PNHP

Obamacare and Its Discontents

Obamacare and Its Discontents

Steven Brill’s new book outlines the shortcomings, as well as the accomplishments, of President Barack Obama’s Affordable Care Act

By A.W. Gaffney, M.D.
In These Times, March 25, 2015

Promising new treatments and technologies abounded, but the rising cost of healthcare was squeezing the finances of families throughout the nation. A research group — the Committee on the Costs of Medical Care — was assembled to study, and perhaps change, healthcare financing and delivery in the United States.

The year was 1927, but the Committee’s final report, released five years later, remains quite timely. “There needs to be some plan,” the report stated, “whereby the unequal and sometimes crushing burden of medical expenses can be distributed.” The report presciently acknowledged the dangers of what was a new phenomenon, the commercialization of healthcare: “The danger which physicians and dentists fear, namely that lay groups organized for profit will control medical practice, is a real one.”

These two very much intertwined problems — high healthcare costs and medical profiteering — have only become more pronounced. They are also the concerns of Steven Brill’s bestselling new book, “America’s Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System.”

Brill — a journalist, lawyer and founder of numerous media ventures — burst onto the healthcare reform scene in 2013 with an explosive exposé in Time that painstakingly demonstrated the wreckage inflicted by massive itemized medical bills on some very unfortunate uninsured and underinsured people. His new book traces the emergence, travails, accomplishments and shortcomings of Barack Obama’s Affordable Care Act (ACA). His reporting on the “backroom deals” that helped sculpt the ACA provide a valuable illustration of just how much influence the “medical-industrial complex” has accrued.

For the pharmaceutical industry, the stakes were high, particularly as some Democrats were talking about allowing Medicare to negotiate with drug companies over prices (which is what the rest of the world does already). Brill describes how a deal was ultimately hashed out in meetings between industry lobbyists, Max Baucus’ Finance Committee staff and the administration. “[My] five principal CEOs,” he quotes from a note written by head pharma lobbyist Billy Tauzin to a White House staffer, “have accepted the terms we discussed with the Committee yesterday.” Those terms, not surprisingly, did nothing to substantially contain astronomically high U.S. drug prices.

Brill stumbles, however, in his prescriptions for the future. As Brill describes, a historic consolidation of the healthcare industry into large, integrated, regional systems is underway, and some evidence has already demonstrated that such consolidation carries the peril of monopolistic pricing. His solution is to accommodate this trend toward “branded, integrated and regulated oligopolies” and also to heavily regulate it, while at the same time encouraging these systems to cut out the middleman and become insurers themselves (which some have done already). Through greater administrative simplicity, redefined provider incentives and a cap on profits, Brill envisions huge potential savings.

Unfortunately, insurer overhead (which his plan would not eliminate) is only one part of the massive administrative waste of the U.S. healthcare system. In reality, the only system that could achieve profound administrative savings would be one in which hospitals receive a “global budget” from a single governmental payer to cover all operating expenses for all patients.

Because healthcare organizations would be both the payer (insurer) and the provider in Brill’s plan, he argues that they would no longer have a profit incentive to overtreat — i.e., offer patients unnecessary tests and referrals. However, the notion that we can dramatically reduce healthcare expenditures by suppressing this “fee-for-service” incentive is itself an oversimplified, if happily bipartisan, dogma. No doubt there is overtreatment in the U.S. system, but there are also areas where Americans use comparatively less healthcare. In a recent survey of 15 developed nations, the U.S. had the highest rate of MRI scans — but it also had the second lowest number of annual doctor visits per capita, and the fourth lowest number of per capita hospital discharges.

In an era when the insured are facing rising out-of-pocket health expenses — up to $13,200 a year after premiums for family plans bought on the ACA exchange — I worry far more about all of the families who sacrifice needed care because of the crushing financial burden of high deductibles and copayments. Brill’s own reporting reveals the problem of out-of-pocket exposure to healthcare costs, but it is unclear if his proposal would do anything about it, much less eliminate it.

At times, Brill implicitly accepts the premise that a public, fully universal, single-payer program might be the best cure for what he calls the “toxicity of our profiteer-dominated healthcare system.” But he is resigned that such a system is simply “never going to happen.” I wonder if fundamental change could be achieved more easily if those with powerful voices, like Brill, were a bit less confident in drawing the boundaries of political possibility, and more willing to join in efforts to expand them.

