Friday, March 13, 2015

The Primary Care Cliff

Just about everyone in Washington knows that the Medicare SGR formula is about to cut payments to physicians by 21% on April 1, unless Congress overrules it.  How many know, though, that primary care physicians are also facing a scheduled Medicare cut of 10% on January 1, 2016, unless Congress overrules it, which would be in addition to the SGR cut?  Not too many, I suspect.

If Congress allows Medicare primary care payments to be cut on January 1, it would be the second consecutive year when federal payments to primary care physicians—and only primary care physicians—would be cut by double-digits.  On the first of this year, Medicaid payments to primary care doctors were cut in most states by an average of 40%, because Congress failed to reauthorize a federally-funded program, called the Medicaid Primary Care Pay Parity program that, in 2013 and 2014, raised Medicaid payments for office visits, vaccines and other primary care services to no less than the applicable Medicare rates.

I call the potential combined impact of these cuts the primary care cliff:  scheduled (and in the case of Medicaid, actual) cuts in federal payments to primary care physicians being allowed to go into effect because of Congress’s inaction.

Oh, and there is another primary care program that could go off the cliff.  The National Health Service Corps (NHSC) provides scholarships and loan forgiveness to enable primary care physicians to be trained to serve underserved communities. The NHSC currently has a field-strength of over 9,000 clinicians and serves almost 10 million patients in underserved communities at more than 15,000 sites.  Yet without dedicated funding by Congress for the new federal fiscal year that begins on October 1, the NHSC will have to cease its operations.

How did we end up with a primary care cliff?

Well, Medicaid Primary Care Pay Parity and the Medicare Primary Care Incentive Program were both created by the Affordable Care Act, aka Obamacare.  Five years ago, Congress understood that if health insurance coverage was going to be expanded to tens of millions of Americans, then steps also needed to be taken to address the growing shortage of primary care physicians.  It reasoned, correctly, that low Medicare and Medicaid payments were creating powerful disincentives for physicians to enter and remain in primary care, and for Medicaid, creating powerful disincentives for physicians to see patients enrolled in the program.  This was a point that ACP continually pressed in our advocacy leading up to enactment of the ACA.  While Congress clearly didn’t do enough in the ACA to address the undervaluation of primary care, the decision to raise primary care Medicare payments by 10%, and to raise Medicaid payments to no less than the Medicare rates, were steps in the right direction.

But resistance in Congress to the ACA’s cost caused Congress to put a time limit on these two programs.  The Medicaid Primary Care Parity Program was funded and authorized for only two years, 2013 and 2014.  The Medicare Primary Care Incentive Program was funded and authorized for five years, 2011 through 2015.  Although ACP wanted both programs to get permanent funding, Congress decided that by putting a time limit on them, it would cause the Congressional Budget Office to come in with a lower “score” (cost estimate) on them,  and therefore a lower “score” on the overall cost of the ACA,  than if they were left permanent and open-ended.

Now, let’s fast forward to 2014.  ACP repeatedly pressed Congress to reauthorize the Medicaid Primary Care Pay Parity Program.  We helped persuade two Democratic Senators, Senators Sherrod Brown (D-OH) and Patty Murray (D-WA), to introduce legislation to continue it.  A House version of the same bill was introduced by Representative Kathy Castor (D-FL).  What we were unable to do was persuade any Republicans to sign on, and without Republican support—especially in the Republican controlled House—the legislation could go nowhere.

The reasons Republicans wouldn’t sign on were varied, but were mostly due to the fact that since Medicaid Primary Care Pay Parity was created by Obamacare, which they loathe and vowed to repeal, they couldn’t see their way to supporting a program created by it. Plus because many of them believe the Medicaid program is fundamentally flawed, they couldn’t see putting federal dollars to prop up its reimbursements to primary care physicians.

It is too early to tell how Republicans this year will feel about continuing the Medicare Primary Care Incentive Program.  We know it won’t be an easy pitch to persuade them to continue it, because it too was created by Obamacare.   But Medicare is far more popular with members of Congress, Republicans and Democrats alike, than Medicaid.  And there are many Republican voters—patients and their physicians —who stand to lose if the Medicare Primary Care Incentive Program is allowed to expire at the end of this year.

The National Health Service Corps received a huge infusion of federal dollars from Obamacare, but it pre-dates it by decades and has long had bipartisan support.  The NHSC website notes that “The NHSC was created in response to the health care crisis that emerged in the United States in the 1950s and 1960s.  Older physicians were retiring and young doctors started to choose specialization over general practice, leaving many areas of the country without medical services. . . Since 1972, the NHSC has connected 45,000 primary health care practitioners to communities with limited access to primary care. Currently, 9,200 NHSC members provide care to more than 9.7 million people in the U.S., regardless of their ability to pay.”  The prospects  for this Congress then to agree on a bipartisan basis to continue the program are pretty good, especially since it was not created by Obamacare, but hardly a given.

