Tuesday, November 10, 2009

AMA reaffirms support for health reform -- with caveats

Late Monday, the AMA House of Delegates rejected, by an overwhelming majority of 350-167, efforts by dissident delegates to put the organization on record as not endorsing H.R. 3962. (The Associated Press/Washington Post has a good story on the organization's deliberations).

The House of Delegates did, however, pass a number of policies that require that the AMA Board of Trustees "oppose inclusion" of cost controls in the Senate Finance Committee bill that would result in redistribution of payments among physicians. With these actions, and the AMA's previous letter of support for H.R. 3926, the AMA effectively (and perhaps ironically) has allied itself with the House-passed bill, which some analysts label as the more "liberal" of the bills because it spends substantially more money than the Senate Finance bill. Among the policies opposed by the AMA are redistributing payments to physicians based on their outcomes and efficiency, redistributing payments from some specialties to increase payments for other (read primary care) specialties, penalizing physicians who do not successfully report on quality measures, and creation of a Medicare commission that would recommend and implement changes in payment and delivery systems to achieve specific savings unless Congress enacted an alternative. Many of the policies opposed by the AMA are the same as those opposed by a coalition of surgical specialty societies. Unlike the surgeons' letter, though, the AMA House action doesn't commit the AMA to opposing a Senate bill that includes such policies, only to advocate that they not be included. It will be interesting to see what the AMA will do, though, if the Senate bill ends up including many of the policies that the House of Delegates has directed it to oppose.

ACP shares some of the concerns about the provisions in the Senate Finance bill, but we have also noted the many policies we support and proposed alternatives -- such as more safeguards over the Medicare Commission -- rather than flatly opposing it.

Whether health reform legislation gets passed or not (and I still think it has a better chance of getting passed), it seems to me that policymakers, both within and outside of government, will insist on changes in payment systems to align incentives with the value of care being provided, which means that there will be redistribution among physicians and specialties depending on the value of the care provided. Just opposing such changes will not be effective if physicians want to influence their design.

Today's questions: Do you believe that organized medicine should oppose efforts to redistribute payments among physicians based on quality, outcomes, and efficiency? Or from other specialists to primary care?


Jay Larson MD said...

Before anyone gets their shorts in a knot, they have to understand how we got to the current reimbursement system to begin with. Basically organized medicine helped get us into our current reimbursement mess. It is very unlikely that organized medicine will get us out of this mess.

Payments among physicians based on quality, outcomes, and efficiency should give cognitive physicians who take time with their patients an advantage over the current “treadmill” approach to medicine. As far as the redistribution issue of reimbursement…it is time to move the carrot. Cognitive skills have been getting robbed by hospitals and procedures enough over the past several decades. Time for a market correction.

An article in Health Affairs July/August 2009 Volume 28, Number 4 1136-1144. “The Political Economy Of U.S. Primary Care. The singular lack of balance between primary and specialty care has serious consequences for health care in the United States.” by Lewis G. Sandy, Thomas Bodenheimer, L. Gregory Pawlson, and Barbara Starfield gives a good history of how we got here.

Some highlights:

Led by advances in surgery, hospitals underwent a major transformation in the early twentieth century. To attract surgeons, hospitals supplied needed facilities and nursing personnel free of charge and allowed surgeons to collect fees for their own services.

When the Great Depression made hospitalization unaffordable for many people, the rise of Blue Cross (closely tied to the American Hospital Association) and Blue Shield insurance plans (sponsored by organized medicine) ensured that hospitals and surgeons would be paid by insurance for inpatient care.

Insurance coverage for surgery and radiology grew much faster than insurance for office visits. Without insurance coverage, primary care physicians (PCPs) generally kept their fees low and affordable.

World War II catalyzed the acceleration of prewar trends favoring specialization. Specialist physicians serving in the war received higher ranks, higher pay, and preferred assignments compared with general practitioners.

The 1946 Hill-Burton Act, enacted to expand hospital capacity, further enabled the growth of specialty services, particularly those based in hospitals.

In the 1950s the payment divergence between generalists and specialists was institutionalized through the advent of the relative value scale.

