The Scarlet Zero: MACRA Completes Government Takeover of Medicine

by Kris S. Held, M.D.

When Medicare and Medicaid were created, the government promised not to interfere in the practice of medicine in any way. President Lyndon Johnson signed the Act into law on July 30, 1965, ironically in Independence, MO.

It read: Nothing in this title shall be construed to authorize any Federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided, or over the selection, tenure, or compensation of any officer, or employee, or any institution, agency or person providing health care services… or to exercise any supervision or control over the administration or operation of any such [health-care] institution, agency, or person. Section 1801, Medicare Act, 1965

Fifty years later, in flagrant violation of this prohibition clause, stands the 2015 Medicare Access and CHIP Reauthorization Act (MACRA), replete with the Merit-Based Incentive Payment System (MIPS). MIPS is a rubric the federal government uses to grade physicians and assign each a score of 0 to 100. The Composite Performance Score (CPS) is used to financially incentivize or penalize physicians, and then the scores are posted on a public website for all to see.

The core of MIPS is the ultimate conflict of interest: the very lives and well-being of America’s patients vs. the money and power of the medico-industrial complex run by a small group of insider elites, implemented and micro managed by entrenched, faceless deep state bureaucrats. Physicians must choose sides.

Will your physician follow the tradition of Hippocrates, who believed the physician works on behalf of the patient, not for the good of the state—risking his livelihood? Or will he follow the Greek philosopher Plato, who urged that doctors refrain from curing the weak and infirm to improve society? MIPS incentives mean punishment and abuse for serving patients first, and rewards for serving society.

MIPS grades physicians on quality (outcomes), advancing care information, improvement activities, and cost. Earning a high score often requires doing what government says instead of what is best for the patient.

“Quality indicators” and “outcome measures” may sound great, but they may deter physicians from taking on the most difficult and challenging patients. For example, one measure of outcome is how many of a physician’s patients achieve a blood glucose level under a certain number. One of my patients told me she has passed out twice, sustaining injuries, since her physician assistant put her on two diabetic medications to get her blood sugar below the government number. Fortunately, she was not driving or alone at home in her bathtub.

Since I have refused to participate in MIPS and the like, I am “out of network” for all insurance plans including Medicare and Medicaid. Ironically, I am seeing an influx of patients with what I call “3rd world cataracts.” One patient had only light perception; he could not even perceive hand motion. He is 60 years old with severe cardiovascular disease that presents a higher than normal surgical risk. I operated on him, and he now has 20/20 vision. Because he had been avoided by several surgeons trying to play the MIPS game, his cataracts were like granite rocks floating in bags of milk, making visibility and removal difficult.

Advancing Care Information (ACI) used to be called “Meaningful Use Electronic Health Records,” but ACI sounds friendlier. MACRA rules mandate that government have full, unblocked access to patients’ records, without their permission. Their “Protected Health Information” (PHI) includes all personal identifying data including all demographics and all medical history, past and present, including all medications ever taken. This is not just a violation of the Oath of Hippocrates and sacrosanct patient-physician relationship, but also of the 4th Amendment. Government will gather all data, not just MIPS data, on all patients, not just Medicare patients, and from all insurers- commercial too, not just Medicare. This data will be sold by government to entities the federal government itself chooses.

Under “improvement activities,” government hopes to “drive physician behavior,” as by having us engage in “education” activities that government deems important. These include learning about the emerging “palliative care” movement, replete with educational material glorifying “aid in dying”—formerly known as “physician assisted suicide.”

The cost category, formerly known as Resource Use, is beyond worrisome. The sample grade chart itself shows that physicians who spend the most on their patients get 0 to 2 points while those that spend the least get 8 to 10 points. In other words, doctors get more money for withholding care and resources from patients and are penalized for delivering care.

There can be no denying that MIPS is a top-down, command-and-control grading system based on perverse incentives. It willaffect you. Already, virtually everyone at all associated with medical care is subject to MACRA, including audiologists, dieticians, and speech pathologists to nurse practitioners, physicians assistants, nurse midwives, clinical nurse specialists, psychologists, and so on. We are all now lumped into a group called “Eligible Clinicians” or “Eligible Professionals.”

In the 50 years since government vowed not to interfere with medicine whatsoever, it has almost completely taken us over. To preserve the final remnants of freedom, ethical physicians should refuse to participate in MIPS and proudly wear our Scarlet Zeroes—a beacon to patients who want personal care.