Friday, July 13, 2018

FOUR things you should know about Medicare’s “historic” changes to physician payments

The word “historic” is often used by PR professionals to hype something that is, well, pretty run-of-the-mill.  They figure that no one is going to read a news release that announces “[Name of organization] proposes small change that really won’t make much of a difference.”  The problem is that when something is done that really measures up to being historic, the recipient is less likely to believe it, kind of like the constant Breaking News chyrons loved by cable news shows. 

Yesterday, CMS—the agency that runs Medicare—issued a press release announcing “Historic Changes to Modernize Medicare and Restore the Doctor-Patient Relationship.”  You know what? This one may actually live up to the billing!

CMS is proposing to radically overhaul how it pays physicians for office visits and other evaluation and management (E/M) services; to lift restrictions on payment for telehealth consults and other physician services that are not part of the office visit itself; and to ease the myriad of crushing administrative tasks imposed on physicians to document their services or to get credit for participating in Medicare’s Quality Payment Program.

Both of CMS’s proposed rules are thousands of pages long, so few readers of this blog will be up to reading them. (Never mind trying to decipher the technical and legalistic language used for federal rulemaking!)  Fortunately, ACP’s crackerjack regulatory affairs staff was at it late last night and early this morning (when do they sleep???), to go through it and find out what is to like, and not like, about it.

They found that there is much to like.  Based on their review, ACP released a statement just a short while ago that expressed optimism that many of the proposed changes will “streamline burdensome administrative and documentation requirements –a proposal that is in line with ACP’s Patients Before Paperwork initiative” as Ana María López, MD, MPH, FACP, president, ACP, put it.  ACP also cautioned, though, that one of the biggest changes proposed by CMS—paying a flat fee for most office visits, regardless of their complexity—needed greater examination because of its potential to undervalue the skill and training required of physicians to take care of patients with more complex medical conditions.

There are 4 BIG changes proposed by CMS that are noteworthy:

1.  CMS proposes to make it less burdensome for physicians to participate in its Quality Payment Program, including streamlining the Promoting Interoperability MIPS category by removing the separate components within the Promoting Interoperability (formally Advancing Care Information) Category score to create a streamlined scoring methodology, increasing the ways in which physicians and other clinicians can qualify for the low-volume threshold  and removing a number of quality measures deemed by the agency to be of low-value, consistent with recommendations by ACP and its Performance Measurement Committee.

2.  CMS proposes to pay for more physician services that are not part of a face-to-face office visit. CMS proposes to add new reimbursable codes for “virtual check-ins,” remote consults of patient videos and photos, and interprofessional online consultations.

3.  CMS proposes to take major steps to reduce the documentation requirements associated with evaluation and management (E/M) services, by allowing medical decision making to be the basis for documentation, requiring physicians to only document changed information for established patients and to sign-off on basic information documented by practice staff. ACP strongly supports these changes, as they will reduce the documentation burden on clinicians, limit redundant information in the medical record, and cut down on duplicative time spent on re-documenting existing information.  CMS also proposes to create add-on codes for primary care visit complexity.

4.  CMS proposes to create a flat, single blended payment for most office visits, regardless of their complexity.  ACP expressed concern that this proposed payment structure potentially could have an adverse impact on internal medicine physicians and subspecialists and their patients, since internists typically take care of elderly patients with multiple chronic conditions.  “While we acknowledge the potential benefit of simplifying billing and associated documentation of E/M services by bundling levels 2-5 together, ACP will be assessing whether this change will have the unintended impact of undervaluing the work associated with caring for more complex and frail patients” Dr. López observed. “Reimbursing the most complex E/M services to such patients at the same flat level as healthier patients with less complex problems could undervalue the physician skills and training needed to care for such patients.”

There is much more to the proposed rules, including several areas where it fell short in ACP’s opinion.

Still, the overall direction of easing the burdens of participating in Medicare’s QPP, simplifying requirements to document office visits, paying for telehealth consultations and other work that falls outside of an office visit, and yes, the proposal to pay a flat fee for office visits of varying levels of complexity (whether this turns out to be a good idea or not after further examination of its impact), might just live up to being “historic.” 

