Wednesday, April 29, 2009

Health care reform on day 100

All of the media are agog with stories about Obama's 100th day in office. I will resist the temptation to join them, but instead focus on major developments on health care reform that have occurred in the last 48 hours.

One, is the confirmation of Kathleen Sebelius. Although her views on health care reform remain largely unknown, her confirmation will allow the administration to finally gets its health care team together, including subsequent appointments of the CMS administrator and Surgeon General.

Second, is the approval today by the House of Representatives of a joint budget resolution, which is expected to be voted upon later today in the Senate. The resolution is a mixed bag for physicians. It does not include funds to permanently eliminate the Medicare SGR payment cuts. Instead, it would at best prevent the cuts for two or three years, after which payment updates would again be subjected to deep cuts. President Obama had proposed that Congress honestly account for the costs of preventing the SGR cuts in its assumptions of Medicare baseline spending - which basically would have meant acknowledging what everyone knows to be true, which is that Congress won't let the cuts go into effect so it might as well just acknowledge the cost involved as contributing to the deficit. Instead, Congress opted for another stop-gap approach that masks the true costs of getting rid of the SGR and preventing further pay cuts.

The budget does call on Congress to enact legislation to improve payments for primary care physicians, which is a good thing, but there is a catch - increased payments would have to be offset by cuts to someone else.

Third, Senators Max Baucus (D-MT) and Charles Grassley (R-IO) released an options paper on health care delivery system reform. It calls for increases in payments to primary care physicians of "at least five percent per year" for designated evaluation and management codes, above the baseline for other physicians. These increases would be budget neutral, paid for by lowering payments for all other codes. It also calls for an accelerated process to test and then implement new payment models - the medical home is listed as an example - to improve care coordination. They also propose to pay primary care physicians a separate fee for "proven interventions" to help the transition from the hospital for recently hospitalized patients with chronic illnesses.

On the SGR, Baucus and Grassley would provide a one percent update to physicians in 2010 and 2011, and a 0 percent in 2012, after which physicians would face a deep SGR Medicare pay cut. Unless Congress bails them out again.

The Baucus/Grassley options paper provides some encouraging ideas on how to design a framework to recognize the value of care provided by general internists and other primary care physicians, but more work is needed to ensure that these and other policies are up to the task.

Finally, my only comment on Senator Specter's switch to the Democrats is that getting 60 Senators to vote in unison on an issue as controversial as health care reform still will be very tough, no matter the party label that they wear.

Today's question: What do you think of the developments in the past 48 hours?


Jay Larson MD said...

A 5% increase reimbursement to primary care docs to stop the primary care crisis is like using a water pistol to stop a charging water buffalo.

DrJHO7 said...

To expand on Jay Larson's analogy...or like using the little umbrella they put in your fruity mixed drink as a parachute when jumping off of a steep cliff, with jagged rocks below...

Robert J. Sobel, M.D. said...

The Senate Finance Committe spent a lot of time developing options for further bureaucratic tangles interfering with our practice of medicine. If I had the interest of independent physicians in mind, I would not condone any of this. I guess we will all have to be in the employ of the big entities.

It is a shame that the 20 % or so of the pie that represents physician services is parsed so significantly, when the costs in the drugs and new technology sectors remain unchecked. Let's focus on cost constraints there and give independent physicians a fighting chance.