New physician payment Rules for CMS,different slicing of a shrinking pie

New physician payment rules from CMS have been proposed, can be found here and will likely go into effect January 2010. The Obama administration has found money to increase the pay of primary care doctors a bit ( about 6-8%) by taking it away from other doctors. Radiologists and cardiologists will be paid less. DrRich comments on the understandable reaction of the cardiology leadership here. In the coming months we may get to see how effective the lobbying efforts of organized cardiology will be in their damage control.

Sandy Szwarz in this entry from her blog Junkfood Science sees more in this proposal that the simple pay-this-doctor-less-to-pay- this- doctor-more. She speaks of the vision of things to come. I quote from her posting:

The core of the new CMS proposals (described in section 1413-P33) was a new method for determining fees for services based on their costs (called “resource-based practice expenses”) and their relative value, as determined by a survey called the Physician Practice Information Survey (PPIS). This survey compiled the returned questionnaires from 3,656 physician and professional groups and had been conducted in 2007-8 by The Lewin Group, the contractor for the American Medical Association and the government.

It does not go unnoticed that the Lewin Group is part of Ingenix which is part of United Health Group.See here for some details of the flawed data used by Ingenix and some of the legal actions against them. It is not clear if the Lewin Group derived data used to determine the new pay scales are also flawed.

I recommend that everyone read the rest of her essay to get a flavor of the type of changes and emphasis we can expect in Medicare as the "reform" plays out.Look for emphasis on "lifestyle medicine"as a key element in the prevention part of purported ways to save money.

As suggested by Ms. Szwarz the plan is basically to cut funds to providers and hospitals and institute a covering of "quality" measures so the claim can be made-see we spent less and quality improved.Look, when we pay the bills , we get to say what quality is.

The change (aka "reform") of health care that is promoted by the administration promises to increase coverage and decrease costs while increasing quality by the magic of the triple whammy consisting of electronic medical records, comparative effectiveness research and prevention. It is instructive to look at what comparative effectiveness research has to say about the extensive efforts that have been made to prevent coronary artery disease by attacking multiple risk factors. This is what the Cochrane Group has to say about that.

In many countries, there is enthusiasm for "Healthy Heart Programmes" that use counseling and educational methods to encourage people to reduce their risks for developing heart disease. These risk factors include high cholesterol, excessive salt intake, high blood pressure, excess weight, a high-fat diet, smoking, diabetes, and a sedentary lifestyle. This updated review of all relevant studies found that the approach of trying to reduce more than one risk factor - multiple risk factor intervention - advocated by these Programmes do result in small reductions in blood pressure, cholesterol, salt intake, weight loss, etc. Contrary to expectations, these lifestyle changes had little or no impact on the risk of heart attack or death. Possible explanations for this are that the small risk factor changes are not maintained long-term or are not real but caused by some of the studies being poorly conducted. This review is based on the findings from 39 trials conducted in several countries over the course of three decades. Its authors discourage more research on the topic: "Our methods of attempting behaviour change in the general population are very limited. Different approaches to behaviour change are needed and should be tested empirically before being widely promoted. For example, the availability of foods and better access to recreational and sporting facilities may have a greater impact on dietary and exercise patterns respectively, than health professional advice."

As primary care physicians' practices have changed in large part due to the tightening of the reimbursement screws one of the effects has been the increased use of ER by the primary care doctors' patients ( in off hours and weekends) and/or those folks who cannot find a primary care doc to begin with. With this change one would think the increasing importance of the role of the ER docs should be evident to all including the policy wonks at CMS. Apparently they do not as their new pay schedule gives these figures for the ER physician and the chiropractor:EM docs are valued at $ 38.36 per hour versus chiropractors valued $65.33 a hour.

Is fee for service really the culprit for health care costs?

Fee for service is said to be a major cause of the high health care costs that we are told must be brought under control to save the economy.Dr. Donald J. Boudreaux,Chair of the Economics Department at George Mason University, argues that is not correct.Rather a major cause is the fact that much of medical care is paid for with someone else's money. Go here to read his entire commentary.

Comment writer asks retired doc about single payer

This post is a reply to a comment made on one of my earlier postings that inquired about the single payer option for U.S.health care or at least what were my thoughts.

I believe the major issue is whether the single payer system that we may eventually end up with allows a parallel system of private care as is the case in Great Britain or if government forbids people to spend their own (or insurance) money for services not provided by the single payer government plan, as is the case in Canada. In the later arrangement the patient's life and health is literally in the hands of the government and without the private option there is no practical appeal to the edicts of the bureaucracy that control the expenditures of the single payer system. Of course, in Canada not infrequently folks go south for health care that is denied or so delayed that it is for practical purposes denied. Also, recently there is an interesting and encouraging move to some elements of private care becoming available in Canada (see here). As the U.S. seemingly is moving to more government involvement in health care, there seem to be a directionally opposite move in Canada where they have had years to see how well or badly their hyper-egalitarian health care system works in the real world.

