The ACP Advocate Blog
by Bob Doherty
Friday, February 21, 2014
We Don’t Need No Stinkin’ Patches
With apologies to the bandits in the classic, “Treasure of Sierra Madre” movie starring Humphrey Bogart, it’s time to tell Congress that “we don’t need no stinkin’ patches” when it comes to the Medicare SGR formula. (When asked by the gold-mining character played by Bogart to prove that they were the Policia, not the roadside robbers they really were, one of the bandits famously replied “We don’t need no stinkin’ badges” before relieving the miners of their gold). Well, Congress’s approach to the SGR has been another form of highway robbery: February 20th marked the 11th anniversary of the first of 16 “patches” passed by Congress to avert the SGR cuts, at a whopping cost to taxpayers of $154 billion dollars! ACP President Molly Cooke observed this “rotten anniversary” by issuing a statement calling on Congress to pass an historic bipartisan bill to permanently repeal the SGR, before the current patch (that’s #16 if you are counting) expires at midnight, March 31.
What did the $154 billion that Congress spent on its 16 patches over 11 years buy us? Repeal of the SGR? Nope. Stable payments? Nope. A better payment system? Nope. Instead, we got more than a decade of frozen payments, accompanied by all of the uncertainty of if and when Congress would enact another patch to stop the next round of scheduled cuts, only to see them pass a patch at the last minute (and sometimes retroactively past the last minute)—and then watch them do it all over again, and again, and again. Year after year . . .a whole decade (plus one) of SGR patches. The latest patch expires at midnight, March 31, and if Congress is true to form, it will pass patch #17, adding tens of billions more to the accumulated price tag of all the prior patches.
If wasting hundreds of billions of taxpayers’ dollars on temporary patches that did not fix the real problem—the SGR itself--doesn’t count as highway robbery, I don’t know what does.
This year could be different though. The Congressional Budget Office has lowered the estimated cost of repealing the SGR to less than half of what it used to be. For the first time ever, the congressional committees with jurisdiction over Medicare in both the House and Senate have reached a bipartisan agreement on an SGR repeal and replacement bill. Organized medicine is unified behind the bill they agreed on in a way it has never been before, with just about every specialty society, the AMA, and state societies working in concert to get Congress to pass it. Just yesterday, 25 internal medicine-related organizations, including ACP, sent a letter to Congress calling for a vote on the SGR replacement bill.
There are obstacles, though: Congress needs to find about $128 billion in budget offsets (that is, goring someone else’s ox) to pay for it, a very high hurdle in an election year. Or they could pass it without finding budget offsets, since the money that supposedly is “saved” because of the scheduled SGR cuts never actually produces savings, because Congress almost always passes a patch to override them. Convincing fiscal conservatives to vote for a bill that technically is not paid for by cuts to someone else isn’t exactly a cakewalk, either.
The only thing that will overcome these obstacles is if rank-and-file physicians tell their members of Congress that enough is enough, it is time to pass the SGR Repeal and Provider Payment Modernization Act of 2014, H.R. 4015/S. 2000, before SGR patch #16 expires on April 1.
I have heard from some of you, though, who question whether this bill is really an improvement over the SGR and its patches. It’s not a perfect bill—is there such a thing?—but by any reasonable standard it is far, far better than current law and the SGR. Here’s why (and thanks to my colleague Shari Erickson in pulling all of this together so succinctly):
1. After 11 years, 16 patches, and $154 billion wasted. It is time to pass SGR-repeal now!
2. The bill establishes stable positive updates of 0.5% for the first 5 years (with rates then remaining stable from 2018-2023). The alternative is a nearly 24 percent cut in 2014, followed at best by a freeze in payments, but more likely deeper cuts.
3. The existing Medicare quality reporting/incentive programs (PQRS, VBM, and MU) vary significantly in terms of measures, data submission options, and payment timelines—which results in significant confusion and hassles for physicians. The new Merit-based Incentive Program (MIPS) would unify these programs.
4. This legislation keeps the money from physician quality incentive program penalties (in 2018 and beyond) in the physician payment pool; therefore, significantly increasing the total funds available to pay physicians. This money would be lost if the current system remains in place.
5. The new MIPS composite score would allow physicians to more clearly determine their eligibility for incentive payments. In essence, it empowers physicians to set their own individual conversion factor, rather than having it determined by a flawed formula or other external approach. Physicians will be able to proactively review their data in order to set their performance goals. The current Medicare reporting programs are not at all clear, transparent, or aligned in terms of performance thresholds that must be met.
