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The End of Empathy

New word of the day: Tele-empathy.

Tele-empathy is not being empathetic over the phone.  It is not crying in the sad parts of your favorite TV show. It is not beaming empathetic thoughts magically across time and space.  No, tele-empathy is a technology.  I should rather say, a group of technologies recently being created to increase the empathy of health care providers.  This is rich, you might say, coming from an industry that brought us electronic medical records, automated “help desks”, and robocallers.  Sandeep Juhar, a writer for the New York Times, tried out one of these devices, one that simulates the uncontrollable shaking suffered by Parkinson’s patients, and describes tele-empathy as follows: (www.nytimes.com/2017/07/29/opinion/sunday/empathy-gadgets.html)

…“tele-empathy”: using technology to improve insight into the patient experience.  Movement disorders like Parkinson’s are one aspect of this work, but there are others. Engineers are studying the airflow patterns of patients with emphysema to replicate their shortness of breath in others. A virtual-reality program is being developed to misalign sound from video, a technique called dephasing, in ways that mimic the experience of disordered thinking in psychiatric illness. Gadgets are being made to numb the feet to reproduce the symptoms of diabetic nerve disease.

Makers of medical devices are usually not motivated by empathy themselves, so they must think there’s a market for this sort of thing.  Why?  Because empathy is in short supply virtually everywhere you look.  The GOP healthcare bill showed a remarkable inability to walk in the shoes of the less fortunate.  The Charlie Gard tragedy demonstrated how little we understand the emotional consequences of our actions on those who actually have to care for terminally ill patients and on the patients themselves. The entire Middle East is a black hole into which sympathy, empathy, and compassion have vanished without a trace.  Juhar asserts that “Lack of empathy in caregivers — doctors, nurses, even loved ones — is one of the most widely voiced complaints in the health care field.”  If true, (Juhar gives no references to back up this statement), then why?

Empathy has been studied fairly extensively.  Some of the things we know are fairly obvious.  For example, empathy has been shown to be lower in people in positions of power and in personality disorders like psychopathy and narcissism, findings that will spectacularly fail to surprise the likes of Sean Spicer and Reince Priebus.  It is also true that our own emotional state can distort our understanding of other peoples feelings, as Tania Singer and her colleagues found in their work with an area of the brain called the right supermarginal gyrus (https://www.psychologytoday.com/blog/the-athletes-way/201310/the-neuroscience-empathy).  Empathy seems to suffer when we have to make very quick decisions.  It is harder for us to empathize with people who are very different from ourselves.  Empathy decreases in people who are in pain or otherwise stressed.

 98% of us (excluding psychopaths and narcissists) have the built-in ability to empathize, and this skill can be enhanced by specific training.  You can show emotionally charged videos to people, teach them about visual cues and body language, raise emotional awareness, and yes, simulate Parkinson’s.  But what it really takes to be empathetic is the ability, and willingness to, engage with people.  Some researchers believe that empathy is actually a choice that we make. https://www.nytimes.com/2015/07/12/opinion/sunday/empathy-is-actually-a-choice.html.  They contend that we choose to feel more empathetic when the object of empathy does not require sacrifice on our part, and that we may choose not to interact with certain groups because we do not want to feel empathy towards them.  It is pretty well known now that empathy decreases in medical school, particularly in the clinical years. This is because being empathetic is hard emotional work, and requires the sacrifice of our own comfort and well-being.  It requires that we slow down, understand our own feelings, ignore our own pain and stress, and confront our differences.

Empathy is the work of a life-time.

 

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Right To Try

I haven’t posted on this blog for quite some time, having gotten distracted by the tempting and ultimately false hope of a do-over.  Despite my best efforts over the last few months two things have become clear.  One, I’m probably never going to play for the New York Philharmonic.  Two, last November isn’t coming back with a different result.  In my fog of violinistic pipe dreams and pink fluffy visions of impeachment I have held on to the belief that I have a Right To Try.

Imagine my amazement when I read that my Right to Try is now enshrined in rule of law in most states.  Not the Right to Try to have a music career.  Any delusional individual has that right.  No, I’m informed that I have the Right to Try…not to die!  Well, thanks, but if you think this means I’m going to renew that gym membership I’ve got a potential music career to sell you.