We have had Medicare since 1965 and it is not going away.The best we can hope for after the re-working of the medical care system comes to pass is for the people to be able to purchase health care denied by the government system without having to travel overseas. ( Maybe the private care movement in Canada will be mature enough by then so we can go there for care.)

An interesting twist on this general topic is the suggestion made in a WSJ October 2008 editorial to "allow"seniors to opt out of Medicare entirely, not just Part B.See here for a discussion of how that might be good for some and harming none, something economists seem to refer to as Pareto Optimal.Currently if someone wants to opt out of Part A he will loose Social security benefits.

I did not realize that until recently.Here is the rule in the words of the government:

"Individuals entitled to monthly benefits which confer eligibility for HI ( hospital insurance,Part A of Medicare) may not waive HI entitlement. The only way to avoid HI entitlement is through withdrawal of the monthly benefit application. Withdrawal requires repayments of all RSDI and HI benefit payments."
h/t to Junkfood Science)

This was not the way the Medicare law was written. You have to wonder what prompted the SS administration to add on this rule. Why would they object to someone opting out of Part A? It would only be a saving for Social Security.

The terms one tier and two tier are sometimes used to distinguish between the systems exemplified by the British and the Canadian systems. One Tier would be Canada and two tier would be Great Britain. In this article in the Archives of Internal Medicine there is a discussion about the ethics of the two systems. Interestingly, one of the authors who supported a two tier system from a practical and ethical point of view is Dr. Ezekiel Emanuel who is the brother of Rohm Emanuel.I hope Rohm will give some thought to his brother's views.

National Demonstration Project for Medical homes-some early observations and concerns

Medscape has a republished a report from the National Demonstration Project regarding the Medical Home concept that appeared in the Annals of Family Medicine in June 2009. See here. The full name for Medical Homes in this context is "Patient-centered Medical Home" or PCMH.The authors examined how the transition of a number of traditional family practices to the PCMH model was working out.

There is much to discuss in regard to the report in particular how difficult a transition is from "regular" practice to the medical home type practice can be but my attention become focused on this paragraph.Bolding is mine.

"Transformation to the PCMH Requires Personal Transformation of Physicians

Transformation to a PCMH requires not only implementing new, sophisticated office systems, but also adopting substantially different approaches to patient care. Such a fundamental shift nearly always challenges doctors to reexamine their identity as a physician. For example, transformation involves a move from physician-centered care to a team approach in which care is shared among other adequately prepared office staff.^[25] To function in this team-based environment, physicians need facilitative leadership skills instead of the more common authoritarian ones. A PCMH requires expanding the clinical focus from 1 patient at a time to a proactive, population-based approach, especially for chronic care and preventive services.^[26,27] In addition, physician-patient relationships need to shift toward a style of working in relationship-centered partnerships to achieve patients' goals rather than merely adhering to clinical guidelines.^[28-30]"

The report is hardly a glowing endorsement of the program at least from the view point of a physician considering taking that road. Not only does the report indicate the costs are greater than anticipated,the transitions take longer than anticipated and the entire process is difficult but the physician may have reexamine his identity as a physician. Does this involve pushing into the background the long standing venerable duty of the doctor to the individual patient? "A PCMH requires expanding the clinical focus from 1 patient at a time to a proactive, population-based approach.."

Does this mean that the physician's strong fiduciary duty to the patient may have to be balanced with more concern for the collective.Trust in the physician commitment to the welfare of the individual patient has been the durable glue of the doctor-patient relationship. One wonders how group meetings and a "population based" approach will collide with the duty-to-the-patient ethic that most practicing physician were inoculated with in the medical training.(I realize that inculcation process has weakened more than a little bit in recent years but still is a strong element in the physician sense of professional identity.)

I wonder if NPs who lead medical homes will have to have that same identity metamorphosis.Earlier I blogged about new Medical Homes funded by a House bill that will allow NPs to independently lead these homes. The American College of Physicians has endorsed this bill, a move that both DrRich and I have critically blogged about.See here and here.

The review indicates that three years is not long enough to transform to this type practice and that the current funding and reimbursements may not be adequate. I find it hard to understand why any internist or family practice doctor ( this study involved family practice physicians) would willingly enter into this experiment considering it to be a more than 3 years process and it having significant likelihood of financial insolvency and may involve taking part in workshops to help you retool your ethical compass so it points to the new correct position in the context of the New Professionalism.

Everyone go read Dr. Wes's Open Letter to patients

Go here.His satire elegantly captures so much of what is happening and is threatening to happen.Those of you who still get up everyday and practice medicine should consider handing it out to your patients.

