Wednesday, September 28, 2011

Has Medicare found a way forward for primary care?

Today, Medicare’s Center for Medicare and Medicaid Innovation announced a Comprehensive Primary Care (CPC) Initiative, which asks private payers and state Medicaid programs to join with Medicare to “help doctors work with patients to ensure they:

1. Manage Care for Patients with High Health Care Needs;
2. Ensure Access to Care;
3. Deliver Preventive Care;
4. Engage Patients and Caregivers; and,
5. Coordinate Care Across the Medical Neighborhood,”

according to an email from CMS’s press office. The initiative will provide qualified practices with risk-adjusted, per patient per month care managements payments, in addition to traditional fee-for-service payments, along with the opportunity to share in savings achieved at the community level.

I believe that the Initiative is a potential game-changer in helping to support and sustain primary care in the United States. But not just any primary care: practices will need to demonstrate that they have the above five functional capabilities aligned with Patient-Centered Medical Homes and be accountable for reporting on the results.

What makes this initiative different from so many other PCMH and primary care pilots?

First, it recognizes that primary care physicians can’t be expected to transform themselves into PCMHs without all payers getting behind them to offer substantial and sustained financial support. Instead of Medicare, or one or two payers trying to go it alone, CMS recognizes that everyone must have some skin in the game to help primary care:

"Without a significant enough investment across multiple payers, independent health plans-- covering only their own members and offering support only for their segment of the total practice population-- cannot provide enough resources to transform entire primary care practices and make expanded services available to all patients served by those practices." The CPC initiative offers a way to break through this historical impasse by inviting payers to join with Medicare in investing in primary care in 5-7 selected localities across the country.

Second, the potential revenue for qualified practices could be substantial. CMS would pay risk-adjusted average of $20 per beneficiary per month for a qualified practice (the monthly payment would range from $8 to $40, depending on a patient’s health risk classification). These payments would be in addition to regular Medicare fee-for-service payments.

If state Medicaid programs decide to join in, there would be additional monthly capitated payments for Medicaid enrollees. And, private insurers who wish to participate will have to submit a “plan for enhanced support for comprehensive primary care aligned with the goals of this initiative.” Practices could be able to share in Medicare savings, calculated at a community (not practice) level associated with the initiative.

Third, practices would have “discretion to use this enhanced, non-visit-based compensation to support non-billable practitioner time, augment care teams (e.g. care managers, social workers, health educators, pharmacists, nutritionists, behavioralists) through direct hiring or community health teams, and/or invest in technology or data analysts.”

Fourth, they’d have access to data sharing from Medicare, Medicaid and other participating health plans on cost and utilization associated with their patients.

Fifth, if it is successful, the Affordable Care Act gives CMS has the authority to expand it throughout Medicare, well beyond the 75 practices expected to be selected in five to seven markets for the initial four years of the initiative. It could, in time, show the way to new ways for Medicare and other payers to sustain and support well-functioning comprehensive primary care on a long-term basis.

Most importantly, Medicare’s Comprehensive Primary Care Initiative could improve care for patients, by giving practices the support they need to implement proven best practices to manage care for patients with high health care needs, ensure patient access, deliver preventive care, engage patients and caregivers, and coordinate care across the medical home neighborhood, which CMS correctly defines as “the framework for comprehensive primary care.”

Today’s question: What is your reaction to CMS’s Comprehensive Primary Care Initiative?

Tuesday, September 20, 2011

Are doctors treated worse than everyone else?

Many physicians, and especially primary care physicians, aren’t happy campers. Why should they be? They feel disrespected, overworked, over-managed, and underpaid. They tell me they wouldn’t advise their children to go into medicine. Some feel that physicians are singularly beset upon. “Our government acts toward the medical profession in an abusive fashion. No other industry or profession is humiliated in this way,” writes RyanJo, a frequent commentator to this blog.

