A nurse's reaction to MACRA haters

Like it or not, the Medicare Access and CHIP Reauthorization Act (MACRA) legislation will affect virtually all health care providers practicing in the U.S. Although I sympathize with Dr. Hahn’s sentiment in his article “If Medicare wants value, it should cancel MACRA,” lamenting this legislation feels like “another layer of senseless rules, data collection and more rules.”

MACRA ushers in a long-overdue value-based payment system designed to foster improved patient outcomes and generate data to measure program efficacy. Medicare’s fee-for-service (FFS) system incentivizes providers to make excessive diagnostic and treatment recommendations, as much of reimbursement is based on volume of services rendered while doing little to hold individuals accountable for outcomes measurement or contribution to standardized and publicly accessible data required to improve evaluation and implementation processes in health care. With over 17 percent of our GDP spent on health care annually. This status quo practice is unsustainable and irresponsible, and it needs to change.

I get it. MACRA requirements are a potential time-suck pulling providers away from direct patient care. My documentation workflow as a registered nurse, though I acknowledge is much different from that of a physician’s, also pulls me away from the already limited time I have for my patients. Over a third of productive nursing time is spent documenting, and I know how he feels. We are expected to have the most direct patient contact. Yet on top of medication administration, education and treatment, we have to find the time to chart and coordinate patient care with other disciplines, vendors, and family. It can be exasperating.

It is obvious, however, that existing conditions in health care desperately need to change. FFS-driven health care reimbursement incentivizes care fragmentation, loss to follow-up and cost inefficiency leading to poorer outcomes at higher costs. For example, one study found that chronically ill patients of primary care providers with the most signs of care fragmentation were more likely to experience preventable hospitalizations, have more health care dollars spent managing them and receive treatments that were a “departure from clinical best practice” compared to those with access to more streamlined care.

Though quality and care fragmentation are difficult concepts to measure due to lack of standardized and available data, a key aspect in medicine that MACRA reporting procedures will change. Most health care providers agree that integrative care management is far too rare in U.S. health care and that current practice is not working in our patients’, nor taxpayers’, best interests.

As an RN wound specialist, I use the scientific method to monitor wounds, using objective data to measure signs of progress or deterioration. If one treatment regimen doesn’t encourage wound healing, our team replaces it with new strategies until we see signs of improvement. As health care spending continues to hemorrhage uncontrollably in the U.S. with no better outcomes than other developed countries spending much less, it is clear that we need to change modalities to heal this structural wound.

MACRA is a novel approach that addresses wasteful spending, ineffective health interventions and our need for standardized and available cost and outcomes data for overall quality improvement. This approach is more congruent with the scientific method than the FFS model and should be trialed as a potential solution to our health and economic crises.

Performance-based payment adjustments to Medicare reimbursements, rather than pay based on volume of services rendered, will incentivize providers to make treatment decisions influenced by interdisciplinary and interspecialty collaboration, cost efficiency and best practice. MACRA’s reimbursement policy promotes care management styles that motivate providers to be more conscientious of outcomes and efficiency. It has major potential to improve health while simultaneously reducing duplication of services, unnecessary medical procedures and costs for individual delivery systems overall. Isn’t that worth the growing pains endured by health care professionals as we change our practice to support this model?

My heart went out to Dr. Hahn as he described in detail untangling MACRA-induced hiccups in the system — wasting 25 minutes of his clinical time on the phone dealing with Medicare D program representatives after they unexpectedly canceled his patient’s prescription for no good reason. Because he is held financially responsible under MACRA if his patient’s health were to spiral out of control on account of losing access to her medications, getting to the bottom of the error was imperative.

But besides empathy, I had another strong reaction this passage — chasing down pencil pushers at the Medicare office is below a physician’s skill set; that task should be delegated to a clerical person or medical assistant. Cumulatively, the time highly skilled health care workers spend doing menial tasks themselves, rather than delegating those tasks to ancillary staff, can lead to some serious profit and productivity losses.

This waste can be reduced through appropriate collaboration with health colleagues. By design, MACRA requirements make it essential for providers to reach out and partner with their peers to share the burden and make time spent individually with their patients more efficient and meaningful.

Physicians and other accountable providers need to more readily exploit the expertise of other disciplines and stakeholders whose professional training- in nursing, social work, rehabilitation, clerical work and even policy and medical sales, compliment, reinforce and enhance provider interventions and outcomes, thus freeing the provider to see more patients and have stronger influence overall.

A little up-front investment in hiring extra staff, learning new organizational skills or by building relationships with other community allies, is very likely to pay for itself through more efficient teamwork and more time for patient care. Together we can help practitioners and physician groups adapt to MACRA requirements so that we all earn what we deserve while improving health outcomes, collecting better evidence through data standardization and lowering health care costs in the U.S.