Friday, September 11, 2015

September 11 reflections

Today is a day for remembering and reflecting on what happened on that terrible day, 14 years ago, when terrorists killed and injured thousands of Americans.   As time goes on, memories will fade, witnesses will pass away,  and there will be fewer first-hand accounts, not just of what happened, but how it felt—just like there are so few left that remember the “date that will live in infamy” when the Japanese attacked Pearl Harbor.  I think  this explains why so many of us who remember 9/11, especially who were in New York City and Washington DC when the attacks took place, feel it is necessary to document what we saw and felt, adding our own small piece to the historical record while we can.  A few years ago, I posted an account in this blog on what I saw and felt on that terrible day, excerpted below:

 I remember Washington the way it was on the day that our nation was attacked. I remember listening to my car radio on the way to work, and hearing that a “small” plane had collided with the Twin Towers in my home city of New York. I remember gathering with my co-workers to watch the event unfold on TV. I remember going to the roof of our office building to watch the smoke rising from the Pentagon. I remember hearing that another hijacked plane was heading to Washington, maybe to the White House, only four blocks from our office, an intended missile that never came to us because we later learned that it was brought down by courageous passengers in rural Pennsylvania.

I remember hearing rumors of more attacks—bombings at the State Department, in Metro subway stations, rumors that were not true, but we didn’t know that then. I remember not knowing what to tell our employees to do—go home, stay in the office until we got further word? Nothing in my training had prepared me for my city being under possible attack. I remember the traffic gridlock as millions tried to flee. I remember the eerily empty streets of DC, many hours after the traffic finally cleared and people hid in their homes.

I remember the helicopters endlessly circling the city. I remember days later, when we were able to return to work, seeing the intersections of the nation’s capital patrolled by tanks and National Guards troops with automatic weapons, something I never expected to see in my life. And I remember a few days later, taking Amtrak to an ACP chapter meeting in Connecticut, looking out the window as we passed Manhattan, and seeing through my tears the smoking, gaping hole where the World Trade Center once stood.

And I remember trying to make sense of the senseless to my young children, trying to reassure them that they were safe when in my heart I was never sure we’d ever feel safe again.

Much has changed in the years since, but in a world where terrorism remains a threat here and abroad, and where mass shootings have become an almost weekly event in the United States, I must still question if we’ll ever truly feel safe again.

Today’s question: What are your reflections on September 11, 2001?

Wednesday, September 9, 2015

ACP to Medicare: Pay internists better!

This is, in a nutshell, what ACP told the Center for Medicare and Medicaid Services (CMS) in a 47-page comment letter on the agency’s proposed rule for the 2016 Medicare Physician Fee Schedule.  Of course, it wouldn’t be effective for ACP to just say that its members should be paid more; we would have to show the agency why (the value to patients) and how (what changes specifically need to be made) to improve Medicare payment policies.

Among its many recommendations, ACP:

- Called on CMS to expand the Comprehensive Primary Care (CPC) Initiative both to additional geographic regions, as well as in existing CPC initiative areas.  The CPC initiative, a Medicare-funded pilot test of the impact of advanced Patient-Centered Medical Homes on quality and cost of care, is currently limited to approximately 500 practices in 7 market areas.  These practices are receiving a risk-adjusted average of $20 per Medicare patient per month, in addition to their usual Medicare fee-for-service payments, and they have the opportunity to share in savings to the program if they can reduce costs while maintaining or improving quality. The College believes that there is sufficient evidence of its effectiveness in improving quality and/or achieving savings to support making it widely available to beneficiaries and practices across the country.  ACP recommended that CMS seek out agreements with other payers in additional regions of the country to join with Medicare to support practices that wish to participate in the CPC initiative, and to open up participation to more practices in the current CPC initiative regions.

- Supported CMS’s proposal to allow Medicare reimbursement for advance care planning services. While this proposal is an important step to improve care for Medicare patients with serious illness, ACP urged that reimbursement for advance care planning be made uniformly available to all physicians and their Medicare patients through a national coverage determination, rather than leaving it to each regional Medicare carrier to decide whether to cover the service.

- Urged CMS to reduce barriers to physicians getting reimbursed for the Chronic Care Management (CCM) Code and allow reimbursement for CCM services that require additional time.  ACP recommended that CMS develop add-on codes for time increments greater than 20 minutes such as 21-40 min; 41-60 min; and greater than 1 hour.  ACP also recommends that the electronic care plan sharing requirement for providing the CCM service be suspended until the time that EHRs have the ability to support such capabilities.

- Encouraged CMS to use payment approaches that are aligned with the goal of moving payments away from volume to value-based care such as by exploring bundling of codes for certain chronic diseases. More specifically, ACP recommended that a code bundle for Diabetic Care Management (DCM) be developed to emphasize better care coordination, communication, and integration of the care team aimed at a better overall outcome cost of care for the Medicare beneficiary.

- Supported CMS’ recognition of the need to value the delivery of behavioral health services within the Physician Fee Schedule.  ACP recommended that the “collaborative care” model described in the proposed rule be implemented through a Center for Medicare and Medicaid Innovation (CMMI) demonstration and be rapidly expanded within Medicare through the Secretary’s authority based upon the results of this demonstration.

- Recommended that CMS investigate the adequacy of payment for physician services that typically take place outside of a face-to-face patient encounter. The College urged CMS to recognize non-face-to-face services-- such as telephone and email consultations-- that facilitate care coordination by internists and other primary care physicians.

ACP ‘s letter also offered comments on:

- Additional specific coding issues, such as Practice Expense (PE) determination, moderate sedation valuation, and surgical global periods.
- Physician Quality Reporting System (PQRS)
- The Value-Based Payment Modifier and Physician Feedback Program
- Physician Compare
- The Medicare Shared Savings Program (MSSP)
- Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging Services
- CMS’s request for comments on issues relating to the  Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) implementation

ACP’s comments were the result of countless hours of analysis by the College’s regulatory affairs staff, and from the volunteer physician leadership on its Coding and Payment Policy Subcommittee, Medical Practice and Quality Committee, Subspecialty Advisory Group on Socioeconomic Affairs, and the ACP representatives to the RVS Update Committee (RUC).

So when someone says the College doesn’t do anything to advocate for its members, or that we care “only” about the big and controversial policy issues like immigration and health, reducing harm from firearms, and LGBT healthcare disparities, it just isn’t so.  While we do care deeply about -- and are proud of our advocacy on -- issues that directly affect individual and population health, we devote at least as much of our advocacy resources and staff to improving the economic and regulatory environment for our members—proudly and justifiably so!

Today’s questions: What do you think of ACP’s recommendations to improve Medicare payments for internists’ services?  What would you recommend?