6. In the current Medicare reporting/incentive programs, physicians receive little to no incentive payment for engaging in clinical improvement activities. And there is currently no ability for physicians to get credit for transforming to a PCMH under the current programs. The MIPS program would change that and give credit for overall improvement from year to year, as well as for engaging in specific clinical improvement activities.
7. Under current law, in 2018, physicians are faced with:
• 2 percent penalty for failure to report PQRS quality measures;
• 4 percent (increasing to 5 percent in 2019) penalty for failure to meet EHR MU requirements; and
• Additional negative adjustments under the VBM program
All of which could add up to 6-8 percent cuts as early as 2018 and 7-10 percent cuts in 2019. However, the new MIPS program aligns all of those incentive payments and caps them at more reasonable limits in the early years (4 percent in 2018), which gradually increase over time.
8. On top of the base positive incentive payments that high performing physicians would receive in the MIPS program, they can also receive additional payment. In aggregate, this additional payment would be up to $500 million per year from 2018 to 2023. This new money does not exist within the current Medicare reporting/incentive programs.
9. Additional new money is also allocated specifically to help small practices ($40 million). There is currently no funding assistance available for the Medicare reporting programs and very limited assistance available for Alternative Payment Model (APM) transition (mostly limited to practices participating in CMS Innovation Center projects).
10. Those physicians participating in APMs would also receive a 5 percent bonus—this is entirely new funding and is on top of any current payment structures that are part of their APM (e.g., prospective care coordination fees, shared savings, etc.).
11. Through its incentives for APMs, this bill would allow for a more rapid and robust expansion of the PCMH and PCMH specialty practices (and other evidence-based models) throughout all of Medicare.
12. Additionally, current law does not require payment for the management of individuals with chronic conditions. CMS recently finalized via rulemaking that they will be paying for a similar code starting in 2015; however, the details of how that code will be implemented have not been finalized. This bill would put the weight of law behind paying for a chronic care management code (or codes) and would ensure that PCMHs and PCMH-specialty practices could bill for them.
Twelve good reasons for physicians to support the SGR Repeal and Provider Payment Modernization Act of 2014. Twelve good reasons for you tell Congress to stop passing temporary patches that waste money and only prop up a broken Medicare physician payment system.
Twelve reasons to tell them that after 11 years, 16 patches, and $154 billion, we don’t need no stinkin’ patches. Twelve reasons to tell them to pass The SGR Repeal and Provider Payment Modernization Act of 2014. When they do, we will be able to celebrate the fact that that SGR patch #16 was the last of the 16 policy failures over eleven long years that got us into current mess.
Today’s question: What will you do to get your members of Congress to pass the SGR Repeal and Provider Modernization Act of 2014?
Tuesday, February 11, 2014
All in the Family
Even the best of families have skeletons: the uncle who had some shady business dealings, the cousin in drug rehab, brother with the messy divorce and custody fight, or the adult kids who are maxed out on their credit and behind in their mortgage payments but have to “keep up appearances” with their expensive suburban lifestyle. When these things happen, there is a tendency to “keep it all in the family” –that is, don’t talk about things that might be embarrassing, because above all else, you have to keep up the image that all is fine and well.
This especially is true if the family already feels it is under attack by others in the community that have made it clear that they don’t like them and don’t want them to succeed—so the last thing the family wants to do is add fuel to the fire. It is true of historically persecuted ethnic groups: my Irish grandmother didn’t want anything bad said about the Irish (and her own immigrant family and believe me, there were plenty of skeletons in my ancestors’ closets!), because there were enough people already who wanted to keep the Irish down.
And of course, there are things one shouldn’t talk about, because they are private and not anyone else’s business.
All of this makes sense, except when it comes to things that are going to come out anyway, or are already well known—in those cases, denying reality isn’t going to help your case.
I may be stretching the analogy, but I think that is what is going on with many liberal (or progressive or just pragmatic) supporters of the Affordable Care Act. They know that not everything is going well. They know that not everyone is going to come out ahead. They know not everyone can keep their own health plan. They know that no one (not even the president of the United States) can guarantee that your own physician will be included in your new health plan. They know some people will pay more for coverage. They know that there still are problems with the federal enrollment website.
