Friday, April 20, 2012

Walking the Walk

Talking the talk about lowering health care costs is easy, walking the walk—not so much. But today the nation’s largest physician specialty organization—the American College of Physicians—released a plan to achieve big savings in Medicare while also improving outcomes for patients. The plan, released at a press conference held in conjunction with ACP’s annual scientific meeting in New Orleans, proposed major restructuring in Medicare pricing, payments, benefits and delivery systems to achieve better value for patients and taxpayers. ACP hopes to set an example for politicians and other advocacy organizations who talk about controlling costs, but aren’t willing to walk the walk by putting any serious proposals on the table.

How does ACP propose to reduce spending while achieving better outcomes?

Allow Medicare to consider the comparative clinical effectiveness and cost of different treatments and diagnostic tests in deciding what it will pay for.

Give beneficiaries some skin in the game by allowing cost-sharing contributions to vary based on evidence of clinical effectiveness and cost, so that they would pay little or nothing out-of-pocket for services of high value, and more for services of lower value.

Cover and pay for advanced care planning and palliative care.

Allow Medicare to get the best prices for drugs by acting as a prudent buyer, just like the VA does for its programs, but Medicare is prohibited by law from doing.

Begin to pilot test ways to adjust the pricing of physician services based on evidence of clinical effectiveness, so that doctors might be paid more for services that have more value to their patients and less for ones of lesser value.

Reward and strengthen primary care, which studies show is associated with better outcomes at lower cost. Pay for models, like Patient-Centered Medical Homes, where internal medicine specialists and other primary care physicians would work with teams of other health professionals to improve care coordination and achieve better outcomes for their patients—with accountability for achieving the desired results.

In other words, allow Medicare to do what any good business or government purchaser of services would do: purchase care that has been shown to deliver the best bang for the buck.

Common sense, you would think, but ACP’s proposals will invite controversy because much of the health care industry benefits from the status quo. If you are a physician who is doing just fine because Medicare pays you more than its services might be worth to the patient, you won’t want change. If you are medical device manufacturer that is doing just fine because you can get Medicare to cover the fanciest and newest diagnostic test without having to show that it offers any real value over existing and less costly alternatives, you won’t want change. If you are a drug manufacturer that is doing just fine by charging the federal government and patients a lot more than you would get if you had to competitively bid for Medicare’s business, you won’t want change.

But for internal medicine specialists and their patients, change is needed because the status quo is not working. You are not being paid commensurate with your value. You are not paid for things that can improve outcomes and save money, like advanced care planning and care coordination of high-risk, high-cost patients. You and your patients are not benefiting when hundreds of billions of dollars are wasted each year on things that have little or no clinical value or are overpriced, money that could be used to shore up support for primary care internal medicine and cut the deficit.

Some controversial ideas to save Medicare money have not earned ACP’s support, because they would shift more costs onto the backs of seniors who can’t afford to pay more. So in the position paper released this morning, ACP reaffirmed its opposition to a Medicare premium support model, unless and until well-designed pilot tests are done to determine the impact of premium support on patients’ access and out-of-pocket costs, adverse selection, and other factors.

Making seniors wait until age 67 instead of 65 to qualify for Medicare also didn’t make ACP’s cut, because this will just lead to more uninsured seniors—although some of them would end up on underfunded Medicaid programs—unless they are provided other affordable coverage options during the two more years they would have to wait for Medicare. For instance, ACP suggested that advancing the age of Medicare eligibility could be accompanied by allowing anyone over the age of 55 to buy into Medicare, with subsidies for lower-income persons, bringing more younger and lower-risk, lower-spending persons into the program while providing a coverage bridge until they reach age 67.

By walking the walk on proposing ways to lower Medicare costs while improving outcomes, ACP will get its share of abuse. I have no doubt that someone will try to pin the "rationing" label on us, even though there is a huge difference between spending money rationally by taking into account value to the patient—ACP’s approach—and denying access to services that actually have been shown to have value because the government doesn’t want to pay for them, the true definition of rationing.

But someone had to take the issue of unsustainable Medicare spending head on, and I am glad it is an organization of internal medicine specialists, because doctors more than anyone else have the credibility with the public, and the understanding of where our health care dollars are going, to make a real contribution to enlightening the debate on health care costs.

Today’s question: What do you think of ACP’s proposals to reform Medicare in an age of deficit reduction?

