Tuesday, September 12, 2017

Notes from the Maryland MVA

Dennis Miller once described the experience of going to the California DMV as being "where Franz Kafka meets (former blonde "Dallas" actress) Charlene Tilton." Today's visit to its Maryland equivalent wasn't quite that bad, but there were challenges.

My license expires Thursday, so I needed a temporary credential until the real one arrives in the mail (They don't give them to you in person anymore, and I thought I missed the apparent window for renewing by mail). I went in with my eye exam and form already completed. All I needed to do was pay $48 and I was good for 8 years.

I checked in at the info desk, then one of the sit down desks where the MVA worker needed to enter my eye test into the system as she performed them to other customers herself (she worked with impressive efficiency.)

They referred me to an automated kiosk to complete the process; there was a long line, abetted by one extremely slow customer and general confusion among people who'd never done the kiosk thing before. Thankfully, MVA staffers intervened and were shepherding people through the process.

Eventually they directed us to a second kiosk outside that only took credit cards and checks, no cash. An elderly couple in front of me completed the laborious process, only to have the payment system fail and the machine go offline.

So I rejoined the line for the original kiosk. They referred me to an online alternative. I completed the process and, when I was ready to print my documents and leave, they disappeared from the screen.

MVA worker: "You were supposed to do it from the kiosk, not the online station."

RJC: "YOU told me to use the online station."

Anyway, they found the paperwork I needed to get out of there.

I was a state employee for four years, and I'm definitely not a bureaucracy basher.  The vast majority of state workers I meet are people doing their best for the citizens of Maryland.

Today's issues were infrastructure, not personnel related. These challenges will improve over time with experience and better education for all concerned. Perhaps an online tutorial teaching Marylanders in advance of an upcoming MVA interaction would alleviate some of the confusion.

The best part: I'm glad I don't have to do this again for another 8 years.

Saturday, June 17, 2017

Of PAMA, MACRA, and the Affordable Care Act: The State of Healthcare Policy 2017

So, I'm back. 

As y'all know, I usually opine about Maryland state political matters on this blog. But during several past career intervals, I worked on Capitol Hill in different capacities, and had some recent experience working on federal healthcare policy for a small nonprofit in Columbia, Maryland. So, topics wise, I figured I’d switch things up with this one.

So, wonk Richard is giving politico Richard a week off, in other words. But I digress. Anyway, let's get to it. 

Before the Comey/Mueller/Russia stuff broke, the emerging Obamacare versus Trumpcare knife fight seemed poised to be the driving issue facing Washington in 2017. As the U. S. Senate mulls its own replacement to the Affordable Care Act (ACA), indications are that the healthcare debate is set to resume soon.

The outcome of that debate will change healthcare policy for the next generation and beyond. Everybody knows that.

Less known outside of the clannish network of providers, payers, administrators, practice managers, manufacturers, legislators, Hill staffers, lobbyists, accreditors, and activists is that change has already arrived.

And none of it has anything to do with the ultimate fate of the ACA or its GOP alternatives.

Two sweeping federal regulations finalized during the waning days of the Obama Administration have already transformed longstanding rules governing how healthcare practitioners in Maryland and elsewhere are reimbursed by Medicare.

One replaces the elaborate formula used to compute payments for clinical laboratory services.

The Protecting Access to Medicare Act of 2014 (PAMA) requires certain laboratories to periodically report to the Centers for Medicare and Medicaid Services (CMS) what they charge for certain laboratory tests. This data will be crunched to establish new, market-based rates starting January 2018.

The other moves healthcare past traditional fee for service medicine towards a model where Medicare payments are calculated using enumerated, quality-based performance targets.

By way of background, the “sustainable growth rate” (SGR) enacted during the 1997 bipartisan budget deal set caps on Medicare compensation for physicians. Unpopular and unsuccessful, it triggered a series of temporary annual congressional fixes.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) replaces SGR in favor of a new, complex “Quality Payment Program" requiring doctors to choose between two different compliance tracks. 

Success is measured by meeting specific quality metrics outlined in the 2,400 page final MACRA rule. Doctors who have done so successfully qualify for rewards. Those that fail are penalized.

Providers across Maryland are now coping with a new set of regulatory complexities and deadlines. 

As for PAMA, confusion exists as to how exactly data should be collected and reported to CMS.

Further, according to CMS, only five percent of clinical laboratories are subject to PAMA requirements. Most hospital laboratory work is excluded, as are laboratories earning less than $12,500 in Medicare reimbursements annually.

Because larger laboratory conglomerates dominate the data reporting pool, many fear they will benefit to the detriment, and perhaps the ultimate extinction, of smaller, physician-operated laboratories (POLs).

In December, the Congressional Freedom Caucus made PAMA #80 on its hit list of 200 Obama-era regulations. A day later, a bipartisan group of 44 members of Congress sent a letter to the Obama Administration seeking revisions to the final rule.  

HHS Secretary Tom Price – who signed the aforementioned letter before he left Congress – extended the initial reporting deadline by 60 days, but based on current evidence, chances that Congress will engage in a meaningful attempt to rewrite the law are negligible.

