Friday, October 30, 2009

Who wins from the House reform bill? Follow the money and find out.

Estimates by the Congressional Budget Office of how legislation affects the federal budget can tell a lot about Congress' priorities. Provisions in bills relating to specific health care sectors (e.g. physicians, hospitals, drug manufacturers, insurers) that the CBO scores as producing "savings" means that that particular sector is going to be hit with payment reductions or tax increases to fund other priorities in the bill. Provisions scored by the CBO as adding to federal budget expenditures means that the bill's sponsors have decided that the affected sector is a priority deserving of more federal dollars.

What does the CBO's preliminary estimate of the new House health reform bill tell us about Congress' priorities? That primary care and prevention are the sectors that Congress has identified as deserving as more federal spending, above all others, and that insurance companies in the Medicare Advantage program is the sector that will take the biggest hit. Other sectors facing steep reductions are hospitals (reduction in their market basket increase and disproportionate share payments), drug companies and home health agencies.

In fact, primary care physicians get the single largest bump in spending of any sector in the entire bill. Here is how:
$ 57 billion more will be spent over the next 10 years to increase Medicaid payments to primary care physicians so that they equal the Medicare rates. This is more than any other sector of providers, suppliers and health professionals will get, bar none.
$ 4.7 billion more will be spent to increase Medicare payments to primary care physicians for office, hospital, nursing home, home and emergency room visits.
$ 2.3 billion more will be spent to fund two Medicare and Medicaid pilots to reimburse primary care physicians for care coordination in a Patient-Centered Medical Home.
$ 1.5 billion more will be spent on Medicare GME, much of it directed at increasing primary care training.

Prevention and wellness programs will also get tens of billions in additional federal spending. The bill creates a $34 billion trust to fund public health investments in wellness and prevention, and another $10.7 billion to fund coverage of preventive services under Medicaid.

Now, I know that many of the regular commentators for this blog will respond with a shrug to the increased spending on primary and preventive care, because they will say that it is not enough to prevent a catastrophic shortage of primary care physicians. And they will have a point: I don't think the policies in this bill, by themselves, will suddenly result in thousands of more medical students choosing primary care, or necessarily persuade those in practice that there is a brighter future ahead, but I do believe that they begin to put in place programs that will help. Still, it is undeniable that the Congress has decided that primary care and prevention are priorities that deserve a lot more money: the combined $100 billion that the House proposes to spend directly on primary care, prevention and wellness over the next decade represents more than 10% of the bill's total net cost of $894 billion. The fact that primary care is now viewed as a top priority also is evidenced by introduction today of a bill, supported by the House leadership, that would repeal the Medicare sustainable growth rate and replace it with a new update system that will allow payments for primary care and preventive services to grow at a faster rate than all other services.

By any standard, a combined expenditure of almost $100 billion on primary care, prevention and wellness represents a huge shift in the priorities of the federal government, and one that I think deserves our recognition and support.

Today's question: What do you think the increased spending on primary care and prevention could mean to internists and their patients?


Steve Lucas said...

As a non-Medicare patient I do not see any short term changes. Longer term I do have some issues.

My concern is that we will see a Medicare based payment system for all medical treatment. It becomes very easy to take the step of limiting payments to doctors based on X number of interactions per day. This would be very similar, to my understanding, of the current system used by the NHS. The end result of this will be the need to hire more doctors, not likely to happen, or rationing.

In many ways I feel it is 1970 and I am back in high school, only now I have much less hair. Many of my classmates and young teachers were all about social engineering and were quite adamant that when they were in charge things would be different.

These people, and their children, are now in charge, and like back in the day, their words are chosen carefully so as not to reveal their true goals. In short, I feel there is a love affair with 1964 England, The Beatles, and All We Need Is Love.

England has spent decades selling off car companies and other nationalized industries. The EU is trying to unwind a medical system they see as unsustainable. The same system we are rushing headlong into trying to create.

Steve Lucas

Jay Larson MD said...

Even though primary care is considered by the federal government as a priority, it still does not address the RVU system used by the health care system.

So long that the current RVU system is in place, primary care and other cognitive services with continue to take a back seat to procedures.

There is no obvious increased reimbursement to primary care physicians by private insurance.

Every one talks about bending the cost curve. Why not deal with the RVU curve also?

PCP said...

It means a bunch more spending on ANPs and other mid-level providers, whose algorithm driven care the remaining PCPs will be asked to oversee/rubberstamp. It will mean more resources for CHCs/FQHCs/IHCs and all the other non Private practice physician primary care practices. It will mean more employed PCPs.
Many Physician Private practices have already decided or are in the process of deciding that Medicare payment rates just don't cut it for Cognitive services performed by Physicians under the current practice environment/costs/overheads. If you don't have a non cognitive source of income outside of Medicare, you are already struggling.

The money allocated toward public health prevention will be spent about as efficiently/effectively and as quickly as the stimulus gov't spending. An example of the efficiency we can expect lies with the now unfolding swine flu shot give-away debacle which I understand cost many billions.
A better more effective allocation of resources would be embedding CDEs/Dieticians in group Physician Practices and reimbursing those services delivered as directed by Physicians and delivered by the aforementioned professionals. Team based care gets a lot of applause correctly. None wants to clearly define who is the captain of that primary care ship. A ship with no captain is destined to sink. Blurring the professional boundaries does not create teamwork, it creates conflict.
It will mean more money for pilot testing of ANP led Advanced Medical homes (acceptable to the ACP) that will be written about in glowing praise by some sensation craving opinion editor like Atul Gawande(typically a Harvard Elite) that will entertain us with the matter of factly stated equivalence or superiority of ANP delivered Advanced Medical Home care.
It will mean a more entitled clientele, who will be pacified/acquiesced by a typically liberal "provider" base, that will accelerate the process of bankrupting the country.