Today’s question: what do you think of CMS’s “historic” proposals to change Medicare payments to doctors and its Quality Payment Program?

Wednesday, May 23, 2018

Physician activism as an antidote to burnout

The growing number of physicians evidencing symptoms of burnout has many causes.  Yet one element stands out, according to research: a perceived loss of control over their time, working conditions, and other stress contributors.   ACP has launched a Physician Well-being and Professional Satisfaction Initiative that includes resources promoting individual well-being, advocating for system changes, improving the practice environment, and fostering local communities of well-being.  ACP’s Patients Before Paperwork is about challenging administrative tasks that contribute to burnout.

Yet over the past three days, I’ve observed another promising antidote to burnout:  individual and collective physician activism to change policies that affect their daily work and professional development.  Nearly 400 ACP members from 48 states and the District of Columbia came to Washington, DC to participate in our  annual Leadership Day on Capitol Hill.  Yesterday, they learned about how to be effective advocates with their elected lawmakers, the political and legislative environment in Congress, and the issues that ACP was asking them to bring to Congress. 

This morning, they heard from Rep. Peter Roskam (R-IL), chair of the Ways and Means health subcommittee, on the subcommittee’s Medicare Red Tape initiative, which gives clinicians the opportunity to inform lawmakers about administrative tasks that could be modified to make them less burdensome, if not eliminated altogether. Then, former CMS administrator CMS Andy Slavitt, recipient of ACP’s 2018 Joseph F. Boyle award for Distinguished Public Service, suggested to the attendees that health care proposals should be evaluated based on a simple test: does it make it easier or harder for patients to get the care they need? 

The attendees then headed to Capitol Hill, meeting with members of Congress and staff from their own states, presenting ACP’s ideas, as supported by their own personal experiences with patients, for improving patients’ care and physicians’ daily lives and professional development.

What does all of this have to do with physician burnout?  The doctors and medical students I observed this week were anything but a dispirited or despairing group, but happy and enthusiastic activists for their patients, and their profession.

When you think about it, it makes perfect sense that physician activism is a powerful antidote to burnout.  If burnout is about losing control, activism is about taking it back.   Physician-activists don’t accept a status quo that devalues the doctor-patient relationship, they advocate for policies to make things better.  As Margaret Meade once said, “Never doubt that a small group of thoughtful, committed, citizens can change the world. Indeed, it is the only thing that ever has.”

There is nothing more empowering than that.

Wednesday, February 28, 2018

Are doctors ready to embrace single payer health care?

Single payer health care is enjoying a boomlet in public opinion. 

A Pew Research Center poll released in June 2017 found that, “Overall, 33 percent of the public now favors such a ‘single payer’ approach to health insurance, up 5 percentage points since January and 12 points since 2014.”  58 percent of those surveyed by Pew said that the government has a responsibility to ensure health for all, with a third saying it should be through a single national government program and 25 percent through a mix of government and private programs.  Another 33 percent said the government is not responsible to ensure health care for all but agreed that Medicare and Medicaid should be continued, while 5 percent said the government should not be involved at all. The poll also showed that a majority of Democrats now favor single payer; support was also stronger among younger persons than older ones.  However, most Republicans and older voters oppose single payer.
Source: Pew Research Center

The Kaiser Family Foundation’s June 2017 tracking poll found even higher levels of support for single payer, with 53 percent in favor and 43 percent opposed.  However, it also described support for single payer as being “malleable” and subject to change when presented with arguments for or against: “While a slim majority favors the idea of a national health plan at the outset, a prolonged national debate over making such a dramatic change to the U.S. health care system would likely result in the public being exposed to multiple messages for and against such a plan. The poll finds the public’s attitudes on single-payer are quite malleable, and some people could be convinced to change their position after hearing typical pro and con arguments that might come up in a national debate.”

A Harvard-Harris poll conducted in September 2017 found even higher levels of support for single payer, with a narrow majority (52 percent) supporting it while 48 percent opposed. 

