September 26, 2016

Patrick Conway, M.D.
Deputy Administrator for Innovation & Quality and CMS Chief Medical Officer
7500 Security BlvdWindsor Mill, MD 21244-1849

Dear Dr. Conway:

I am writing on behalf of the NPCHP (National Physicians’ Council for Healthcare Policy), a multi-specialty physician led council. Our physicians come from all over the country and represent all modes of practice. We believe that we provide a dynamic think tank focused on generating thoughtful solutions to the myriad of problems plaguing the health care industry.

We want to thank you for your recent public comment extending the opportunity for physicians to engage in a more flexible “dive” into MACRA/MIPS. Your willingness to work with the medical community is so necessary if we are to come through this transition with a system that can reliably improve quality and decrease cost.

I would suggest however that we have not yet solved the difficulties that MACRA/MIPS presents to the typical solo / small practice or rural physicians and that is among other things the investment both in capital and staff necessary to comply with the regulations. These hindrances are exacerbated for the small or rural practice threatening insolvency to the very physicians caring for patients who otherwise have limited access to care. And you have not addressed the threats of insolvency looming over small and rural practices.

If we’re going to solve the problems that MACRA/MIPS present to the small and rural practices we must make sure that our assumptions are correct and that there are no known obstructions preventing our predicted outcomes from coming to fruition.

First, the idea that physicians are expected to use population based protocols that are unreliable for an individual patient basis is specious. On the other hand, there is not a single study that demonstrates that there is any improvement in quality or decrease in cost when physicians are forced to report data other than the need to transmit billing data.

Second, CMS assumes that administrative data represents clinical data. It does not.

Third, while physicians are expected to use EHR systems to report data, CMS has not enforced current EHR regulations. The promised data sharing (the fundamental rationale for engaging in computer systems delegated to healthcare) does not exist in spite of the law. The HER requires more time devoted away from patient care and is a source of more work, much of it a waste of time as has been reported by both the public and the private sector studies.

Furthermore, the idea that the government or any entity other than the consumer can manage or rate the quality of his/her purchase is false as is the idea that fixed pricing will result in a) a control of demand or 2) will result in decreased cost.

Fixed price physician contracts ultimately move risk to the physician and in the case of MACRA, that risk is not compatible with the sustainability of any small or rural physician groups. Business owners are entitled to make a living. If the government contract is too far below market, physicians will find other means to make ends meet. A businessman friend of mine once warned the government, “I will not allow you to make a thief of me.” It is not the responsibility of the government to decide what businesses fail and which succeed.

It has always been assumed that the laws of economics do not apply to health care, but that is not true. Applying sound economic principles will, we believe result in the transparency the government has been promising the American consumer. It will provide more patient choice, lower cost, and the competition will spirit a new robust race to improve quality.

We acknowledge that not everyone will want to work in our new found marketplace and many large groups have geared up for the MIPS track or have invested in an alternative payment model. We do not feel it prudent to interfere with that opportunity. MIPS/MACRA should proceed for those willing and able to engage.

We ask that in order to sustain the small and rural practices, responsible for millions of lives, that CMS establish a floor of participation determined either by the number of patients a physician sees yearly or the volume of dollars the practice is paid yearly by the government. Practices not meeting the floor area entirely exempt from participation. Those not participating should not be expected to make the high cost investment necessary to comply with the new law. It is this investment that poisons the future of small and rural practices.

Finally, we suggest that CMS accept as an APM the direct pay model. There are many varieties of direct pay models that have proven themselves successful for both patients and their doctors. How that is accomplished would be for future discussions.

We invite any member of your CMS team to meet with the members of the NPCHCP when we meet in DC in November. Hear from our membership directly and work with us to accomplish the goal(s) we all are so eager to meet, a healthcare system that works for patients and for doctors.


Marcy Zwelling, M.D.
National Physicians’ Council for Healthcare Policy