Medicare Access and CHIP Reauthorization Act

The Medicare Access and CHIP Reauthorization Act (MACRA) changed the way health care providers are reimbursed through Medicare, provided an increase in funding, and extended the Children’s Health Insurance Program (CHIP). MACRA placed conditions upon care providers in order for them to receive reimbursement: care must be quality care, i.e., care that helps them to keep from having to come back for more treatment—rather than just treatment after treatment, keeping patients coming back through the revolving door of medicine without every actually helping them. The type of quality care required by MACRA is preventive medicine and health literacy promotion. As Licthenfeld (2011) pointed out, too many doctors are diagnosing patients with health problems that are insignificant and do not need treatment—but because Medicare was always willing to bankroll treatment it made good business sense to treat every patient for every symptom. The problem is that people are like cars—as they age, they break down—that is just nature. Too much treatment can actually decrease the quality of the life of the patient, just as always having one’s care in the shop can make one wish one had a different care. MACRA was not only designed to save money for Medicare but also to increase the quality of life of patients by obliging doctors to increase the quality of care they provide instead of just increasing the quantity of care. Likewise, Glasziou, Moynihan Richards and Godlee (2013) have noted that too much testing and not enough care “worsens health inequalities and drains professionalism, harming both those who need treatment and those who don't.” This was another issue that MACRA sought to address.
The positive effects of the policy are that it reduces the emphasis on treatment and focuses instead of quality care. Many physicians adopt an attitude of “let’s fix everything wrong” even though that is not really needed all the times. Welch, Schwartz and Woloshin (2011) show that most professionals in health care “push the idea that the best way to stay healthy is to look hard for things that might be wrong” (p. 136). This leads to a type of over-treatment and over-diagnosis. Patients should instead be taught how to care for themselves, the importance of eating right, the value of exercising, and why they should get enough rest at night. Instead, care providers will use treatment services simply to increase revenue streams: for instance, it often happens that “health-care companies, hospitals, and some doctors advise people to be screened because they are in the business of selling the service” (p. 136). For them, health care is a business first and profits always come before people. MACRA was developed to prevent this type of health care from spreading and ruining the industry as a whole. As Moynihan (2015) notes:
“A key theme here is the need to get better, clearer information to people–to get closer to the truth of the uncertainties around early detection and the potential harms of unnecessary treatment…Building processes for mandatory and meaningful informed consent into the very infrastructure of medicine could be a big win for people who don’t want to become patients needlessly–but will likely mean a rather large loss for those who benefit from treating them” (p. 350). This process is one that MACRA could embrace.
However, the negative effects of the policy are that some patients do require multiple treatments and MACRA could end up penalizing doctors who provide the care patients genuinely need. As Welch et al. (2011) observe, sometimes health care providers do have “the best of intentions: disease advocacy groups and some doctors advise people to be screened because they believe it is right thing to do” (p. 136). For instance, testing for breast cancer or monitoring for the spread of cancer cells in one’s body—these are steps that will necessarily bring patients back for routine evaluation. MACRA makes it harder for doctors to be willing to see patients again, and that means less access to care for patients.
Recommendations that I have to enhance the policy in its current state would be to actually incentivize the promotion of preventive care and health literacy. Health care providers should not just be incentivized to provide treatment: they should also or, rather, mainly be incentivized to prevent illness and sickness by teaching patients what they need to know to live healthier lives. Care providers should be reimbursed and given bonuses to increase health literacy in communities and with patients. They should be reimbursed and given bonuses to engage in preventive care because ultimately this is what will make people healthier long term—and as a result it will inevitably drive down profit revenue for physicians and health care providers. If the federal government really wants to promote quality care, it has to find a way to incentivize doctors, because as Welch et al. (2011) show, many doctors engage in over-diagnosis because they want to profit from their business of treating patients. The health care industry thrives on fear and the federal government should put a stop to that approach. The industry creates business for itself by selling fear to people and making them think they better get screened for cancer before it is too late. For example, Welch et al. (2011) explain that thyroid cancer is not a serious problem for most of the population but that overdiagnosis of thyroid cancer is a problem because it can lead to unnecessary treatments that end up harming the person’s health and quality of life.
Another option is for MACRA to take Moynihan’s (2015) advice and make it a regulation that before patients can be treated they must give their informed consent, which means they are told about the harmful possible effects of treatment and of other options that are available as well as why treatment may not even be the best option and that if nothing is done the patient will likely go on having a happy, healthy life so long as a little preventive care is given.
Still, what would really make MACRA even better would be if it included a way for doctors to be reimbursed for essentially putting themselves out of business. The idea of preventive care is not going to appeal to every doctor because they see it as a threat to their business model. However, some health care providers could focus exclusively on prevention and Medicare could offer support, such as subsidies, tax credits and other incentives—just as the federal government offered subsidies and tax credits for electric vehicle manufacturers in order to get people interested in buying them. To provide quality care means to make better the health of the patient, which is what the point of MACRA is all about. It is not necessarily going to be about padding the pockets of doctors, which is why many do not want to embrace preventive care. If the government subsidized preventive care and health literacy initiatives and allowed these approaches to health care to be seen as revenue streams by doctors, they would become more attractive in their own right and the government could achieve the health outcomes it is interested in achieving. The more that doctors can feel supported financially in their approach to improving quality of life, the more likely they will be to focusing on that particular method.
References
Glasziou, P., Moynihan, R., Richards, T., & Godlee, F. (2013). Too much medicine; too little care. BMJ, 347, f4247.
Lichtenfeld, L. (2011). Overdiagnosed: Making people sick in the pursuit of health. The Journal of Clinical Investigation, 121(8), 2954-2954.
Moynihan, R. (2015). Preventing overdiagnosis: the myth, the music, and the medical meeting. BMJ: British Medical Journal (Online), 350.
Welch, H., Schwartz, L. & Woloshin, S. (2011). Overdiagnosed. Beacon Hill.