Friday, April 13, 2012

"You say you want a revolution, well you know, we’d all like to see the plan"

Many skeptical doctors react to the mantra about revolutionizing health care delivery the same way John Lennon did when he wrote these lyrics for the 1968 Beatles anthem. Well you know, they’d all like to see the plan.

Well, you know, this week Medicare released two critical pieces of its plan to revolutionize health care delivery, naming the 27 medical organizations/groups selected for Medicare’s Shared Savings (Accountable Care Organization) program, and the geographic sites chosen for the Comprehensive Primary Care Initiative. (As I blogged in September, the Comprehensive Primary Care Initiative could be a game-changer for primary care, because it will provide sustained financial support and revenue opportunities from Medicare and private payers for participating practices.)

The Innovation Center’s announcements this week effectively counter two pernicious myths about the Affordable Care Act and physicians:

Myth # 1: That the government is trying to put independent physician practices out of business.

Myth # 2: That the government wants to put hospitals in control of physicians.

Actually, a majority of the organizations selected for the Shared Savings Program are "physician-led," as the AMA noted in praising the CMS announcement. But you don’t have to take the AMA’s (or my) word for it: just look at the descriptions from CMS and the physicians themselves of several of the 27 organizations who voluntarily agreed to join the Shared Savings Program:

The Atlantic Integrated Health Network "is one of the oldest self-sustaining physician-led networks in North Carolina."

The Coalition of Athens Area Physicians "represents 300 independent physicians from Athens, Georgia and surrounding counties."

Mississippi Coast Physicians "was founded by community physicians to offer accessible, cost effective and high quality healthcare services to employers and healthcare consumers along the Mississippi Gulf Coast."

North Country Physicians Organization "is a physician organization of 160 physicians" in upstate New York.

The Independent Physicians Network is "a Physician managed and controlled medical delivery network established in 1984" in the Milwaukee, WI community.

Accountable Care Coalition of Texas, Inc. is "an ACO created through a partnership between an affiliation of Independent Physician Associations, medical groups and health systems in the Houston/Beaumont area of Texas and Collaborative Health Systems."

"Owned and managed by physicians, AppleCare Medical ACO partners with more than 800 physicians in the region, as well as major hospitals and medical centers across Southern California to provide access to a full spectrum of facilities for receiving whatever care a patient may require."

"Located in Buffalo, NY, Catholic Medical Partners is a network of more than 900 independent practicing physicians."

"Coastal Carolina Health Care, the ACO’s sole participant, is a physician-owned and operated medical practice with over 50 providers."

There’s many more physician organizations in the 27 ACOs selected by CMS, but I think you get the point: physicians are the ones who will be leading the ACO revolution, through physician-controlled and owned organizations, ranging from tightly integrated group practices to looser coalitions and networks of independent smaller practices. The Comprehensive Primary Care Initiative will soon provide an opportunity for another 500 or so physician practices to lead the transition to the Patient-Centered Medical Home model, supported but not controlled by Medicare and other payers.

Well, you know, this is the way it should be: ACP has long argued that physicians are uniquely qualified to achieve the triple aim of better individual patient health outcomes, better population health, and lower per capita costs—not the government, not the hospitals, and not insurance companies. It is good to see this is Medicare’s plan as well.

Today’s question: What do you think CMS’s announcements say about its view of the role of independent, physician-owned organizations in revolutionizing health care delivery?

Friday, April 6, 2012

Overturn the ACA, and chaos will follow

Imagine you’re a physician, and you have a full schedule of patients to see the day after the Supreme Court has thrown out the entire Affordable Care Act. Imagine you never liked “Obamacare” in the first place, so you are feeling pretty good about the Supreme Court decision.

Your first patient, an elderly retiree named Mrs. Jones, comes in for her annual Medicare wellness visit—one of the new Medicare preventive benefits offered at no cost to the patient. But this new preventive service benefit was created by the ACA, so presumably with the ACA overturned, Medicare no longer is allowed to pay for wellness visits. Do you tell Mrs. Jones that Medicare might not cover the visit? Provide the visit anyway, hoping that somehow Medicare will find a way around the Supreme Court ruling and pay for it? Offer it at no charge, or try to collect the 20% you would collect for a normal (non-preventive) office visit? 

Your second patient, Mr. Jones, another senior, comes in for a follow-up visit for an ongoing chronic condition. You decide to renew his expensive brand-name prescription drug, knowing that he is eligible for a 50% discount because he has fallen into the Medicare Part D “doughnut hole.” Oh wait ... the Medicare Part D drug discount was part of the now-defunct ACA. So does that mean he now has to pay full price? Do you prescribe the drug anyway, knowing he can’t afford to pay the regular retail price? Prescribe a lower cost no-name brand drug that he doesn’t tolerate as well?