But they don’t want to acknowledge these or other potential ACA shortcomings, because they don’t want to give away anything that opponents will use to help make the case that it isn’t working. So they will talk among themselves about things that aren’t going so well with Obamacare—but not in public, everything must be kept inside the family of ACA supporters.
I understand the sentiment, because ACP supports the ACA, and we want to help ensure that it succeeds, not undermine it by saying critical things about it.
But when the ACA’s progressive supporters aren’t willing to acknowledge problems and unintended shortcomings, they can come across as having a blind-eye to the legitimate problems some people are having. It doesn’t help the ACA to cast a blind eye to the problems that people have had signing up. It doesn’t help the ACA to cast a blind eye at the people who lost their current coverage and now have to pay more for it. It doesn’t help the ACA to cast a blind eye at people who couldn’t keep their doctor because the only affordable plan they could find had a “narrow network.” It doesn’t help the ACA to dismissively say “well, most people are better off” because of the ACA (even though, factually, most are) without acknowledging and empathizing with those who feel that they aren’t.
Casting a blind eye to the disruption caused by the ACA only appears to make you seem indifferent to the people who feel ill-served by it. That isn’t any way to make any new friends for Obamacare.
Later today, Tuesday, the American College of Physicians will be releasing a progress report on the ACA’s implementation. We will talk about the millions it is helping. We will express our opinion that it is the right thing for the country.
But we also will talk about things that have come up in its implementation that are causing problems—especially the narrow health plan networks and restrictive formularies that are making it harder for people to continue to see the doctors they trust and the medications they need. We will offer specific ideas to make improvements in how the ACA is being implemented, so that there doesn’t necessarily have to be a trade-off between getting health insurance and keeping your doctor.
Do we run the risk of adding fodder to the anti-Obamacare crowd? Sure. But I also think that there is no one in a better position to help improve the ACA than its supporters. When the ACA’s opponents find fault with it, their motives are suspect because their single-minded objective is to discredit it and get it repealed. When ACA supporters point out things that aren’t quite right, it is to get them corrected so that the law works better for everyone, including those who now feel ill-served by it.
If we really care about the ACA’s reputation, we can’t keep it all in the family when we know there are things about it that can be made better.
Today’s question: Do you think supporters of the ACA should talk about its shortcomings, even if that gives fuel to the law’s critics?
Thursday, January 23, 2014
The Confusing Conservative Critique of Obamacare
Conservatives could muster a clear-thinking critique of Obamacare if they wished, and maybe even put forward a genuine alternative. Unfortunately, though, many of the conservative attacks on Obamacare don’t make much sense, when evaluated against conservative’s own heretofore views, not against liberal concepts of good policy.
Let’s breakdown conservatives’ confusing arguments against Obamacare that don’t jibe with their previous positions:
1. Conservatives used to be for high deductible plans, until they were against them, when it comes to Obamacare, that is. Bloomberg News points out that Republicans in the early 1990s advocated for high deductible plans as an alternative to the more generous benefits proposed by President Clinton:
“As Democrats pushed for universal health care during the Clinton years, Republicans argued that consumers should pay a greater share of their medical bills. In 1996 the GOP-controlled Congress passed legislation allowing some people to pair high-deductible plans—which barely existed—with tax-free health savings accounts. That meant that small business owners and their employees, as well as others with limited insurance options, could put away pretax earnings to pay for routine care and buy cheap insurance to cover catastrophes. In 2003 Congress, still under GOP control, passed legislation making health accounts more widely available.”
Today, Republicans are in a lather about Obamacare’s high deductible plans, exposing what policy wonk Ezra Klein deems “their hypocrisy” over Obamacare (his words, not mine—I think inconsistency is a fairer description). Aaron Carroll, a professor of pediatrics at the Indiana School of Medicine, opines in Bloomberg that conservatives newfound dislike of high deductible plans brings them to the right (correct) position:
“The revelation that many plans in the Patient Protection and Affordable Care Act’s health insurance exchanges have high deductibles, has put many of the law’s conservative opponents into a corner: Once in favor of high deductibles, these critics of Obamacare are suddenly worried about the risk to consumers. The data show why their new position makes more sense.”