Doctors also appear to be warming to single payer, according to some recent polls.  And, as I have traveled around the country in recent months to visit ACP chapter meetings, I’ve found more and more ACP members are advocating that the College come out strongly in favor of single payer health care, and not just in so-called liberal leaning “blue” states.  I’ve explained that a 2008 ACP paper, which I co-authored on behalf of our Health and Public Policy Committee, examined what the United States could learn from other countries’ health systems.  We recommended “that the federal and state governments consider adopting one or the other of the following pathways to achieving universal coverage:

  1. Single-payer financing models, in which one government entity is the sole third-party payer of health care costs, can achieve universal access to health care without barriers based on ability to pay. Single-payer systems generally have the advantage of being more equitable, with lower administrative costs than systems using private health insurance, lower per capita health care expenditures, high levels of consumer and patient satisfaction, and high performance on measures of quality and access. They may require a higher tax burden to support and maintain such systems, particularly as demographic changes reduce the number of younger workers paying into the system. Such systems typically rely on global budgets and price negotiation to help restrain health care expenditures, which may result in shortages of services and delays in obtaining elective procedures and limit individuals' freedom to make their own health care choices.
  2. Pluralistic systems, which involve government entities as well as multiple for-profit or not-for-profit private organizations, can assure universal access, while allowing individuals the freedom to purchase private supplemental coverage, but are more likely to result in inequities in coverage and higher administrative costs (Australia and New Zealand). Pluralistic financing models must provide 1) a legal guarantee that all individuals have access to coverage and 2) sufficient government subsidies and funded coverage for those who cannot afford to purchase coverage through the private sector.”

(Note that this paper was written a year before the Affordable Care Act (ACA) became law; the ACA is an example of the second option, although it has fallen short of assuring universal access).

Recognizing the growing interest in single payer, and in other models that may still involve multiple payers but with the government having a much large role in financing and ensuring coverage (most European countries are not truly single payer, because they still allow some role for private insurance), ACP’s Health and Public Policy Committee will over the next several months begin examining different alternatives to advance universal coverage.   As it does, I think there are several important questions that will need to be asked, particularly of single payer:

  1. Will all Americans be required to get their coverage through a single, government-financed system (compulsory coverage), meaning that they would have to give up their employer-based or individual coverage?  (If not, it really isn’t single payer; if so, will Americans react favorably to being compelled to get their coverage from the new program?)
  2. Related, will Americans conclude that the coverage under the new program is better or worse than what they have now?  Will deductibles and co-payments be higher or lower?  Many single payer advocates assume that deductibles will be lower under single payer than most Americans typically now pay, but that is in no way a given; one could imagine a single payer plan based on the ACA’s silver plans, for instance.  Will the covered benefits be more or less generous?  Will premiums—or if funded solely through taxes, the taxes they pay—cost them more or less compared to what they and their employers now contribute?  Will taxes be progressive, meaning the wealthier pay more, or regressive, as is the case with Social Security taxes?  Will they have limited networks of physicians and hospitals, like Medicare Advantage plans, or complete choice of physician and hospital, like traditional Medicare?  Will they and their physicians be able to have access to any FDA-approved prescription drugs, or will there be a limited formulary to choose from?
  3. Will the government contract with insurance companies to run the new system, like is the case today with Medicaid managed care, Medicare Advantage, and even Medicare Part B (administered by private insurance carriers) and Part D (pharmacy benefit managers)?  It would be so typically American to create a single payer system, and then pay insurers to administer it.
  4. How will costs be controlled?  With global budgets, price controls, limits on capacity, and/or limiting access to care based on determinations of quality-adjusted life years like in other countries? How will physicians, hospitals, drug companies, and medical device manufacturers be paid?

This may seem like I am arguing against single payer; I’m not.  The same questions might be asked of other approaches.  And models that continue to rely on multiple payers, as is the case with the ACA, may never be as effective and efficient as a single payer system in ensuring that everyone has affordable coverage. Single payer almost certainly would have lower administrative costs and be more egalitarian.

Rather, what I am suggesting is that as ACP, and the country, considers different approaches to achieve universal coverage and access (not the same things), the questions that will need to be considered are far more complex than the snapshot (do you favor or oppose Medicare for All) questions asked in polls.  How those questions are answered will likely determine if the public, and physicians, are truly ready to embrace single payer health care.

Today’s question: What is your view of single payer (Medicare for All) health care?