Your billing person prepares to submit the claim for Mr. Jones’ office visit. It ordinarily would have been eligible for the 10% bonus that Medicare pays for all office visits, nursing home and custodial care visits provided by primary care physicians. But that was before the Supreme Court overturned the ACA, and with it, wiped out the primary care bonus created by the law. With the bonus gone, your practice will lose about $4,000 over the next six months. Does the bonus disappear immediately—with this visit? What happens to bonus payments that were already paid out? Who knows?

Next up is Ms. Wilkins, a single mother of three who is seeing you for her diabetes and congestive heart failure. She is fortunate enough to be among the 50,000 Americans enrolled in the low-cost Pre-existing Condition Insurance Plan created by the Affordable Care Act and administered by the state. Oh wait, that was until the Supreme Court decision. With the ACA gone, the authority and funding for the Pre-existing Condition Insurance Plan disappears. Will she still be covered for this visit and any tests or medications she needs? And if so, for how long before the program is forced to shut down? Where else will she find affordable insurance? Will she go without it? Who knows?

A text message comes into you from your 22 year old son, a recent college graduate who hasn’t found a job. He has a doctor’s appointment for the knee he hurt playing rugby, and wants to know if he still will be covered by your health insurance plan. But the requirement that young adults up to age 26 be covered by their parents’ plans was part of the ACA, so presumably, your health plan no longer is obligated to keep him. Will it drop him? If it keeps him on, for how long, and for what extra premium? 

You start thinking about your oldest daughter, a fourth year medical student who plans to apply for a loan repayment program from the National Health Services Corps in exchange for providing primary care in an underserved community. But the funding for NHSC in 2012 comes entirely from dollars mandated by the ACA. Will the NHSC now have to cut back on its award amounts and recipients? When, and by how much? Will she no longer be able to get a NHSC slot?

Your practice has joined with other primary care physicians in the community to become an accountable care organization (ACO) under the Medicare Shared Savings Program. It has spent tens of thousands of dollars and countless hours to do the planning and set up the infrastructure to qualify. But the federal money to pay for the Shared Savings Program comes from funds obligated by the ACA, so with the ACA gone, the ACO program may be suspended as well. Does that mean your practice wasted all of that money preparing to become an ACO?

Your local medical school has applied for Title VII primary care grants for faculty and scholarships for low-income students—the only federal program specifically designated to support primary care training. But the Title VII grant program was part of the ACA. Does that mean that the grants will be suspended? Who knows?

Your hospital expanded its internal medicine residency program because of a provision in the ACA that redistributes unused residency slots in other specialties to primary care. Who will pay for them if Medicare can’t? Will the slots have to be eliminated?

I could write pages and pages more of programs created by the ACA that would be invalidated if the Supreme Court overturns the whole law. What I can’t tell you—what no one can tell you—is how the federal government will deal with the absolute chaos that will follow.

Rules will have to be withdrawn and re-written, contracts suspended, agencies closed down or downsized, agreements renegotiated, delivery reform pilots terminated or scaled back, and mandated insurance protections suspended—with little guidance from the Supreme Court or Congress on what to do next. And there’s almost no chance that Congress will step in to repair the wreckage.

In the meantime, physicians and patients will be left reeling by the resulting chaos and confusion created by the court’s decision.

I haven’t even mentioned the 32 million Americans who would have gotten coverage in 2014 if the law was sustained—but will lose the most if the court overturns it. 

Henry Aaron, a renowned health care expert at the Brookings Institution, also predicts chaos if the Supreme Court overrules the law:

“And what if the Supreme Court throws out the whole bill?

That would leave America, including the nearly 50 million uninsured, even worse off than we were four years ago: with higher costs, more uninsured and a political atmosphere poisoned by the failure of an all-out effort to reform a health care system everyone knows is flawed.

Health insurance costs, driven by the steady march of new technology and population aging, will claim ever larger shares of our income. Those higher costs will make health insurance unaffordable for more and more people.

It would be hard to imagine any President or Congress returning for a generation to touch the endless political grief of basic health care reform with a ten-foot pole.

Is that the future we want?”

Today’s questions: What are you going to do to prepare for the chaos that will happen if the Supreme Court overturns the entire Affordable Care Act? Is that the future we want?