Does SGR demise doom the private practice?

When the Senate passed the Medicare Access and CHIP Reauthorization Act (MACRA) permanently repealing the fatally flawed Sustainable Growth Rate (SGR) formula, political observers proclaimed it a rare bipartisan victory and medical organizations celebrated the end of the SGR. However, I and many other doctors protested this as a “Trojan Horse” bill. 

What we mean is that this act does more than just dismantle the doomed SGR: it portends the demise of private practice. Many of the specialty societies were unaware of the hidden pitfalls. In a poll of physicians done on SERMO (the largest social network exclusive to physicians), 81 percent of physicians who responded felt they were not given accurate information from these societies before they were asked to contact Congress and give their support.

Hidden in the 265 pages of this new law are hidden agendas that will increase the burden on doctors — especially private-practice doctors. Government mandates are being created like never before: meaningful use, patient-centered medical homes, PQRS, etc. For most doctors, complying with regulations is time-consuming and labor-intensive. Employed doctors don’t have so much to worry about because large groups and hospitals have staff hired just for such tasks. But, it is killing small practices. It diverts attention away from patients and requires us to spend time on tasks that do not improve clinical outcomes. Many doctors will leave private practice just because they cannot or will not follow these mandates on their own. The more the government throws at us, the more difficult the task is becoming. And now, we will be financially penalized if we disobey. This happens at a time when overhead costs are soaring and reimbursements are stagnating or decreasing.

The next piece of this act that will bring significant burden to private practice will be the new Merit-Based Incentive Payment System (MIPS). While doctors are given a choice on how they will be reimbursed under Medicare — through MIPS or by participating in an alternative payment model — the whole idea of paying based on certain metrics is unreasonable. Doctors cannot control our patients’ behaviors. It may be good enough to spend 30 minutes to convince my sedentary patients to start walking 30 minutes every day. But, under outcomes-based reimbursements, I will be docked financially for that extra time unless that patient hits a defined number on his/her LDL cholesterol or HbA1c or whatever other measure the government determines. Patients bear no responsibility in their bad lifestyle choices while doctors must bear all financial burden.

In fact, many complicated patients will be hurt under this payment arrangement. Some patients will never get better no matter what you do for them. These patients should be reimbursed at a higher rate for the time spent. Many practices will simply be unable to afford to treat these patients, and these patients will be unable to find doctors. They will likely end up in the ER, driving up costs for the entire healthcare system.

While many rejoiced when the president signed MACRA into law, the rest of us feel the weight of it on our shoulders. It foreshadows more government reach into the practice of medicine and the health of the population. Sure, the SGR needed to go, but is this the price we really wanted to pay?

Linda Girgis MD, FAAFP, is a family physician in South River, N.J. She has been in private practice since 2001. She holds board certification from the American Board of Family Medicine and is affiliated with St. Peter's University Hospital and Raritan Bay Hospital. She teaches medical students and residents from Drexel University and other institutions.  Dr. Girgis earned her medical degree from St. George's University School of Medicine. She completed her internship and residency at Sacred Heart Hospital, through Temple University and she was recognized as intern of the year.  She has been a guest columnist and contributor to many media outlets. She authored the book “Inside Our Broken Healthcare System” and has been interviewed in US News and on NBC Nightly News. Dr. Girgis’ primary goal as a physician remains ensuring that each of her patients receives the highest available standard of medical care.