Actually, many states have passed Right to Try laws that concern end-of-life treatment options.  These laws are meant make it possible for terminally ill patients to get access to experimental or unconventional treatments that are not yet generally available, ie., that haven’t been approved by the FDA.  There’s even a website, righttotry.org, created by the Goldwater Institute, a conservative think tank.  Here’s what these folks say about the Right to Try concept:

Under Right To Try, a terminal patient would be able to access an investigational medicine if:

  1. The patient has a terminal disease and has exhausted all conventional treatment options
  2.  The medication has successfully completed basic safety testing and is part of the FDA’s on-going approval process
  3.  The patient has provided “informed consent” acknowledging the potential risk of the drug
  4.  The company developing the medication is willing to make it available to the patient

I am not opposed to people getting access to potentially helpful treatments.  I’m all for it.  There is some room for caution, however, when I consider a few facts about science, the FDA, and human nature.

First, science.  It is no secret that science has a mixed track record when it comes to medicine.  Science is the reason people don’t die of smallpox anymore, and the reason the maternal death rate is so low, and the reason we sterilize surgical instruments.  But there have been some spectacular fails as well.  Consider the anti-nausea medication Thalidomide.  The recent discovery that many of the stock breast cancer cells used for breast cancer research are not, in fact, breast cancer cells (read Rigor Mortis: How Sloppy Science Creates Worthless Cures, Crushes Hope, and Wastes Billions, by Richard Harris).  Or the striking discovery that real arthroscopic knee surgery is not any more useful than fake arthroscopic knee surgery (N Engl J Med 2013; 369:2515-2524December 26, 2013).

Second, the FDA.  Basic safety measurements are small pre-clinical trials done in the lab and on laboratory animals, not people.  Furthermore, some sources suggest that 90% of experimental medicines and treatments fail to pass FDA approval because they ultimately don’t work.

The irony here, of course, being that while no one believes in science any more, everyone still believes in science.  For now we come to the human nature factor.  A meta-analysis of studies of patient expectations, done by Tammy Hoffman and her team and published in the Journal of the American Medical Association Internal Medicine, showed that “…the majority of participants overestimated intervention benefit and underestimated harm.” (JAMA Intern Med. 2015;175(2):274-286.)  This despite the fact that nothing can be done for or to a patient without informed consent, and we can talk another time about how useful informed consent is, both informationally and legally.  Here’s what Daniel Engber of Slate magazine, who reports on this sort of thing, says about this:

Patients seem to overvalue innovation, as a rule, and assume that newer drugs have a better chance of working than any other treatment, just because they’re new. Not only does this sanguine view of scientific progress fail to fit the facts; it also leads patients to the converse, false impression that “nonconventional” treatments aren’t likely to be harmful in themselves. A more sober view suggests that the hope that often moves people to seek out these types of treatments—and the ever-present pressure to fight until the end—is not as useful as we think.

Despite all of the above, people have a seemingly endless capacity for hope.  It is part of what makes us human and allows us to get up every morning, practice, write, raise our children, develop new drugs, and vote.  We all have the Right to Try.

Is Your Hospital Anti-Baby?

Pregnant women – a public service announcement: the facility of choice for your birth experience might be Baby-Hostile.  You should probably check.

The World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) has created a “global initiative” entitled The Baby-Friendly Hospital Initiative (BFHI).  And thank goodness.  What new mother would want to be around people who hate babies?  I’m sure they’re promoting things like baby blankets, diapers, stuffed toys.  Maybe they have elderly people volunteering to be temporary grandparents.  They probably have Twinkle Twinkle Little Star on heavy rotation in the nurseries, which of course are outfitted in top-to-bottom Pottery Barn Kids.

Here’s what the BFHI website says the organizations mission is: (https://www.babyfriendlyusa.org/about-us/baby-friendly-hospital-initiative)

The Baby-Friendly Hospital Initiative (BFHI) is a global program that was launched by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) in 1991 to encourage and recognize hospitals and birthing centers that offer an optimal level of care for infant feeding and mother/baby bonding. It recognizes and awards birthing facilities who successfully implement the Ten Steps to Successful Breastfeeding.

Oh.  It’s a breastfeeding initiative.  I see.  Now, full disclosure – I did not breastfeed my kids.  I tried it with the first one. For a week.  It hurt.  I dreaded feedings.  The baby didn’t like it.  She cried.  I cried.  We stopped trying.  Our relationship got much better.  So far, my kids are healthy, happy, normally-weighted, and intelligent.

