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?


ryanjo said...

Some of these ACP proposals are quite good, both for the healthcare budget and physicians. As usual, the devil is in the details -- CMS has proven to be quite rigid when implementing past guidelines. Witness the near daily standoffs my patients face with Medicare D denials of their established meds -- the benign concept of "stepped care" turns malignant when CMS-supported PBM intransigence forces patients to repeat ineffective drug programs or ineffective meds. Would these new programs further undermine physicians individualizing patient care?

Without a doubt, these proposals will face an uphill fight, partially because of health industry titans who benefit from wasteful CMS payment policies, but also because our national physician leadership has been satisfied with half measures and patches (the SGR debacle). Only 12% of CMS' budget pays physician fees, and yet the legislators and cubicle-dwellers in Washington make us the first to be attacked. We need an organization that advocates our work. holds us accountable to our patients and doesn't make any more one-sided deals with Washington.

Steve Lucas said...

This is an excellent start. Ryanjo makes the point of the battle with entrenched entities who have gamed the system for their own benefit, while patients and doctors are left trying to navigate an ever changing system, designed to confuse at best, maximize revenue at worse.

An example of the current mind set is the Ryan budget. While it may not be the best concept it is a concept that should be taken seriously. The problem was not the specific criticisms but the general dismissal of what represented a start, and we need to start.

The ACP will certainly battle those who will find one small item that cost them revenue; imagings comes to mind, and use this as a lever to dismiss the whole concept. I hope the ACP pushes this forward, realizing the political cost.

Steve Lucas