The basis of much of your trust in the reform is that this is the start of changes needed to restore Physician led primary care. Many of us in the trenches feel that, this represents about as far as congress feels able to go, not now but ever, and they want to do it their way........"the give away goodies to an entitled public" way. Additionally many of us feel that far from solving the issues, we will create a bigger problem down the road, by hastening the retirements of Specialty Physicians leading to access issues, which will turn the political tide on this issue faster than anything we have seen since the HMO movement of the 1990s.
The end result over time will be a bifurcation of our health care system into a Physician delivered care to Privately insured patients, and Other mid-level provided care to Gov't insured patients. The former will work in CHCs/FQHCs etc. Those will continue to expand, for a lack of access to alternatives for Gov't insured patients.
The latter group of Doctors will constantly be under attack but provide care in a shrinking privately insured pool. Until the only option is to quit or join the former.

So in summary, if you ideal view of your career is to work at a CHC, supervising 5 other mid level providers, providing care to a very entitled public, while taking all the medico-legal responsibility, with limited access to specialty referral, while making perhaps 30-40% higher than your Nurse Practitioner whle being peer reviewed by her, all the while being compared to said professional by management. This is it, support this legislation. You will be thrilled.
If not, lets reboot at a later time. We will all atleast have the chance to see the Mass. debacle unfold fully.

BDoherty said...

In response to Jay's comment, both the House and Senate bills would establish a process to improve the accuracy of the relative values. The House bill requires that the Secretary of HHS examine the RVUs for services for which there has been the fastest growth; codes (and families of codes as appropriate) that have experienced substantial changes in practice expenses; codes for new technologies or services within an appropriate period (such as three years) after the relative values are initially established for such codes; multiple codes that are frequently billed in conjunction with furnishing a single service; codes with low relative values, particularly those that are often billed multiple times for a single treatment; codes which have not been subject to review since the implementation of the RBRVS (the so-called `Harvard-valued codes'); and such other codes determined to be appropriate by the Secretary. The Senate bill has similar language.

Any reductions in payments for services that would result from this process would be redistributed back into the entire physician payment pool.

Rich Neubauer MD said...

I am, of course, thrilled that Congress appears to be “getting it” with respect to the need to bolster primary care.

It is important to note that no one really knows the answer to the question of what exactly will be enough to reverse the trend toward collapse of the primary care “system”. The trend toward collapse has been going on for some time now, and reversing the trend is likely to be a little like changing the course of a supertanker about to hit a reef. Furthermore, while the patient centered medical home concept has been well articulated, finding the payment methods to make it work have not been so well articulated. What is reasonably clear is that strict fee for service is not a payment system friendly to evolution of a functional primary care system.

I think there is legitimate fear that the current legislative proposals all may fall short of doing enough for primary care. On the other hand, we have to start somewhere. If we end up with sub-optimal solutions in the current legislation to reverse the downward decline of primary care, my expectation is that there will be prospective monitoring and further additional steps taken quickly.

The primary care of patients should be one of the most attractive jobs in medicine, not one that is shunned by the best and brightest. To the extent that a toxic payment system, perceptions of low prestige and an adverse lifestyle, and large student debt make primary care seem a lowly choice, we have the means at hand to make change.

Jay Larson MD said...

Thanks for the update.
Nice to know that RVU's will be looked at again. Must of missed that little tid bit somewhere in the 1900 pages.

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

Bob, thank you for bringing HR 3961 to our attention. It does look like I was right about us paying for service utilization from which we have no financial benefit or control. Obviously, fee-for-service will never be perfect. Nevertheless, the active surveillance of legitimate testing for opportunities to reapportion seems a neglected issue of late.

I am doing my best to further review what Congressman Waxman refers to as Waxman-Hatch. I need to have prescribing authority returned to me. The current status is untenable and should be illegal. Who takes responsibility when the administrative glitches of managed care interfere with patient outcomes? Certainly not the faceless third party.

I am willing to be regulated by the state, the federal government, my specialty boards. The excesses that characterize "consumer-driven" healthcare do not serve the common good. We should simply out law publically-traded, for-profit health care entities. Their modus operandi of financial coercion and cost shifting would be unnecessary in a better regulated system.

Let us price fix a bit. The fee schedule being fairly reapportioned periodically is fine. An overbearing bureaucracy is to be avoided. My proposal for including drugs and new technologies in the Medicare fee schedule seems more efficient than the current up-front financing which fuels legal entanglements, me-too distractions, and brand-generic warfare. Prices negotiated in the current un-level playing field with Hatch-Waxman drug lifes cycles cannot be sustained. In exchange for accepting a regulated price, the patent holder would enjoy an indefinite royalty, one that would come with the responsibility to manufacture and monitor to the highest standards. Pharmacy benefit operations and the third party wellness initiatives could cease and desist.

I can't believe there isn't enough for real primary care in the $ 2.5 trillion. As PCP remarked, working with a CDE/dietician as we have for over 25 years works for patients and should be rewarded. I hope I have some time to watch the House debate unfold. Thanks for keeping us in touch.