So breastfeeding is Baby-Friendly.  Which implies that if you are not breastfeeding, or promoting breastfeeding, you are, what, Baby-Unfriendly?  Anti-Baby?  Baby-Neutral?  Well, regardless of what BFHI is implying, it is most definitely not Mother-Friendly.  Here are those Ten Steps:

  1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
  2. Train all health care staff in the skills necessary to implement this policy.
  3. Inform all pregnant women about the benefits and management of breastfeeding.
  4. Help mothers initiate breastfeeding within one hour of birth.
  5. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.
  6. Give infants no food or drink other than breast-milk, unless medically indicated.
  7. Practice rooming in – allow mothers and infants to remain together 24 hours a day.
  8. Encourage breastfeeding on demand.
  9. Give no pacifiers or artificial nipples to breastfeeding infants.
  10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center.

Those are awesome recommendations!  For women who are really motivated to breastfeeding and don’t require sleep, with babies who also take to breastfeeding like proverbial fish.  It will be a perfect nightmare for anyone else.  Breastfeeding hurts at first.   Babies do not always take to it right away.  Milk comes in late, or in short supply.  Mothers are human beings who need sleep.  In a Baby-Friendly hospital, if you can’t or don’t want to breastfeed, if your child has trouble getting the hang of it, if you have other kids at home and really need a rest before you go home with this one, well, your hospital stay will be less than pleasant and probably not a great way to start the journey of motherhood.

Well, what does BFHI say about this?

When a mother specifically states that she has no plans to breastfeed or requests that her breastfeeding infant be given a breast milk substitute, the health care staff should first explore the reasons for this request, address the concerns raised, and educate her about the possible consequences to the health of her infant and the success of breastfeeding. If the mother still requests a breast milk substitute, her request should be granted and the process and the informed decision should be documented.  Baby‐Friendly is not about making a mother feel guilty; it is about preventing her regret for decisions made without the proper information. Further, Baby‐Friendly policies protect the mother from the influences of commercial interests so that she may make decisions on the basis of scientific evidence and not marketing material.

We Baby-Friendly hospitals know that grown women can’t protect themselves from Similac and won’t take responsibility for their own decisions.  I mean, we have “allowed” mothers and infants to remain together 24/7 after all.  Mothers who make bad decisions…well, at least we made them sign something acknowledging their unfitness as mothers.  Not to make them feel guilty or anything.

Along comes the Journal of the American Medical Association (JAMA), to save the day.  In an article published in August, a meta-analysis found that such institutional implementation of breastfeeding policies don’t actually have the effect of increasing breastfeeding rates.  http://jamanetwork.com/journals/jama/article-abstract/2571222#.WBjMUzJ8KfY

In contrast to evidence supporting individual-level interventions [which do work], the evidence review included nine fair- to good-quality studies evaluating the effectiveness of system-level primary care interventions to support breastfeeding and reported that there was no consistent association between system-level interventions and any beneficial outcomes.

Well, when the Baby Friendly folks got wind of this, they struck back with a two-page statement that started with accusing the JAMA article of being “filled with comments not supported by research”.  They cited research to support their side (R. Pérez‐Escamilla, J. Martinez and S. Segura‐Pérez, “Impact of the Baby‐friendly Hospital Initiative on Breastfeeding and Child Health Outcomes: A Systematic Review. doi: /mcn.12294.,” Maternal Child Nutrition, 2016) and published an opinion paper in the October issue of JAMA laying out their evidence.

A recent meta-analysis of studies evaluating the BFHI found that the implementation of the BFHI increased exclusive breastfeeding by 49% and any breastfeeding by 66%. (http://jamanetwork.com/journals/jamapediatrics/article-abstract/2546143)

Well, sure, if you bully and guilt women into it.  And who is right about such initiatives anyway?  The people that think it helps, or the people that don’t?  Who the F@#$!% cares?  You know who is right?  The mother is.  Each individual woman, the adult, thinking being attached to the breasts and producer of the milk in question, decides what to do for herself and her baby.  And she’s right.

 

All mothers are not Kate Middleton.

Good news, all you new mothers out there!  Now you have something else to feel guilty about, because you needed one more thing to feel guilty about!  You already know that you baby must be put to sleep on his back in a crib with a firm mattress and no pillows, blankets, toys, or bumpers.   What, that sounds uncomfortable?  Your baby can’t sleep like that and screams bloody murder all night?  Did you know that you baby now has to share your bedroom?  For a year? Fun times!