So what is ACP doing about the primary care cliff?  Yesterday, we released a new report, called Healthcare and the 114th Congress: A Dynamic Guide to the Top Issues Affecting Internal Medicine Specialists and Their Patients, which provides short—two page—explanations of six issues before Congress that will have the greatest impact on internists, and ACP’s recommendations on each.  In the top six were continuing the Medicare Primary Care Incentive Program,  restoring the Medicaid Primary Care Pay Parity Program, and ensuring funding for vital health care programs, including the National Health Service Corps.  Repealing  the SGR, ensuring sufficient funding for Graduate Medical Education, and continuing premium subsidies  established by the Affordable Care Act were our other three top priorities.  We also released a three page summary  of our recommendations on all six.

We recognize that getting Congress to agree with us on won’t be easy, especially in today’s hyper-polarized political environment.  But they represent the issues that we will be fighting for, despite the obstacles, because they are so important to our members and their patients.  We will need your help to explain to members of Congress, Republicans and Democrats, that driving primary care off the cliff is bad for patients, no matter what they might think of Obamacare.

Today’s question: What would you tell Congress about the primary care cliff?


Jay Larson MD said...

Those attending Leadership Day this year will have a lot on their shoulders. I have been watching the slow death of primary care for over a decade now. Even though the 10% primary care bonus and Medicaid parity may have slowed the dying process a bit, it surely has not turned the tides. Probably only about 5% of internal medicine residents go into primary care. This is down from over 50% when I completed residency in 1990. Over the past 20 years, Medicare has increased its conversion factor rate by about 0.5% per year. It is to the point that Medicare reimbursement no longer covers the cost of overhead of running a medical office. If SGR goes into effect and the primary care bonus goes away, Medicare payments will drop to levels not seen for decades. That may not be a bad thing for primary care in the long run. Our country has a tendency to respond to crisis. If Medicare and Medicaid rates drop, PCP’s would stop seeing Medicare and Medicaid patients. That would result in an uproar and maybe something would finally be done that would significantly improve the value of primary care. Otherwise the death of primary care will continue on its slow agonizing course.

Jay Larson MD said...

Correction, the medicare conversion factor has gone down in the past 20 years. In 1995 the conversion factor was $36.38 and in 2015 it was $35.90.

Unknown said...

Times have changed but have we?
In the issue of the Annals of Internal Medicine (January 3, 2006) a paper authored by officers of the American Board of Internal Medicine (ABIM) and the American College of Physicians (ACP) entitled
“Who Is Maintaining Certification in Internal Medicine—and Why? A National Survey 10 Years after Initial Certification” attributed the decrease in rates of general internists seeking to maintain certification related to a decrease in their numbers leaving for other occupations. An accompanying editorial in that issue recognized a developing crisis in primary care.
Well, the crisis has arrived. As a general internist it was then apparent to me as financial pressures led to the creation of hospitalists who rapidly replaced us in the hospitals.
How can we be relevant when we are unavailable to our patients' when they need us most?
We are told now that even with the best results in solving the SGR incomes for primary care internists would increase at an annualized rate of 0.5%. This is considerably less than the projected rate of inflation. Forget about Medicaid, when I last checked we were called “providers” not philanthropists. We cannot write off our losses on 501 c 3 form 990s.
It is a tragedy that the ABIM Foundation, ACP Foundation and others were sponsoring politically correct manifestos “Medical Professionalism in the New Millennium: A Physician Charter “ that ignored the individual patient and physician and diminished the worth of this relationship .
The officers of these cabals cheered from the sidelines as the (Un) Affordable Care Act led to further decimation of the careers and finances of its members as Hospitals, Health Plans and Big Pharma cut themselves deals.
Position papers from the ACP, AMA and others are near worthless and meaningless.
In the Annals of May 2006 I had a letter published. I am deeply saddened that I correctly predicted the future “Academic medicine is the carpenter that fashioned the coffin of internal medicine. Instead of reengineering internal medicine to accommodate change, it cannibalized the discipline by reducing its worth, creating the hospitalist and ambulatory care internist. These were both nails that helped seal the coffin; the former reduced the influence of the internist in the acute care environment, and the latter blurred distinctions between internists and those without medical degrees who practice in ambulatory care settings.
Medical sub-specialties that are nurtured in the ivory towers of academia have further reduced the stature of the internist. Effective lobbying by their affiliated societies and by commercial manufacturers of the medical devices they use assured them disproportionately higher reimbursement than that of their generalist colleagues. Absent an identity, the internist's only remaining role is thought to be that of provider of ambulatory care to the chronically ill whose medical problems are beyond procedural intervention and lucrative compensation.
A continuing decline in professional stature and income, when coupled with deteriorating working conditions, makes the continued existence of internal medicine untenable. I am pessimistic that current political and professional interests will allow significant change to resuscitate internal medicine. Would it then not be opportune to draft an obituary for internal medicine and commission a requiem to its memory?”
“What would you tell Congress about the primary care cliff?”
I would answer that they created lemons or should I say lemmings?