As for MACRA, CMS initially estimated that smaller practices would be disproportionately most likely to receive penalties rather than bonuses. This sparked concern the law was biased in favor of large practices.

CMS adjusted the final role to ensure maximum compliance flexibility for physicians in 2017. But many healthcare advocates believe the MACRA final rule should be revised as well. 

Thanks to Hopkins Medicine, the University of Maryland Medical System, the National Institutes of Health, and many outstanding community-based hospitals and providers, Maryland is nationally regarded as a healthcare Mecca. The fundamental impacts these changes will have on these signature institutions is already being felt.

As the patients and families they serve, few know they even exist. But the specter of reduced patient choice seems likely if these two experiments fail.

Many patients prefer the convenience of testing performed during their regular visit with their family practitioner, as opposed to trekking to a remote reference laboratory, dealing with strangers, and longer wait times for results. This concern is especially evident in underserved rural communities.

The obvious benefits close-to-patient testing yield will become less and less available as the number of POLs shrinks.

Similarly, should MACRA breed a culture where smaller practices fail under the new regulatory rubric, patients will ultimately suffer due to the constriction of provider options.

Members of the House and Senate blinded by the politics of the moment must not shirk their responsibility to educate patients and practitioners about these changes to the healthcare system. In the wake of sweeping healthcare change, the rewards of success, and the responsibility of failure, rests with those who enacted them.

But patients always bear the ultimate consequences.

Friday, January 13, 2017

I'm Back

Well, the bad boy blogger is back.

Sorry for the long absence. I retired the blog for a while because, quite frankly, I didn’t know what to do with it. 

When I started it years ago, I was seeking a creative outlet as well as a platform to opine about politics. And, to be honest, I wanted to needle some of my adversaries in Maryland political circles.

Well, the needling got old.

I found I enjoyed writing about policy and politics in an agnostic fashion more than personalities. So, I focused on opeds for newspapers such as The Sun and The Hill.

This approach got me into as much trouble as my blogging did. But I’ll get to that in a moment.

Anyway, 2016 was a year of highs and lows for everyone, and my experience was no exception. But in my case, the highs outweighed the lows for three reasons.

1) I wrote a tribute to my ailing, formidable first boss – Congresswoman Helen Bentley – which appeared in The Sun on the day she died. But what made the experience special is that I got to personally show it to her when I visited her with former Baltimore Councilman Todd Huff about 10 days before she died. Crusty former journalist that she was, she read it carefully as I stood there – the acolyte waiting for the mentor’s verdict. She nodded, quietly handed it back to me, grabbed my arm and said, “You can visit me anytime.” I nearly cried.

2) I participated in the GOP convention in Cleveland, where I had the opportunity to write the so-called “Benghazi mom’s” incendiary speech. Then, when I got back home, I wrote an oped that summarized the experience which got me both national attention (“Anderson Cooper would like you to appear on his show. Can we send a car to pick you up?”) and a boatload of trouble (“The convention people are really mad at you”).  In both cases, I felt like a hunted animal.

3) In December, I closed out the year appropriately by returning to my alma mater, St. Paul’s School in Brooklandville, where I had the chance to speak to students about these experiences (Thanks to Alumni Director Charley Mitchell for making it happen).

On the less positive side of 2016, I turned 50 and it wasn’t a fun experience. I dealt with career and personal angst, and wrestled with some health issues. Part of the aftermath of 2016 is that a lot of people are mad at me at the moment - even more than usual.

So why am I resurrecting this blog, which I last updated in November 2015?

Well, my friend - life coach, fellow blogger - and I were talking about the value of New Year’s resolutions. She found them trite, and while I agree, given the volatility of 2016, I probably need to set some goals if not outright “resolutions” for myself.

So here they are…

 I    I will spend more time focusing on the future than dwelling on the past.

      I will be a better friend. Other than my sister, I have no surviving family – at least not that I care to ever talk to again. The positive side: it gives you the chance to build your own “family,” so to speak, from the ranks of the people you meet and connect with organically. I truly love my friends, but let some of them down last year. Specifically, I have committed what I have long regarded as the cardinal sin of friendship: I cancelled plans at the last minute, on multiple occasions. This has cost me dearly in some cases. I am ashamed.

      I will do a better job of listening. I don’t think I am a selfish person, but I have a tendency to get wrapped up in my own stuff, especially when I am in a period of transition or tumult. It's an introvert thing, I guess. Consequently, some people I care about a lot now think I take them for granted and, in some cases, take me for granite.

      I will learn to integrate my emotions with my intellectual side. I have always been a better Spock than a Kirk, and this led to some awkward moments in 2016.

      I will work to Make America Great Again.

OK, that last one was a joke.

Anyway, I promise to blog in a less confessional, Richard-centered manner, and with greater regularity, in the future. I may also make it less political - the Kardashians need love too.

Coming out of a fractious year, I need to hit the “reset” button. If I have disappointed you, I hope you will give me the chance to reset.

My hero, Richard Nixon, was once asked why he still got out of bed in the morning. “I do it to confound my enemies,” he replied.

I’m not looking to confound enemies in 2017. But I do want to shatter expectations.

Happy New Year.