Yes, folks, the American Academy of Pediatrics, in its infinite wisdom, has created a new recommendation in the list of things parents should do to prevent Sudden Infant Death Syndrome: (https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/American-Academy-of-Pediatrics-Announces-New-Safe-Sleep-Recommendations-to-Protect-Against-SIDS): 

  • Place the baby on his or her back on a firm sleep surface such as a crib or bassinet with a tight-fitting sheet.
  • Avoid use of soft bedding, including crib bumpers, blankets, pillows and soft toys. The crib should be bare.
  • Share a bedroom with parents, but not the same sleeping surface, preferably until the baby turns 1 but at least for the first six months. Room-sharing decreases the risk of SIDS by as much as 50 percent.
  • Avoid baby’s exposure to smoke, alcohol and illicit drugs.

SIDS is a serious problem, I get it.  More than 3,000 babies age 1 and under died of SIDS in 2010.  That’s not nothing.  If you are a parent to whom this tragedy has struck, you have burden that will last you your whole life.  It’s horrible.  However, for a little perspective, 4 million babies were born in 2010.  Now I suck at math, but 3,000 divided by 4,000,000 is… mumble mumble…divide by 2… scratch head… carry the 1… that’s like, what, 0.0005%?  The all-cause infant mortality rate in 2010 was 0.2%.  So clearly there are other dangers for infants in the first year of life besides SIDS.  Here are two:

Post-partum depression – According to the CDC, an estimated 15% of new mothers will have some degree of post-partum depression, or roughly 600,000 women per year.  The American Psychological Association (APA) lists some risk factors for PPD including… wait for it.. Yes! The stress of caring for a newborn! (http://www.apa.org/pi/women/resources/reports/postpartum-depression.asp). The Mayo clinic says that:

When you’re sleep deprived and overwhelmed, you may have trouble handling even minor problems. You may be anxious about your ability to care for a newborn. You may feel less attractive, struggle with your sense of identity or feel that you’ve lost control over your life. Any of these issues can contribute to postpartum depression. (http://www.mayoclinic.org/diseases-conditions/postpartum-depression/basics/causes/con-20029130)

Uh huh.  And what are the consequences of PPD on children?  The American Academy of Pediatrics itself can tell you: (https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/Managing-Maternal-Depression-Before-and-After-Birth.aspx)

Maternal postpartum depression can have serious adverse effects on the mother and child relationship, resulting in an environment that can disrupt the infant’s development. Infants who live in a neglectful or depressed setting are likely to show delays in development and impaired social interaction.

Sleep deprivation – Studies have shown that staying awake for just 17 to 19 hours straight impacts performance more than a blood-alcohol level of .05 percent (the level considered legally drunk in most western European countries). This level of impairment slows an individual’s reaction time by about 50 percent compared to someone who is well rested. Twenty-four hours of continuous wakefulness induces impairments in performance equivalent to those induced by a blood-alcohol level of 0.10 percent, beyond the legal limit for alcohol intoxication in the United States. Sleep deprivation may also impair learning, memory, alertness, concentration, judgment, problem solving and reasoning, as well as increase your risk of accidents. To make matters worse, lack of sleep hinders your ability to realize that your own performance is impaired, making you think you’re functioning well when you probably aren’t. healthysleep.med.harvard.edu/…/judgment-safety

I’m not discounting SIDS, nor am I questioning the accuracy of the AAP.  I’m sure their data is solid.  And in a perfect world, like in Kate Middleton’s for example, where childcare is plentiful and there is a hairdresser on call, I’m sure all mothers could blissfully adhere to this most recent instruction.  However, this is not a perfect world, nor is it the world of parenting in the 19th century, and thank goodness for that.  Mothers now work, their own extended family is far away, childcare is expensive, breastfeeding is hard when you’re away from home all day, there is no maternity leave.  Pressure from voices of authority like the AAP are just not terribly helpful.  By the way, this is not the first time that AAP recommendations have defied reality.  In 2011 the organization decided that kids should ride in rear-facing car seats until at least age 2 or to the weight limit of the seat, causing millions of parents to watch as their child’s legs grow slowly up toward the ceiling.  The breastfeeding recommendations have resulted in a profitable industry for Medela and the now-common sound of whirring and squirting, with the occasional “MOO”, from the bathroom stall next to you in the women’s restroom at work.  Breastfeeding, of course, also helps prevent SIDS, but even there you have to be careful.  Here is a hilarious quote from the AAP website:

“If you are feeding your baby and think that there’s even the slightest possibility that you may fall asleep, feed your baby on your bed, rather than a sofa or cushioned chair,” said Lori Feldman-Winter, MD, FAAP, member of the Task Force on SIDS and co-author of the report.
“If you do fall asleep, as soon as you wake up be sure to move the baby to his or her own bed.” 