A.W. Gaffney is a physician and a writer on issues of healthcare policy, politics and history.

http://inthesetimes.com/article/17765/obamacare-and-its-discontents

Boehner: H.R. 2 begins the process of entitlement reform

Debate on H.R. 2, “Medicare Access and CHIP Reauthorization Act of 2015”

United States House of Representatives
C-SPAN, March 26, 2015

Speaker of the House John Boehner:

We expect to end the so-called doc fix once and for all. Many of you know we’ve patched this problem seventeen times over the last eleven years, and I decided about a year ago that I had had enough of it. In its place we’ll deliver for the American people the first real entitlement reform…

Today it’s about a problem much bigger than any doc fix or any deadline. It’s about beginning the process of solving our spending problem, and it’s about strengthening and saving Medicare which is at the heart of that problem. Normally we’d be here to admit that we’re just going to kick the can down the road one more time. But today, because of what we’re doing here, we’re going to save money 20, 30, 40 years down the road. …

We can’t become complacent. We’ve got more serious entitlement reform that’s needed. It shouldn’t take another two decades to do it, and frankly I don’t think we’ve got that much time. But I’m here today to urge all of our members to begin that process, and the process begins by voting yes on H.R. 2 today.

http://www.c-span.org/video/?324978-1/us-house-medicare-payments-doctors&live

Comment:

By Don McCanne, M.D.

H.R. 2 passed in the House today by a vote of 392 to 37. It goes to the Senate where it will be voted on tomorrow. But is this really about the “doc fix” – eliminating SGR? Speaker of the House John Boehner clarifies that for us. It’s about entitlement reform and H.R. 2 begins that process.

Entitlement reform…

The Importance of Health to Life, Liberty, and the Pursuit of Happiness

By Anna Zelivianskaia, MS3
AMSA On Call Blog, March 25, 2015

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” – Martin Luther King Jr.

Health care is not listed as a basic human right in most constitutions, including our own. Yet I suspect the majority of citizens of any country would agree with the Rev. Martin Luther King Jr.’s statement. Most people rightly believe that access to health care is implied in the social contract. It certainly is for citizens who live in countries with single-payer medical systems. However, why is healthcare an implied human right? Besides the intuitive feeling that as a future physician, I should care for anyone who walks through my doors, I could not explain why healthcare is so transparently intertwined with justice and citizenship.

In a broad sense, what are the basic human rights? The knee-jerk answer from the American experience is life, liberty, and the pursuit of happiness. The Bill of Rights reflects these principles: freedom of speech and the right to bear arms fall under the “liberty” category; fear from excessive bail and unusual punishment allow for the pursuit of happiness. Yet, as I tread further into my medical training, I realize that health care is interchangeable with the right to life. Preventing a person from accessing the medical system is condemning them to death.

I am currently on the general medicine wards — the bread and butter of a medical student’s training. As I started the roller coaster of inpatient care, I expected long hours, difficult patients, and even spending a substantial amount of time documenting my every move. What I did not expect was talking about medical insurance ten times a day. When my team creates and fine tunes a care plan, we constantly have to check what insurance the patient is on, if our hospital is in network, and which hoops we need to jump through for a specialist referral. And that is for the patients who actually have insurance. Even at a state hospital, like ours, which is genuinely committed to serving the under-served, the majority of patients who do not have insurance do not make it through our doors.

Just like any other hospital, there are times when we cannot provide a particular medication or service to a patient because the patient’s insurance prohibits it. Recently another student asked what happens to these patients. Apart from the momentary frustration I feel every time we have to limit someone’s care, I had not really thought about it. I assumed patients who are denied care would get it somewhere else. Perhaps they would receive a slightly less effective medication — but they would get by somehow. But some patients go bankrupt after being taken to an out-of-network hospital by an ambulance. And some patients die without their treatment. Even choosing the slightly less effective medication that the insurance will actually pay for can shorten a person’s life span as their disease slowly gnaws at their “quality of life years.”

Furthermore, what about the patients we never even see? Their ghosts will haunt my career and the extra years not lived trickle wastefully through the cracks of our broken system. Health care is a human right because it allows you to live fully. Good health gives you the liberty to contribute to society in the most prolific way. Having a home in the medical system allows you to pursue happiness in the finer things in life. From my standpoint, health care is embedded in every one of our basic human rights. Our medical system needs to live up to that high standard. The only way to protect the basic human rights of all citizens is to institute a single-payer health system that removes all financial barriers to necessary care.

Anna Zelivianskaia, is an M.D. Candidate 2016, University of Illinois-Chicago College of Medicine.

http://www.amsa.org/amsa/homepage/takeaction/amsaoncall/15-03-25/The_Importance_of_Health_to_Life_Liberty_and_the_Pursuit_of_Happiness.aspx

H.R. 2 has replaced H.R. 1470

H.R. 2, “Medicare Access and CHIP Reauthorization Act of 2015” replaces H.R. 1470, “SGR Repeal and Medicare Provider Payment Modernization Act of 2015”

By Don McCanne, M.D.