DrJHO7 said...

In our state medical society, the folks who serve on the legislative committee have commented that the state legislature will not enact pro-physician legislation until there is "blood in the streets." Our state is just north of the middle of the pack re: access to care for mcr beneficiaries. Our senators and representative in DC know this, and they don't sense an access issue - yet. They are also comfortable re: the issue of re-election, so despite being sympathetic to the cause of physicians, they don't feel pressure - yet. The cms "primary care bonus" is no longer a bonus. It is simply viewed by the physicians who operate in this mode as income: necessary to operate our practices, and at least for me, to remain in practice. MCR is my best payer. The commercial payers in my area have sunk below mcr re: reimbursement by several % and will continue to do so as long as they can get away with it. So, when my best payer, responsible for more than 1/2 my practice volume, cuts my revenue by 10%, I will close my practice. The guys in DC, might say, "too bad, but he'll take a job with a bigger group, so we won't lose him as a provider, a PCP...". Really?
How many PCP's will take an additional 2% hit for not attesting for MU-2?
How many will take yet an additional 2% penalty for not submitting for PQRS/VBP? This is what our medical practice is becoming: operating under the threat of penalty for government mandates of time consuming activities that detract from our personal and professional lives, and that lack relevance and don't accomplish anything that is substantially meaningful.
MOC was really not the problem, just an expensive inconvenience. This other stuff: is. Add in a 10% revenue cut - that pushes us over the cliff, without a parachute.

PCP said...

Markets have a way of finding their own solutions, if allowed to do so, by now the market signals for primary care physicians would have been screaming incentives. The fact that they are not doing so is teatament to the power of gov't force and inventiveness in dropping standards.
Gov't are often the only force capable of standing in the way odd market forces, but only to a point, history shows us that eventually the dam always breaks.

Dr Larson's post effectively illustrates the pitiful sub-inflationary fee adjustments that have been given to physicians in general, but with less high paying and volume scalable procedures, General Internists have felt the brunt of the impact.
The results also speak to the impotence of our lobby in representing our profession, all whilst preaching idealism such as universal access to an ever withering herd of front line primary care practitioners.
The end result of all this is that if that is the only price that the gov't is willing to pay, then the business model of a General IM practitioner is irreparably broken.
The void will certainly be filled, rest assured. And the access issues will be masked. But as in other socialist systems it will be filled with less than optimal solutions. Our system is devolving from a fee for service doctor patient centric one(pre medicare), to now a quasi gov't controlled, price fixing bureaucracy, with stifling regulation, whose participants are hassled and threatened by force from gov't.
Anyone else see shades of Nicholas Maduro's decree that grocers sell basic food items for x price calculated on a falsely maintained currency rate?
The void in this country is likely to get filled with armies of nurses and PAs armed with white coats, protocols and smiles. Some might even call themselves Doctors(of nursing of course). We all intuitively know the flaws in that model done wrong, but alas that is the way the void will get suboptimally filled.There will be other things as well like obscenely reimbursed (on a cost based basis) CHCs, FQHCs, IHS, etc etc. and the hospital based/owned clinics with their higher reimbursement rates will expand, all of these 'solutions' will grow significantly over time and fill the void created. It will not at all be cost effective, but who cares. It will all be called 'primary care' and ACP and Mr Doherty will then claim to represent their interests, but gone will be the days when a general internal medicine physician would take the personal responsibility for the longitudinal care of a patient for years, knowing them well and saving the system countless dollars through thoughful testing, decreased referrals, sensible early diagnosis, good coordination, thoughtful after hours advise, and carefully discussed and planned end of life care from a trusted figure, and countless other ways.
The sheeple will not know better as this change will happen imperceptibly and very slowly, very similar to how they boiled the primary care frog with sub-inflationary adjustments to our fee schedule starting 18 yrs ago.
As they did while imposing no SGR on Medicare A, C, or Subsequently formed D. Such is the uselessness of our lobby that even when isolated for a kicking they went along.
And now we discuss the primary care cliff! I have concluded a few years ago that an abrupt 20 or 30% cut will not be a bad outcome for general internist in the long run and therefore to restore its presence in substantiative numbers. Like Mr Eastwood says'go ahead make my day'.
It will perhaps force those like my friend Harrison to rethink their approach and trust in gov't.

Harrison said...

Hey, Wait
I didn't even comment on this post.
Leave me out of it.