Are you F*&^% kidding me?

 

 

Practice vs. Performance

It is one of the most boring truisms on the planet: “Practice makes perfect.”  It is also one of the most misleading.  Practice merely ingrains certain patterns after deciding on the best course of action after constant criticism and problem-solving.  Performance requires that the body forget the work required to ingrain the pattern and let the pattern happen.  Performance requires that we drop all criticism and technical considerations.  These two activities are vastly different.

The transition from practice to performance, it turns out, is a matter of belief.  I was thinking about this today after reading Seth Godin’s blog.  Godin is a fantastic management and leadership expert who also happens to know a lot about performance.  Here’s what he said: http://sethgodin.typepad.com/seths_blog/2016/06/taking-notes-vs-taking-belief.html

Is there anything easier than listening to a lecture or reading a book and taking notes?  And is there anything more difficult than setting aside our preconceptions and the resistance and acting ‘as if’, being open to belief, at least for a moment?

Practicing is like taking notes.  You are trying to ingrain patterns in the brain.  At some point you have to decide that the ingraining process is complete and just go take the test.  You have to trust your preparation.

Another writer I really like is James Clear, a fitness expert and all-around wise man when it comes to making real change.  Here is a bit of one of the central tenents of his philosophy: http://jamesclear.com/identity-based-habits

Changing your beliefs isn’t nearly as hard as you might think. There are two steps. 1. Decide the type of person you want to be. 2. Prove it to yourself with small wins.

Here are some examples of what I’m talking about.

Suppose you are a patient whose doctor has told you that you need to make some lifestyle change for the good of your health.  You go and read every book ever written about this change, talk to five different experts, and draw up a fool-proof plan that you have memorized.  None of these things is worth anything unless you decide “I am the kind of person who integrates this life-style change into his everyday life.”  You have to take the knowledge (practice) and turn it into belief (performance).

Say you are a nurse who is trying to decide whether or not to go to medical school.  You read all the books. (Actually there really aren’t any on this subject although I’m working on one.  I haven’t quite gotten to the stage of believing I’m the kind of person who can write a book.)  You talk to all the experts.  You consult with people who have made the transition.  You decide medical school is indeed the best choice for you for all of the right reasons (a life-time project in itself).  None of this makes any difference unless you decide “I am the kind of person who can successfully complete medical school.”  Knowledge, and choice, into belief.

Or perhaps the contrary.  You decide that you are happy in nursing.  You don’t want to change.  You’ve done the research and made your choice.  Fine.  Same thing.  You’ve done the work, now commit to and believe in the choice you’ve made.

Maybe you are a young person from a foreign country and you would like to live and work in the United States.  You research your (legal) options, talk to friends who have been to the US, interview people who have done the job you’re interested in.  You’re not going anywhere unless you decide “I am the kind of person who can move thousands of miles from my family in pursuit of new experiences.”  Choice into belief.

Say you play a musical instrument and you want to get a good orchestra job.  You practice for 20 years, put in your focused 10,000 hours.  None of those hours count unless you can stop the self-evaluation you have been perfecting for 10,000 hours and trust that those hours have ingrained the necessary patterns and that, at the moment of performance, no more self-evaluation is needed.  You just play.

If you’ve done the work, just play.

Prove It

I was recently honored by a request to write a piece for the journal Outpatient Surgery.  Having duly provided a pithy and witty ditty about the Veteran’s Administration MD vs CRNA kerfuffle, the editor dutifully came back at me with an edit.  He said:  “Can you give a specific example of how the broad knowledge of medicine gives MD anesthesiologists an advantage?” or something to that effect.  Hmmm… trying to stir the pot, I thought.  Controversial?  You want controversial?  I thought.  So I sent out an email/text/tweet to my colleagues specifically asking for examples of how the broader knowledge of medicine gave them an advantage when it came to the safe practice of anesthesia.  Here are some of the responses I got (my friends will likely cease to be my friends after I post this):

“They’re [CRNAs, I assume] often pretty cocky and it’s usually because ignorance is bliss.”