Ignoring history-doomed to repeat it ?

President Obama recently spoke to the American Medical Association and offered in part some reassurances that the public choice option would not lead to a single payer and his Secretary of HHS assured NPR listeners that their plan is not a Trojan horse with a single payer lurking inside.Various administration spokesmen have promised a plan that will increase coverage, save money and improve quality of care.

Sometimes insight may be gained by sitting back and reflecting on some recent (1965) past history.Here is food for thought from the Medicare bill.

I quote from section 1801:

"Nothing in this tittle shall be construed to authorize any federal official or employee to exercise any supervision or control over the practice of medicine..."

So how has that worked out?

American College Physicians (ACP) endorses house bill that allows NP lead Medical Homes

Note this is a republication of an earlier version with a new headline and some introductory remarks..As pointed out by Bob Doherty in a comment to my earlier posting ( I am not sure that comment will survive this editing but that reflects my lack of mastery with blogger rather than an intent to silence his criticism) that the earlier headline was "demonstrably wrong". It said " The American college of Physicians endorses independent NP practices." To avoid misleading anyone I should have said what the current headline says namely that ACP has endorsed a house bill that does allow NP lead medical home practices.The ACP does not endorse NP lead practices in general only in the context of what is outlined in the house bill, ie in the context of the medical home practices.. Although my earlier headline is arguably technically accurate, it could be misleading and I hope my correction will satisfy Mr. Doherty's concerns. Judging from comments on Bob Doherty's blog I am not the only internist who has serious concerns about the issue of ACP going along with this element of the House bill and the ACP's support for what they do support is bad enough without me implying they are endorsing something worse. So here is the rest of the posting without any changes.

The American College of Physicians is endorsing a bill before the house that would enable NPs to practice independently in the context of the ACP sponsored "Medical Home". Further they seemingly welcome the opportunity to take part in a contest using certain quality measures to see who is the better provider.The bill,HR2350,can be read in all of vagueness and details yet to worked out here.

Go here to read what the ACP's man in Washington, Bob Doherty, has to say about how real practicing internists should enthusiastically get on board and strive to follow the appropriate quality driven guidelines to prove to the world that an internist provides better medical care that a RN with an extra two years Master degree that qualifies him as a NP.

Doherty says that the leaders of the ACP are endorsing this proposal because they are so pleased with the other elements of the bill, which include more training slots for general internists and some very modest increases in reimbursements from CMS and it furthers promotion of their highly touted Medical Home proposal. With these and other elements in the bill they are willing to endorse it even though the NP provision "goes past" what they had previously supported.

Doherty argues that if internists really were confident in their superior training they would welcome the opportunity to show they are better than folks with significantly less medical training. They should relish the opportunity to play a game even those it will likely be with rules that not disclosed (those devils in the details will be worked out later) and are likely to be written by folks who may well have an agenda which would be well served by either a victory for NPs or even a tie, which would also be a victory for the NPs . Go to the proposed bill and see if you can find what will be the rules of the comparison game between doctors and nurses.They are to be worked out later. So we should agree to a contest with rules to be worked out later?

Go here to read from the virtual pen of DrRich of the situation facing the general internist and his views of this "capitulation" of the ACP in his commentary that laments the now official nature of the death of the general internists even if the bill is not passed. (With the current state of the Republican party left toothless since the last election just about any democratic sponsored bill will be passed.) By virtue of their current stand the ACP has already stipulated that NPs are for practical purposes equivalent to internists.HR 2350 may set up more general internal medicine training programs but as DrRich points out what medical students with any modicum of cognitive function left would choose to enter a field of medicine that its professional organization has publicly stated that its members are equivalent to other health care providers with much less training. What does that about what the ACP thinks of an internist training and worth? What good will the Medical Home be to internists or the ACP when its Medical Home becomes a NP run organization?

The assertion that internists will prevail in a head to head who-gives -the- best- care contest seems to me to be naive or hypocritical. Does anyone really believe that such a comparison would be based on anything other than the usual "quality" measurements of compliance with easy to account guidelines and/or coarse grained outcomes too crude to show a difference in the short run.

If you think that it is not possible for this development be spun as a good news-bad news story read the second related commentary by DrRich. Go here for that. He suggests that this ACP capitulation could be taken as a opportunity for internists to get out of this "primary care" farce and become retainer docs leaving what primary care has become to a few internists who may just want to run the clock out and the NPs and whatever level of provider that the NP lead practices may devolve into.

This type of internist he and I trained to be may find professional satisfaction in a retainer practice ( at least before medical "reform" deems that to be illegal) or by becoming a hospitalist . The primary care environment that the internist turned officist now faces is-for many of us-not worth doing.