I can appreciate why many physicians are upset. They’ve had a decade where the Medicare SGR formula repeatedly has threatened to cut their fees, only to have Congress enact last minute reprieves that replace the cut with a small token increase that has not kept pace with their costs. Last year, Congress actually allowed the cut to go into effect and then retroactively restored it, creating havoc in physicians’ offices during the four weeks when they weren’t being paid. Like Charlie Brown and Lucy’s football, they are told each year by their members of Congress that that “this will be the year when the SGR will finally get repealed, really, for sure, we promise, this time will be different”--only to see it pulled away at the last minute.

In the meantime, they are constantly hounded to be more accountable for the care they deliver, to fill out just another form, to document their encounters, to get permission before they order a test, to double-check on whether their patient really needs that motorized wheelchair peddled on late night TV, to report on their performance, to e-prescribe (or else!), to buy an electronic health record and make damn sure that it is complies with “meaningful use” rules (or else!), to spend thousands of dollars to convert to new diagnosis codes (or else!) just because someone in government says they must . . .can we blame them for being unhappy?

Surely not. Health care payers, government and private sector alike, have a responsibility to stop piling on more paperwork and rules. Congress has a responsibility to fix the problem it created with the SGR, and ensure that physicians are paid fairly for their services. Primary care physicians have the right to expect that their services will be valued appropriately and sufficiently. And organized medicine has a responsibility to show its members that it is fighting against such intrusions and for fair payment policies.

But as we make the case that physicians deserve better, we also need to be aware that much of the rest of America has it much worse. Just read Robert Samuelson’s column in Monday’s Washington Post, documenting the economic devastation created by the Great Recession and lost decade of stagnation. He writes that the Census Bureau has found that “Median household income (the income precisely in the middle of the distribution) was $49,445, down 6.4 percent from 2007 ($52,823), the recent peak, and the lowest since 1996 ($49,112).” About 10 million more people have fallen below the official poverty line since 2006. The jobless rate remains stuck at over 9 percent.

But things are actually much worse than these numbers suggest, he argues:

“Even for millions of Americans with jobs, there’s a palpable sense of loss and anxiety. One reason is the devastating housing slump, subtracting huge amounts from people’s wealth. About half of households also own stocks through retirement accounts, mutual funds or ordinary brokerage accounts. The market’s daily gyrations inflict a feeling of endless vulnerability.

Perhaps as powerful are parents’ fears for their children. The jobless rate for young workers (ages 20 to 24) is always high — the young are restless and move between school and jobs — but now it is an astronomical 14.8 percent. Getting started is hard; studies suggest that young workers who experience intermittent work and low wages in a harsh economy may suffer permanently depressed lifetime earnings.”

Physicians have a lot to be unhappy about, but they almost never have to worry about being laid off from work, they are still relatively well-compensated, and they are trusted and respected by the public. Internists on average earned $189,000 in 2009, according to the Bureau of Labor Statistics; surgeons earned a bit more than $225,000. (Yes, I know that some internists make much less than the average, but some also make more—that’s how it works with averages.) For all occupations, the average income was $44,410.

I also know that there is much more to career satisfaction than having a job and a good income, and the country should pay attention to the physicians’ grievances. We should want physicians to be happy in their work. We should want smart young people feel that there is a future in medicine, including primary care. We should want to join with physicians to protest government actions that abuse and humiliate them. We should want to pay doctors fairly for their services and eliminate much of the paperwork that is driving them (and their patients) crazy.

At the same time, the medical profession won’t garner much public sympathy if it acts unaware that it remains a stable and highly compensated profession, at a time when wages for most Americans have been stagnant for a decade, one out of ten of us is out-of-work, millions more have become officially poor, many who have jobs fear losing them or worry that their kids won’t find them, creating what Samuelson calls a “fatalistic sense that the economic slump will never end.” Let’s remember that even as physicians have legitimate complaints about how they are treated, tens of millions of Americans have it far, far worse.

Today’s question: Do you think physicians have it worse than the rest of the country?

Monday, September 12, 2011

Health care spending: It’s enough to make a grown man cry!