“Just doesn’t demonstrate a solid foundation in the basics of physiology or pharmacology.”

“They often can’t think outside the box.”

“Physiology, pathology, pharmacology, anatomy is just not there.  I think it’s a depth of knowledge and problem solving skills.  Everything they know is very superficial.”

“Pathophysiology.  That’s why we make the plan.  They can complete it very competently, but don’t have the extent of knowledge regarding all conditions to make the safest plan for the patient.”

Of all these responses, the last is the only one that comes even close to a specific reason for the existence of the MD anesthesiologist.

Please don’t misunderstand – I truly believe that the presence of an MD in the supervision of the administration of anesthesia is very important.  But, friends, we need to be very specific and persuasive.  Simply saying “it’s not safe” and “we know better” isn’t going to sway administrators who see cost savings instead of patient savings.  We can’t just say we’re worth our price.  We have to prove it.

MACRA – doubling down on acronyms.

The Centers for Medicare and Medicaid Services (CMS) has felt your regulatory pain, apparently. They have watched you flounder in the muddy waters of ICD-10 and Meaningful Use.  They have agonized with you over Quality Indicators.  So, in an effort to “streamline” the “quality” metrics, and thus get a better handle on who is a good doctor and who is not, our wise legislators have come up a new, equally muddy law with the somewhat apocalyptic name MACRA.
MACRA stands for Medicare Access and Children’s Health Insurance Program Re-authorization Act of 2015.  Here is how CMS describes it: (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/NPRM-QPP-Fact-Sheet.pdf)
“Currently, Medicare measures the value and quality of care provided by doctors and other clinicians through a patchwork of programs, including the Physician Quality Reporting System [PQRS], the Value Modifier Program, and the Medicare Electronic Health Record Incentive Program [meaningful use].  Through the law, Congress streamlined and improved these programs into one new Merit-based Incentive Payment System (MIPS).
So MACRA created MIPS.  And QPP  (Quality Payment Program).  Oh, wait.  MACRA created QPP.  MIPS is a pathway under QPP.  The other pathway is APM (Alternative Payment Models).  Clearly.  Try to keep up, will ya?
Here’s CMS again:
The MACRA makes three important changes to how Medicare pays those who give care to Medicare beneficiaries. These changes create a Quality Payment Program (QPP):
  • Ending the Sustainable Growth Rate (SGR) formula for determining Medicare payments for health care providers’ services.
  • Making a new framework for rewarding health care providers for giving better care not more just more care.
  • Combining our existing quality reporting programs into one new system.

These proposed changes, which we’ve named the Quality Payment Program, replace a patchwork system of Medicare reporting programs with a flexible system that allows you to choose from two paths that link quality to payments: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models.

CMS continues:

Consistent with the goals of the law, the proposed rule would improve the relevance and depth of Medicare’s value and quality-based payments and increase clinician flexibility by allowing clinicians to choose measures and activities appropriate to the type of care they provide.

Wait, what?  There’s about 100 things wrong with this sentence.  MACRA does absolutely nothing to improve the relevance of the government’s “quality” indicators.  The indicators are, for the most part, completely irrelevant to actual quality. The metrics are simply percentages of people who received a certain treatment or test deemed appropriate by large organizations like the AMA.  Such percentages have little to do with the actual quality of the interaction between doctor and patient.   And the flexibility mentioned is merely the flexibility to choose between MIPS and APM.  Which isn’t really a flexibility since APM billing pays more.

Clinicians who take a further step towards care transformation – participating to a sufficient extent in Advanced Alternative Payment Models – would be exempt from MIPS payment adjustments and would quality for a 5 percent Medicare Part B incentive payments.

What is and Advanced Alternative Payment Model?  Bundled payments, meaning Accountable Care Organizations.  Remember those?  Lump payments to a group of doctors, money that they keep if they spend less than the lump payment, but that they’re on the hook for if they spend more.  CMS wants to funnel everyone into a bundled payment model.  Not super flexible, those CMS folks.

OK, one last thing and then I’ll quit bugging you.  Here’s the breakdown of the scoring for the incentive payment system:

10% – cost
50% – quality – based on six metrics
15% – clinical practice improvement (systems improvement, not personal improvement, I assume). 90 options to choose from!
25% – Use of EHR

To prove you’re a good doctor, you better use that EHR to document those quality metrics!  Otherwise, CMS might take away your lunch money.

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