Jumping Through Hoops

Years ago, physicians had a lot of autonomy. Mostly, we worried about taking care of patients: what were the best treatments and best ways to manage patients’ care. But now that the government has thrust so much regulation on us, physicians are forced to be somewhat sidetracked, entering information into electronic medical records (EMRs) – because that is how we get paid. The way that EMRs are designed is not very intuitive, and the whole process of reporting is very cumbersome and laborious – there is just so much more meaningless work than before, and this has led to high levels of frustration among physicians.

All this “quality reporting” started with the 2009 passage of the HITECH act – which first brought us EMRs – and we’ve just had more and more regulations ever since. We recently got rid of the Sustainable Growth Rate (SGR) formula, and it was replaced with the Medicare Access and CHIP Reauthorization act of 2015 (MACRA). But none of the quality reporting has gone away: the physician quality reporting system (PQRS), meaningful use, and the value-based payment modifier – have all been morphed into the MACRA legislation. And physicians will be subject to possible penalties; in 2019, we could be subject to a 4 percent cut if we don’t report things appropriately in 2017, and by 2022, we could face cuts of up to 9 percent. There is a chance for bonus money if one’s performance is better than that of peers, but the winners have to be offset by losers since Medicare Part B is a zero-sum game.

So why all this reporting? The government wants to collect data from our practices. They’re trying to improve outcomes, and believe that they can achieve this by making physicians report on all sorts of metrics that hopefully will reflect quality. The government wants everything perfectly delineated, but one can’t do this with every disease process – one can’t quantitate and qualitate every aspect of a patient’s health. We are being micromanaged by the government which is using us as data collectors, and physicians are extremely frustrated. Many physicians (who can afford it) are retiring early because of this excessive regulatory environment that is time consuming to comply with and actually takes away from actual patient care and the enjoyment and satisfaction of practicing medicine.

As physicians, we are trying to take care of patients, but now when we go to medical conferences we have to consider taking course offerings on how to avoid penalties, how to protect our practices and so on, rather than concentrating on learning new treatment modalities to help our patients. The government thinks they are going to force us into taking “better” care of patients by making us jump through all these quality hoops, but what is really happening is that we’re spending so much time on quality reporting and EMR that we’re finding it harder and harder to spend quality time with our patients. There are of course certain doctors who choose to take the penalties, because they have big practices that are able to cope with the cuts.  Eventually all physicians who care for Medicare patients are going to have to comply with regulations – or face significant financial penalty. Opting out of Medicare is a possibility, but for most ophthalmologists, including myself, opting out really isn’t a viable option. As 65 percent of my patient base is Medicare, my practice would be greatly affected by patient defection to other Medicare physicians if I opted out, and it’s likely that I wouldn’t do much surgery after that.

Organized Medicine actively communicates these concerns to Congress; physicians have fly-ins in Washington D.C. to talk to the senators, congressmen and their assistants, educating them that the regulatory burdens are significant. But this really only addresses one aspect of the system – the writing of the laws.  The laws that Congress creates are interpreted by the regulatory agencies in the executive branch, and Congress does not really review or oversee these regulations to make sure that they actually reflect the intent of the law. Because of this, Senator Rand Paul of Kentucky has introduced the REINS (Regulations from the Executive branch In Need of Scrutiny) act, and if that could pass, then Congress would have to oversee more of the regulations coming out of the CMS and the FDA. In my opinion this would be a good idea as there would be checks and balances by Congress on the rules created by the regulatory agencies allowing for mitigation of onerous legislation. Right now, there is not enough support for the act, and we will have to see what the mix is now the election has past.

I still love what I do – I love ophthalmic surgery and I love what I do for my patients. But, the government is so pervasive in its attempted control of everything that I and other physicians do, we are feeling smothered. It is a shame that the noble medical profession, consisting of the most highly trained professionals, is being micro-managed by bureaucrats under the guise of quality. We need to reduce this over-regulation for the health of our profession and patients, but until something big happens – like doctors dropping out of Medicare en masse – the government has no real reason to acquiesce to us.