Liberal and conservative economists disagree on many things, but not on the need to reduce health care spending in the United States. The United States already has higher per capita health care spending than any other industrialized country, and absent major changes, costs will continue to rise, the federal government will pay more and more for Medicare and Medicaid, and there will be little money left for anything else. Before long, relentless spending on health will lead to deep benefit and reimbursement cuts, crippling tax increases, and bigger budget deficits. It’s enough to make a grown man cry. (My apologies to the Rolling Stones, who had a much different topic in mind than health care spending when they penned this rockin’ line!).

This is the stark reality facing the new congressional Super Committee charged with finding at least $1.2 trillion in ten-year budget savings by Thanksgiving. They really can’t get there without cutting health care spending, but any changes they might make will be met with stiff opposition from politically powerful interests—hospitals, doctors, drug and device manufacturers, and seniors’ advocacy groups. I suspect that much of the health care sector secretly wants the Super Committee to fail to reach an agreement, figuring that they would do better under the maximum 2% cut in 2013 Medicare payments (which automatically goes into effect if the Committee deadlocks or Congress turns its recommendations down) than by a deficit reduction package that gores their own oxen. Physicians, though, stand to lose much more than the 2% required under sequestration, since they already are facing a 30% Medicare SGR cut on 1/1/12, and likely, double-digit cuts in 2013.

It is in this context that the American College of Physicians had to decide what it would say to the Super Committee. It could join with everyone else in just saying no: no to cuts in Graduate Medical Education funding; no to changing the way that care is delivered or paid for; no to anything and everything that is on the table. Or it could offer its own ideas for reducing health care spending in a socially and fiscally responsible way.

The latter is the choice made by ACP. In a letter to the Super Committee, ACP offered a menu of options to reduce health care spending by hundreds of billions, potentially enough to pay for permanent SGR repeal and to preserve funding for GME and other critical programs to ensure access to care.

The cornerstone of ACP’s recommendation is to establish a national, multi-stakeholder initiative to increase the use of high value care and to cut the estimated $700 billion that the U.S. spends on marginal and ineffective care. The initiative would develop a plan to provide patients and their clinicians with information on comparative effectiveness, change incentives for clinicians to reward value rather than volume, redesign insurance benefits so that patients have some financial skin in the game if they ask for ineffective care, and base coverage decisions on evidence of effectiveness with considerations of cost.

ACP also advocated a pathway to eliminate the SGR, stabilize physician pay for a five year period during which new value-based models would be tested, followed by a transition to models shown to be most effective by the end of the decade. On GME, ACP proposed broadening the base of funding by requiring all payers to chip in and spending the available dollars more strategically.

ACP also offered for consideration a menu of additional policy changes that the CBO and other experts say could reduce federal health care spending by hundreds of billions. Included in the options, which generally are supported by ACP policies, are strengthening primary care and care coordination ($83 billion in savings), lower defensive medicine costs (saving up to $62 billion), requiring drug manufacturers to pay a rebate to low income patients and/or allowing the federal government to negotiate drug prices under Medicare Part D (saving $110-$300 billion), enrolling Medicare-Medicaid “dual eligibles” in managed care (saving $12 billion), accelerating an excise tax on high cost health plans or phasing down and capping the tax deductibility of employer-sponsored health plans (saving $113 billion to $309 billion), creating a single cost-sharing structure for Medicare Parts A and B combined ($32 billion saving), and adding a public plan to the health exchanges created by the Affordable Care Act (saving $88 billion). Altogether, such options could save between $500 and $886 billion over the next ten years.

Many of ACP’s options are controversial and not likely to be accepted by the Super Committee or Congress. Even the seemingly non-controversial concept of reducing low value care is going to step on the toes of physicians, hospitals, medical device manufacturers, and drug companies that make money from the same services that may be found to offer little or no benefit. Transition to new “value-based” payment systems will be exceedingly difficult, especially for physicians in smaller practices.