In 1952 the California Medical Association (CMA) became concerned that insurers would abandon the “usual, customary, and reasonable (rates set by doctors)” system because of the wide variation in fees charged by different physicians.

To avoid the UCR’s demise in favor of an insurer-determined fee schedule, the CMA created a Committee on Fees, which examined hundreds of services, assigned each a “service code,” and defined for each service a relative value unit (RVU).

The RVUs set by the CMA committee reflected the fees for different services existing in the community in the early 1950s. Because patients tended to have insurance for procedural services provided by surgeons and imaging services performed by radiologists, fees for those specialists were already much higher per time spent than fees for PCP visits which were rarely covered by insurance.

PCP said...

I believe that specialists will say what is in their best interest and Generalists will say likewise.
That is why I have said all along, that the ultimate unbiased arbitrators of this ought to be our medical students with their career choices. When 2% of them say they plan General IM as a career, and they line up around the block for the "ROAD" specialties, it speaks volumes. Where does this originate? Why with the AMA and the way it constitutes the RUC! Primary care doctors have virtually abandoned the AMA. I know very few internists under the age of 50 that belong to that organisation. They are with the ACP/AAFP/AAP/SHM etc. The vote of the delegates on the Primary care support issue reinforces that for me.
If the AMA ever wants to start growing its membership base they would do well to listen to the concerns of the aforementioned specialties. We may be shrinking but we are still over a third of all doctors, add in the cognitive specialists who also get the short end of the stick with AMA policies and you would be exceeding half of all Doctors. Once this inequity within medicine is addressed, and there is better unity, we can move on to other things. The advocacy for Tort reform, scope of practice issues, balance billing, Stark laws, transparency in pricing, reimbursement differentials based on point of service etc etc. There are so many such issues that ought to unite us, yet standing in our way is this idiotic caste system within medicine that AMA policies have created.
I agree with you Bob, it will indeed be interesting to see where the AMA comes down on this issue when the crunch time arrives. That said, I feel the writing is on the walls for this one, since facts speak a lot louder than rhetoric. 2% is a loud shout indeed, from our medical students. Everyone but the AMA delegates appear to be hearing it.

Steve Lucas said...

As a business person I would answer both. I feel we have a finite amount of resources we should spend, as a percentage of GDP, on medical care. Currently our expenditures are double those of other industrial countries with poorer outcomes.

While understanding that often the income levels of those we rile against the most, represent only a fraction of those practicing medicine in any given field, I do feel we need to address the overall compensation of any given group.

In my very first economic class we were taught money was made on change. In this instance some will, and should, see a change in their compensation, unfortunately this will come at the expense of others in the group.

Troubling is the attitude in some parts of medicine that the solution is simply to be given more. There is no more to give. We do need to look at funds spend and results achieved.

As usual the devil is in the details and the success or failure of this will depend on an equitable division of existing funds.

Steve Lucas

Rich Neubauer MD said...

I believe it is a societal responsibility to provide the proper milieu for medical professionals to perform their work in a responsible manner. This is part of a reciprocal responsibility the flip side of which is the responsibility of the profession as articulated in both ancient and more recent documents such as the professionalism charter.

Part of that societal responsibility is to apportion how medical professionals are reimbursed in a fair, reasonable and practical manner to achieve the goal of a balanced functional medical system. It should be crystal clear that the current situation is dysfunctional in several regards. First, it has led to a steep decline in primary care. Second, it encourages that more procedures be done whether they are really indicated or not and regardless of how much benefit they accrue to the patient on the receiving end. Finally, the gap between what those engaged in doing procedures vs. those who are in specialties and sub-specialties generally labeled as “cognitive” earn has steadily and inexorably widened in the past few decades.

So, to answer your question, I think our government as a proxy for society has the responsibility to re-think how physicians are paid. It is absolutely understandable that organized medicine (whatever that is) would have a hard time outlining how this should be done. But for “organized medicine” to actively oppose reasonable redistribution within the ranks is just plain wrong. The demographics of the AMA already raise serious questions about how representative it is of physicians as a whole, and its ability to present itself as the voice of medicine especially when it comes to the most difficult questions we face.