2. Conservatives used to be in favor of moving people out of employer-based coverage but now bemoan every employer who drops coverage because of Obamacare. Typical is an anti-Obamacare screed from the Republican Senate Policy Committee, warning that people “relying on employers to cover employees’ spouses on the company health plan may find the health care law isn’t ‘working fine’ for them. The law’s mandates and fees are driving up health care costs and making it harder for employers to continue offering health insurance to workers’ families. Some employers have even stopped offering spousal coverage altogether.” Avik Roy, a conservative physician commentator and former Romney advisor, has predicted that Obamacare will result in employers “cancelling” policies for 80 million employees (which, by the way, has been disproven by independent fact-checkers—his estimate is way too high, and the policies aren’t actually being cancelled, just changed to meet Obamacare’s requirements, such as the requirement that young adults be eligible for coverage under their parents’ plans).
But even if it were true that some employers eventually will decide no longer to provide health insurance in favor of allowing their employees to buy individual (and subsidized coverage) from the competing health plan offered through Obamacare’s exchanges, delinking health insurance from employment used to be what conservatives favored (and some still do). For example, the libertarian Cato Institute supports elimination of the tax deductibility for employer-sponsored insurance—a far more radical and disruptive approach to ending employer-based insurance than any drop in employer-based coverage from Obamacare:
“In any case, with the removal of the subsidy for health care above catastrophic coverage, the incentive to obtain so much insurance would diminish. Thus, many people would reduce coverage to that level. Insurance companies could help individuals with catastrophic risk management—their traditional function. Firms could get out of the business of managing, rationing, and buying health care. We would delink insurance from employment, ending the portability problem and dramatically reducing the brouhaha over pre-existing conditions. Individuals would have better incentives and more control. More broadly, we need to move away from third-party payment and toward two-party transactions in health care.”
3. Conservatives invented the idea that individuals should be required to buy health insurance but now vociferously oppose Obamacare’s individual mandate. Forbes magazine recounts conservatives’ “torturous” shift on the individual mandate, from originally favoring it as a market-based, personal responsibility alternative to compulsory government-mandated coverage (single payer) or employer-mandated coverage, to now decrying it as socialism:
“. . . Some conservatives, seeking a more market-oriented path to universal coverage, began endorsing an individual mandate over an employer mandate. An individual mandate would address the ‘free rider’ problem caused by EMTALA, by requiring people to buy their own insurance. In addition, moving to a more individual-based system from the employer-based one would significantly increase the efficiency of the health-insurance market.
With these considerations in mind, in 1989, Stuart Butler of the Heritage Foundation proposed a plan he called ‘Assuring Affordable Health Care for All Americans.’ Stuart’s plan included a provision to ‘mandate all households to obtain adequate insurance,’ which he framed explicitly as a way to address the ‘free rider’ problem and employer mandates.”
To be fair, there is plenty of inconsistency among liberals, and people often change their minds, for good or at least justifiable reasons in their own minds. But the fact is that until Obamacare, the conservative alternative to government-run health insurance was to provide tax incentives for people to enroll in high deductible plans, to delink coverage from employment, and to require that people to buy coverage. Yet they oppose these elements when associated with Obamacare.
This is a problem, because this country needs to have a spirited debate about today’s conservative alternative to Obamacare, one that would limit government and promote free markets yet still expand access to millions of uninsured. But conservatives need to first figure out what they are for, not just what they are against, which apparently is anything having to do with Obamacare, even if similar to the things they used to be for. Do they still favor high deductible plans? Do they still want to delink coverage from employment? If they no longer support an individual insurance mandate, what alternative do they have in mind to make sure that risk is spread among the young and healthy and the old and sick? We need to know.
Finally, before readers of this blog accuse me of only going after the conservative response to Obamacare, stay tuned. My next post will be about liberals’ blind-eyes to the unintended adverse consequences of Obamacare.
Today’s questions: Do you agree that conservative critiques of Obamacare are confusing and inconsistent with their past views? And if so, is this a good or bad thing?
About the Author
Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog
Email Bob Doherty: TheACPAdvocateblog@acponline.org.Follow @BobDohertyACP
- We Don’t Need No Stinkin’ Patches
- All in the Family
- The Confusing Conservative Critique of Obamacare
- What my auto accident taught me about Obamacare
- The Twelve Weeks of Obamacare
- What Should Physicians Expect When the ACA goes li...
- Congress Takes Giant Step Toward Repeal of Medicar...
- Why I Fight for Obamacare
- Guess what! Obamacare is working . . .
- Is it “paternalistic” to set minimum standards for...
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