Friday, February 15, 2013

Not in My Lifetime

An elderly doctor passes away, and he find himself standing before the Pearly Gates.  The Almighty greets him and says,  “In recognition of your stellar life of service to your patients, family and community,  I welcome you to paradise.  And because I know that doctors have a great sense of curiosity about all things, you can now ask me any question—any—and I will answer it.”   The doctor ponders for a moment or two,  thinking about all of the mysteries of the world, and comes up with the one question that has troubled him the most.  “Can you tell me, your greatness, whether Congress will ever get around to repealing the Medicare SGR?”   God hesitates for a moment, and responds, “Yes . . . but not in my lifetime.”

(A version of this joke has been around for years, only the question asked was whether Congress would ever enact universal health insurance coverage.  With the ACA getting us close to universal coverage, I thought that substituting the SGR would make for a more timely question for the good doctor to ask the Almighty!)

And after more than a decade of botched efforts, who can blame doctors if they begin to think that it will take an eternity—or longer, if that is possible!—for Congress to finally get around to repealing the SGR.   Year after year, they have seen the same tired script replayed.  CMS announces that the SGR will cut physician payments (by an escalating amount each year).  Members of Congress pledge that it won’t happen and that this will be the year when the SGR will be repealed.  You can believe us for sure, this time will be different, we promise you, wink, nod.   They then ask physicians not only for ideas on replacing the SGR  but also commitments (like agreeing to be measured on their performance).  Physicians dutifully offer serious proposals and commitments, Congress thanks them, then dithers for months, gets itself into a partisan spat about how to pay for SGR repeal, waits to the very last minute before the cut is supposed to go into effect ( and in some instances past the last minute, requiring a retroactive fix) and then finally—hallelujah!—passes something that averts the cut for a few months, or maybe a year or two (at best). 

And then we start the whole darn thing all over again.  If that isn’t the earthly equivalent of eternity, it is pretty darn close.

But maybe, just maybe, there is now cause for hope that this year could be different. 

First, the Congressional Budget Office cut in half its estimate of the cost of repealing the SGR, down from $244 billion to $138 billion (over ten years).   Yesterday, Glenn Hackburth, chair of the Medicare Payment Advisory Commission, told the House Energy and Commerce Committee that “In effect, SGR repeal is now on sale. But the sale may not last forever.”  (Still a lot of money, but with the new CBO numbers, it makes it easier for Congress to find a way to pay for SGR repeal.)

Second, for the first time in a very long time, there actually is a draft plan on paper to eliminate the SGR that has the support of congressional leadership.   The plan, offered by the Republican leadership of the two House committees with jurisdiction over Medicare, would eliminate  the SGR in three phases and begin to link future updates to physicians’ participation in quality improvement efforts or new payment models.

Third, Congress actually is talking about putting partisanship aside—imagine that, what an idea!—to come up with an SGR repeal plan.   Rep. Fred Upton (R-MI), chair of the House Energy and Commerce Committee, said his hope is to get a bill on the floor of the House by August, and that he would seek support from Democrats on a bill that could pass the Senate. Related, a bipartisan bill, the Medicare Physician Payment Innovation Act, to repeal the SGR, stabilize payments, provide higher updates for undervalued evaluation and management services, and  transition to new models was re-introduced by Reps. Allyson Schwartz (D-PA) and Joe Heck (R-NV).   The bill, which is strongly supported by ACP, is in many respects similar to the one proposed by the House committee leadership. 

Finally,  Congress is actually listening to the doctors!  The plans being floated directly reflect ideas offered by ACP, AMA, and more than 100 physician organizations—demonstrating an unprecedented degree of unity.

It still may require divine intervention for Congress to enact legislation to repeal the SGR, and I wouldn’t bet on it.  But at least for the first time in a decade there is at least a prayer of making some progress.

Today’s question: What do you think of the latest developments on the SGR?


PCP said...

Here are my observations on SGR.

Congress loves having this cudgel over our heads. Remember these are power hungry people above everything else, and they enormously enjoy that power over a vitally necessary and important service.
They also enjoy being able to force us to do X, Y and Z at each turn, why would they gove that up? You miss the point if you don't see that. We as a profession went from usual and customary to this cup in hand beggars.
So having got us right where they want us,, they started reasonably at first and now every whim and fancy of their liking. First, quality umprovement, then EHR, then Obamacare, then da da da, the list goes on and all while private practice withers on the vine. Eventually the goal of turning this once venerable profession into just another controlled, corporatised and employed one is accomplished.
They also enjoy the feeling of having amngst the most revered profession in society begging them at every turn, they like it so much sometimes they get us to do it 3 times a year. Oh the jollies of absolute power.
They understand all too well that the evolution to a situation where the public payer is now in excess of 50% of market share, and where private payers piggyback on medicare fee schedule and coding and payment system means they have a virtual rate setting bureaucratic monopolistic mechanism at their disposal. Ah, the power that comes with that.

