The Biden administration will offer bonuses to doctors who "create and implement an anti-racism plan" under new rules from the Department of Health and Human Services, a move meant to update Medicare payments to "reflect changes in medical practice."

Effective Jan. 1, Medicare doctors can boost their reimbursement rates by conducting "a clinic-wide review" of their practice's "commitment to anti-racism." The plan should cover "value statements" and "clinical practice guidelines," according to HHS, and define race as "a political and social construct, not a physiological one"—a dichotomy many doctors say will discourage genetic testing and worsen racial health disparities.

The "rationale" for the bonus, the new rules read, is that "it is important to acknowledge systemic racism as a root cause for differences in health outcomes between socially-defined racial groups."

Such premises have found a receptive ear in the Oval Office, which has taken steps to institutionalize them throughout the federal bureaucracy. Hours after his inauguration, President Joe Biden signed an executive order launching a "whole-of-government equity agenda," one plank of which was the "equitable delivery of government benefits."

The new bonus scheme, HHS stresses, is "consistent with" this order. It follows a series of steps by the Biden administration to integrate "anti-racism" into government policy: in November, for example, the Department of Homeland Security listed "diversity, equity, and inclusion" as one of its top two priorities, ahead of "cybersecurity."

HHS did not immediately respond to a request for comment.

The new rules update Medicare's Merit-Based Incentive Payment System, a scoring rubric that determines eligible doctors' reimbursement rates. Congress set up that system in 2015 to reward clinicians for high-quality, cost-effective medical care—and to penalize them for providing unnecessary, costly services.

Doctors had been billing Medicare for services "regardless of how necessary they were," said Chris Pope, a scholar at the Manhattan Institute who worked on the legislation as a Hill fellow. Sold as a way of controlling costs, the payment reform passed with broad bipartisan support.

"Republicans who voted for [the scoring system] weren't voting for this," Pope explained. "The idea that this would be used as a tool of racial policy never came up."

But the scoring system did reward "improvement activities" that advance "health equity," creating a mechanism for HHS to inject ideology into medical compensation. The new rules add "anti-racism" plans to the list of such activities, which are broken up into "medium" and "high-weighted" categories. "Anti-racism" plans will fall into the second weighting, giving doctors extra incentive to implement them. Under the complicated scoring system, the highest possible bonus is 1.79 percent of a doctor's Medicare reimbursements.

Medicare is one of the most expensive social programs in the United States and has been growing more so over time. In 2020 alone, it cost nearly a trillion dollars. Efforts to lower the price tag, such as the 2015 payment reform, have produced administrative headaches and bureaucratic bloat. The Medicare Payment Advisory Commission, an independent federal agency that advises Congress on Medicare policy, has called for the merit-based payment system to be repealed, arguing that its complicated rules have little relation to medical outcomes and saddle doctors with unnecessary paperwork.

"No one went into medicine to check all these boxes," Rita Redberg, a cardiologist on the commission, said at a public meeting in 2017.

The new improvement activities could exacerbate this regulatory burden, especially on small clinics. According to HHS, one public comment on the rules stated that "anti-racism" plans "would be easier for larger, more established practices than smaller or solo practices to adopt." The agency said it "disagree[d]" that the bonus would have a disparate impact because a "small or new practice could tailor the activity to their context."

Clinics can also boost their reimbursements by implementing "a Trauma-Informed Care Approach to Clinical Practice," which seeks to "avoid re-traumatizing or triggering past trauma." That includes "multi-generational trauma, whereby experiences that traumatized earlier generations, such as the genocide of Native American tribes, are passed down" to subsequent generations. In 2018, the New York Times science section called the evidence for multi-generational trauma "circumstantial at best," saying it "falls well short of demonstrating that past human cruelties affect our physiology today."

Medicare has always straddled the line between medical and social policy, Pope noted. By conditioning payments on compliance with civil rights law, the program played a key role in desegregating Southern hospitals in the 1960s. In that sense, Pope said, the new payment scheme is "in tradition of how Medicare has operated since the outset."

But, he added, "the world in 1965 is very different from the world of 2021."

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