MACRA (the Medicare Access and CHIP Reauthorization Act of 2015) replaced the threatened but never implemented annual fee cuts of the Sustained Growth Rate formula with a complex system of bonuses and penalties. The Centers for Medicare and Medicaid Services (CMS) predicted that 87% of solo practice physicians would be penalized.

According to a Medscape Medical News survey, almost four in 10 physicians in solo and small group practices predict an exodus from Medicare within their ranks because of the program's new payment plan.

The 962-page Final Rule received more than 2,200 comments. AAPS noted that:

• A physician's "compliance score" is tied to "resource use." Physicians will be increasingly pressured to make decisions that save resources for Medicare instead of decisions that are in the best interest of their individual patients.
• Compliance is also tied to mandatory use of government-certified electronic health records (EHRs), which are harmful to patient medical privacy and also detract from face-to-face patient care. The government would gain even greater ability to access patient medical records.
• The rules allow ALL insurance-based care, not just Medicare, to be phased in to these harmful payment models.

AAPS executive director Jane M. Orient, M.D., commented: "It is impossible to practice medicine under this rule, for ethical and practical reasons. The rule makes it impossible to protect confidentiality, and one is in a constant conflict of interest: What is best for the patient may be bad for the financial viability of the practice. It would take a dedicated team of legal specialists to even attempt compliance. Full compliance is probably impossible even with such a team, which is beyond the means of a small practice."

She concluded: "Physicians need to withdraw from Medicare or any other program that subjects them to this rule." AAPS offers detailed instructions on how to opt out of Medicare, and regular workshops on building a successful practice to serve patients without third-party shackles.

Association of American Physicians and Surgeons

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