Medical societies and lobby is the weakest and most splintered amongst the 'cost centers' in medicare ir Insurance, Hospitals and Pharma.
As a result of policies driven my ideology rather than in the professions business interest, Our professions standing has gradually eroded. Furthermore the internal divisions within the profession fostered by unfairly constituted AMA sponsored RUC and its RBRVU system have further diluted already woeful and self neglectful lobbying efforts. I've asked this a dozen times and am yet to hear an answer. When the balanced budget act was being signed into law 15 yrs ago, where was the outrage by organised medicne? Why did we not demand that SGR be imposed on Medicare A and later on Medicare D of it is on us? Where were the Ads, the opposition, the cry and ruckus.
If it is vital to control costs in B, surely it is just as important in A and D? Why do we not go after the absurdity of subsidies in Medicare Advantage at a time of deficit spending and to the detriment of relative medicare spending? Why were we singled out, and given the divergence of the payment curves to Hospitalv Doctors, was it not inevitable that as their pockets stabilize and ours shrivel, that Hospitals swallow us whole? Was it not evident that primary care would be first and eventually specialists?
Why is this trend further accelerated by the absurdity of differential payment rates for the same service based on location of service? Can you imagine any other industry in our country where this occurs?

Why were we banned from owning hospitals, yet hospitals allowed to buy up physician practices and interfere in all sorts of ways in clinical practice. I suppose conflict of interest oly works one way!
Why are we prevented from directly contracting with patients in the same tax advantaged way that employers and the insurance oligopoly enjoy. Heck even permanent HSA limits are now imposed in Obamacare.

Look Bob, you can say anything you want and ask why all you want. The point is results speak louder than anything. The advocacy on our behalf has been dismal as evidenced by the results. I ask all the doctors on this blog, is your practice environment better or worse than it was 15 yrs ago? What of the future trajectory? Bob, the way I see it, You and the ACP along with the AMA got some 'splainin to do. I don't anticipate that you see it that way, however I grieve at what has become of my profession under organised medicine's watch.

ryanjo said...

"... link future updates to physicians’ participation in quality improvement efforts or new payment models". As suspected, carrot and the stick approach. I hope that ACP is firmly opposed to politicians setting terms for paying physicians fairly.

"... the Medicare Physician Payment Innovation Act, to repeal the SGR, stabilize payments, provide higher updates for undervalued evaluation and management services, and transition to new models was re-introduced by Reps. Allyson Schwartz (D-PA) and Joe Heck (R-NV)." More helpful. The devil is in the details however -- "new (payment) models" has an Orwellian tone.

Steve Lucas said...

From the business guy: You will not have an SGR fix until you have a budget, and not having a budget is all about politics, not about good governance.

Steve Lucas

Jay Larson MD said...

PCP, I made the decision this year that I will no longer see any Medicare patients effective this summer. Over 40% of my practice will be looking for a new physician. Because we are so deficient in internists in town, my practice is already filling up with patients with private insurance. This was the only way that I could stay in practice beyond a couple more years. This game of chicken that Congress has been playing with physicians is pathetic.

Harrison said...

PPO's under pay compared to Medicare here in San Diego county.
Straight Medicare pt's are okay.
Now they may be even better because they are being put into the ACO mix and so if I can convince them to call me before running off to a test and visit heavy specialist the savings will be calculated by the ACO bean counters and I will get part of that.
It is however a number that is hard for me to track personally.

Patients who have switched to the HMO product we contract with are asking to see their cardiologist because his office called and said it was time to do so.
I have to be willing to go along with the referral.
The thing is though that the cardiology note from 2 months earlier was all about cholesterol lowering.
And the visit being requested is for review of cholesterol labs and meds.
Not only do I not think that a cardiology visit is needed for that, I am not sure a visit with a doctor at all is needed for that -- but instead just a phone call.

We charge too much and we test too much and we have set up expectations from our patients that we are doing more than we are.

We really need to be willing to have our practice patterns observed and changed.

Yes, we live in a free country and we are trained and we should feel free to practice as we choose.
But our patients have chosen to pay a third party for their medical care, and we have to live with the reality that that third party wants a profit because we defend that health care delivery model, and for them to get that profit they will be demanding proof of value to patients from us.
We have to work smarter in this model.

Choosing to select for only those patients who can pay will work for those who move early to do that, but it cannot work as an industry wide model.


PS: I'm not holding my breath for the SGR to be changed. It will continue to be a year to year issue for a long time. The Republicans lost the popular vote in the House but maintained control. They have set up the districts to allow them to gear their politics for people who are very far to the right. They face almost no threats from the left in their districts. They have no motivation to listen to nationwide popular majorities of even 75% or more on any issue.
It is hard to know where we go next, but the SGR fix is hard to imagine in this political environment.

ryanjo said...

Hmm -- so a motivation to make money by declining to authorize patient services is more ethical than making money by providing those services? And treatment by phone call...I don't remember that from my medical residency.

But that was years ago and the medical world is now catering to "ACO bean counters". After all, they have the experience & professionalism to do the best for our patients, don't they?

Harrison said...

In Medical Residency there was a lesson about having a perfectly stable patient come in every two months to discuss excessively repeated lipid lab values?

I guess I missed that.


Harrison said...


Not only am I certain that treatment by phone is something you learned in residency training, I'm quite sure it is something you practiced virtually every day several times while in training and that you have continued to do so since then.