OMG The Sky Is Crashing In On Us Again!!

How quickly we forget. Just a year ago, every health care practitioner participating in Medicare (on average less than 1% of physicians have opted out of Medicare — though of course now we are hearing scare stories of pending “mass exodus”) the annual “will they or won’t they really impose the 25% or so ‘sustainable growth rate’?” dance. SEVENTEEN YEARS of short term “fixes.” Seventeen years of not being able to plan our business models for the next year well into November of preceding years, sometimes up to three, four, six months into our fiscal years. My recollection is we whined about this every one of those years.

In case you didn’t notice, perhaps the only useful thing Congress has done in recent years, was to fix — abolish — the SGR.

Now, grown up health care practitioners ought to understand the financial pressures on the Medicare system, a system which runs much leaner in costs than the for-profit health insurance industry which, by definition, has worse problems than Medicare. Abolishing the SGR did not mean the rate of growth in costs to provide services — or charges to patients and third party payers — magically went away. SOME alternatives were absolutely necessary to set reasonable brakes on the rate of growth. The ACA set the groundwork. Alternative payment models will fill in the details. No one has the crystal ball to foretell which alternative models will be most successful in “bending the cost curve.” But, if you are paying attention, some early data are in (e.g., Medicare ACOs Provide Improved Care While Slowing Cost Growth in 2014).

One thing does seem certain to me. Colleagues, you must forget about being paid based on how many patients you see, for how many minutes.

Get used to being paid for contributing to keeping large populations of patients healthy. Regardless of how many you see or how long your sessions are.

Or get used to not getting paid.

That is, if you want to continue to participate in third party reimbursement (i.e., now about 90% of the U.S. population).

This is an extremely painful reality for many of my psychology colleagues, so painful that many do not want to look to directly at this. Practitioners who seem to have limited notions of treatment or payment models other than seeing individual patients (or, if really thinking expansively, couples, families, and small groups) one at a time, for 45-60 minutes, and who have limited notions of how to contribute to SYSTEMS of care, for large populations. We do know how to measure treatment effects, but seem to have extreme reluctance to apply this to the patients we see one at a time in our individual practices.

And so, comes MACRA (Medicare Access and CHIP Reauthorization Act) and MIPS (Merit-Based Incentive Payment System). Goodbye SGR. Hello 0.5% annual “increases” in reimbursement through 2019. Hello quality and outcome measures and EHR mandates. Hello decreases in reimbursement for not participating in measurement systems, and vanishing possibilities to opt out of such requirements. Hello bonus payments for participation.

Now it would be a huge understatement to say that MACRA/MIPS rules as currently constructed are not universally warmly embraced. For example, the AMA and two dozen specialty medical associations have called for substantial changes, including noting the impact on small and/or low volume Medicare practices.

But neither will you find universal, or even widespread, calls to return to payment-for-service, unmeasured, disintegrated delivery and payment models. Though I do detect plenty of misty-eyed longing for “the good old days,” particularly among my independently-practicing (as if anyone really is fully independent in our health care system) psychology colleagues, along with plenty of idealization of those years. Years that, in reality, included steady decreases in reimbursement, an ecology particularly biased against mental/behavioral health, and unsustainable growth in costs.

Those days are gone.

Sign me up for a system in which I can demonstrate my effectiveness, join with large numbers of other health care practitioners to improve outcomes and, by the way, act together to influence reimbursement, contribute to the health of large numbers of people, earn bonuses for demonstrated value and, yes, even accept the possibility of being penalized for not demonstrating contributions to patient health. My colleagues should well understand the effects of noncontingent reinforcement.

In my view, a fully mature psychology profession will adapt to contributing responsibly — by measuring and reporting effectiveness, by identifying and dropping ineffective methods, by innovating successful alternatives, and by becoming accessible to large numbers of our citizens.

Turn and face the strange.

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