The truth, though, is that there is no easy way to reduce spending on health care. Physicians could sit back and let the politicians, economists, business executives, and others decide who to cut and how, or they can offer their own ideas for achieving savings in a socially and fiscally responsible way, as ACP has tried to do.

Today’s question: What do you think of ACP’s ideas for reducing health care spending?

Thursday, September 8, 2011

Is Graduate Medical Education Funding worth it?

Graduate Medical Education has for the most part escaped big budget cuts in the past, mainly because powerful lawmakers have aligned to protect funding for teaching hospitals in their own states and districts. Plus, the Association of American Medical Colleges, the American College of Physicians, hospital organizations, and many others long have made funding for GME a top legislative priority.

GME, though, could be on the chopping block as Congress’s new “Super Committee” comes up with recommendations to reduce the deficit by at least $1.2 trillion over the next decade. A report from the Congressional Budget Office of options to reduce the deficit to reduce the deficit suggests that $69.4 billion could be saved over the next decade by consolidating and reducing GME payments. Earlier this year, the bipartisan Fiscal Commission on Fiscal Responsibility and Reform also proposed trimming GME payments.

How then should those who believe that GME is a public good respond? One way is to circle the wagons and just fight like heck to stop the cuts. But that raises a basic question: is GME so sacrosanct that there shouldn’t be any discussion of its value and whether the current financing structure is effective and sustainable?

Another approach, the one taken by the ACP in a position paper released yesterday, is to acknowledge that GME financing needs to be aligned more strategically with the country’s workforce needs, and that the responsibility of paying for it should be shared among all payers, so the federal government’s share would gradually decline.

In its 26-page policy paper, ACP provides 11 recommendations to preserve sufficient funding to support GME in the United States while ensuring that such spending is used effectively, including policies to:

• Require that all payers (insurers) be required to contribute to GME financing.
• Strengthen transparencies, accountabilities and value, including aligning financing with an assessment of workforce needs,
• Weighting funding to support programs that train primary care physicians and other specialties facing shortages,
• and funding pilots of innovative models to train physicians in the specialties and with the skills needed to meet societal needs.

ACP notes that the recommendations are made with the perspective that the federal deficit is at an all-time high and that there is an increased commitment to fiscal responsibility.

GME, in ACP’s view, is a public good. GME is a public good— it benefits all of society, not just those who directly purchase or receive it. All payers depend on well-trained medical graduates, medical research, and technical advances from teaching hospitals to meet the nation’s demand for a high standard of care. ACP believes that all payers derive value from this system and should share the investment in education and research. All payers should be concerned about preserving the nation’s system of GME, maintaining high standards of quality for patient care services and that opportunities for entry into the medical profession are available to the best-qualified candidates. Accordingly, ACP calls for a mechanism to be established to require all payers to explicitly contribute to GME.

I anticipate that there will howls of protest from the health insurance industry about having to pay their fair share of GME; many Republican lawmakers are likely to resist imposing a GME “tax” on health plans, and many Democrats will be concerned about even opening the door to any reduction in the federal government’s contributions to GME. But if we all benefit from having well-trained doctors, shouldn’t we all chip in? Why should taxpayers—and seniors enrolled in Medicare—be expected to pay almost the full freight?

And shouldn’t taxpayers, and others who contribute directly or indirectly to GME, have the right to insist that GME funds be spent more strategically, based on an assessment of the workforce that the country actually needs and the success of programs in producing doctors with the right skills and training?

Today’s questions: Do you think GME is a public good? Should all payers be required to contribute so that the federal government’s share gradually declines? Should training programs be accountable in how they use GME funds?

Thursday, September 1, 2011

Should the government be "non-consequential" in our lives?

The role of government will likely be the defining issue for the 2012 elections. GOP presidential candidates are trying to out-do each other by promising to make the federal government "non-consequential" as possible in our lives; President Obama continues to make the case that the federal government must play a role in regulating markets and providing help to Americans who can't make it on their own. Polls show that this is not a good time to make a case for government, with the public's trust in government hitting all-time lows.

