ve met, and if he can’t understand the programs, no one can. We have been third-party free for four years, and we did it slowly over a 3-4 year period beginning in 2009. The FIRST insurance to drop was Medicare. As a solo practitioner, I was intimidated by the prospect of a federal audit as OCare was shoved – opting-out of MCare was one of the most liberating feelings!. Volume dropped by 30% for around four months, and when volume returned to baseline, we then dropped the lowest reimbursing private payor.… Read more »

donn chatham md

Well crafted expose of another bureaucratic extortional power grab for more data. “Quality’ is the sheep’s clothing.
The quality of life in our practice is enhanced by non-participation.