Like so many other polarized issues today, the role of government has been framed as an either-or, yes-or-no proposition: you are either for "big government" or against it. But the fact is that the federal government already has a hugely consequential--and often positive--role in our lives, intervening in markets in a way that all but the most radical libertarians accept. The real debate is how much--not whether--the government needs to be involved.

Let me illustrate by describing my experiences with government over the past two days. I am writing this blog today from the combined ACP scientific meeting of the Wyoming, Alaska, South Dakota, and Nebraska chapters, held in beautiful Jackson Hole, WY. It is hard to find a more conservative group of "red" states than these four. I am here to talk to the 75 internal medicine physician attendees about the past, present and future of health care reform.

I'll come back to health care reform later in this post, but first, let's go back to Tuesday, when I headed to Dulles airport to catch my flight. The airport was built mainly--you guessed it--with federal dollars. The roads to the airport were paid for by the government. The safety of the airplane I boarded and the pilots who flew it were regulated by the federal government. The air traffic controllers who guided it safely to a wind-buffeted landing between 14,000 foot mountains surrounding the Jackson Hole airport are federal employees.

The cab I caught from the airport had seatbelts and airbag. I paid a bit more for the ride because of these federally-mandated safety features, just as I did for my own car at home. But I am glad to pay more to ride in a safer car, unlike the death traps that my parents drove me around in as a kid.

The airport is located in the spectacular Grand Teton National Park, and within 40 miles of Yellowstone, both owned and operated by the federal government (eminent domain, anyone?). We passed construction crews doing work on the parks' main highway. I imagine they are very happy to have work paid for by U.S. taxpayers.

We arrived in the town of Jackson Hole. Jackson Hole likes to think of itself as a rugged individualist Cowboy town, but its economy is almost entirely based on tourism associated with the national parks and the adjacent ski resort, located on national forest land leased from the federal government. The thousands of gift shop owners, tour guides, waiters, and bar-tenders would be out of work and out of luck if it wasn't for the federal government's presence in the local economy.

I went out dinner, and the steak that was served to me (great beef out here!) had to meet U.S. inspections and safety standards to reduce food-borne illnesses. My GI track is thankful.

The next day, I had to pick up a few toiletries from the local K-Mart. I walked through the store's pharmacy, and saw shelf after shelf stocked with OTC drugs regulated by the FDA, and of course the pharmacist behind the counter could only dispense prescriptions that meet the FDA's safety standards. Much better than the days when snake oil salesmen could sell vile and often toxic remedies from downtown Jackson Hole!

Oh, and right now, I write this blog connected from a PC connected to the Internet. The internet, you know, was created by federal research and development money. And when I speak to the doctors in a few minutes, I would wager that most of them had their graduate medical education paid for by the federal government, make much of their incomes from Medicare, and regularly prescribe drugs regulated by the FDA and avail themselves of medical research conducted by the NIH.

What does this have to do with health reform? Well, if we accept that the federal government has a necessary role in making sure that planes don't fall out of the sky or crash into mountains or each other, in ensuring the safety of the cars we ride in, in owning and preserving some of the most beautiful places on earth as national parks and forests, by buttressing local economies by the tourism created by these great spaces, by regulating the safety of food and drugs, by giving us the enormous benefits of federally funded research and development, then why shouldn't government have a consequential role in ensuring that all Americans have access to health insurance and regulating the worse aspects of the private health insurance market, like turning down people because they are sick? Government is necessary when unregulated private markets can't or won't protect or provide necessary benefits to the public on their own. Too much government can be bad, but too little government would leave us without the demonstrated benefits of having it involved in so many good and necessary ways in our daily lives. Just look at Jackson Hole, Wyoming.

Today's questions: Do you think the government should have an "inconsequential" role in our lives and in health care? If so, would you get rid of FDA, NIH, Medicare, and Medicaid? And can the private market really be counted on to ensure the safety of food and drugs, fund medical research, and provide access to health insurance? How?