Yesterday, March 24, H.R. 2 was introduced in the House of Representatives. H.R. 1470, the subject of recent Quote of the Day messages, has been included in H.R. 2 as Title I. H.R. 2 is the legislation that the House will pass tomorrow.

The bill is now 263 pages long. It contains the following Titles:

TITLE I–SGR REPEAL AND MEDICARE PROVIDER PAYMENT MODERNIZATION
  SGR repeal and replacement with MIPS and APMs

TITLE II–MEDICARE AND OTHER HEALTH EXTENDERS
  Twenty-one Medicare and other health extenders, including extension of funding for community health centers and the National Health Service Corps

TITLE III–CHIP
  Two year extension of CHIP

TITLE IV–OFFSETS
  Means-tested Medicare premiums and elimination of deductible coverage in Medigap plans

TITLE V–MISCELLANEOUS
  Twenty-five miscellaneous provisions

https://www.congress.gov/bill/114th-congress/house-bill/2/text

THIS EXPANSION  OF THE ACT DOES NOT CHANGE ANY OF THE RECOMMENDATIONS SENT OUT EARLIER TODAY:

1. REPEAL SGR

2. EXTEND CHIP FINANCING FOR FOUR MORE YEARS

3. EXTEND FUNDING FOR COMMUNITY HEALTH CENTERS

4. REJECT UNPROVEN AND DETRIMENTAL POLICIES CONTAINED IN THE ACT

In addition, beneficial measures added to H.R. 2 should be enacted, but they need to be sorted out from inappropriate or deleterious policies that have been added to this act.

At this time Congress should simply repeal SGR, fund CHIP, fund community health centers and the National Health Service Corps, and refer all other provisions for further study by the appropriate committees.

Repeal SGR, but don’t privatize Medicare

Repeal SGR, but don’t privatize Medicare

March 25, 2015

By Don McCanne

In the fervor to finally rid us of the flawed SGR model of setting Medicare payment rates, Congress is about to pass legislation (H.R. 1470) that includes ill-advised, misguided and detrimental policies that could cause irreparable harm to our traditional Medicare program. Instead, Congress should revise the current legislation to comply with the following recommendations.

Recommendations

1. Repeal SGR

2. Extend the funding of CHIP for four years

3. Extend funding for community health centers

4. Reject unproven or detrimental policies

   a. Reject the Merit-based Incentive Payment System (MIPS) which threatens the traditional Medicare program by creating an administratively burdensome but unproven method of replacing volume with value

   b. Reject the Alternative Payment Models (APMs) as the only options for escaping MIPS since APMs also remain unproven methods of replacing volume with value

   c. Reject the threat to quality care that can result from burnout of health care professionals overburdened with the administrative excesses of MIPS and APMs

   d. Reject the false argument that SGR – a policy that has not been implemented for many years – must somehow be paid for by other reductions in public spending

   e. Reject the political chicanery of introducing unrelated issues into the legislation such as policy positions on pregnancy termination

   f. Reject the expansion of means-tested premiums in Medicare which would threaten solidarity in support of our Medicare program

   g. Reject imposing deductibles under Medigap plans which would cause too many patients to delay or forgo beneficial health care services

   h. Reject these unproven or detrimental policies that would reduce support of our traditional Medicare program, opening the door for those who would privatize Medicare through premium-support (voucher) proposals.

Backgrounder on the 2015 SGR ‘doc fix’

Trojan horse for Medicare privatization

By Ida Hellander, M.D.

The bipartisan “Doc Fix” legislation (H.R. 1470, now H.R. 2) and proposed amendments will undermine traditional Medicare and advance the goal of privatization, according to Dr. Don McCanne in a series of posts to his popular health policy blog, the Quote of the Day. If enacted as it presently reads, it will:

1. Limit choice of physician in traditional Medicare. Physicians in traditional Medicare would be subject to onerous new documentation requirements for payment and financial incentives to avoid complex patients under the proposed “Merit-based Incentive Payment System.”  The additional paperwork burden will push physicians to stop seeing patients with traditional Medicare, retire, avoid older and sicker patients, or go to work for large organizations using “alternative payment models” (which are exempt from the requirement and more likely to have contracts with private Medicare plans).

2. Reduce access to care in traditional Medicare. Imposes a deductible that cannot be covered by Medigap insurance (starting in 2020) to encourage patients to join a private plan. The current Part B deductible is $147 annually, although that figure has been rising in recent years; 95 percent of traditional Medicare beneficiaries have supplemental insurance that covers the deductible and other cost sharing in Medicare. The only way to avoid the deductible in the future will be to join a private Medicare Advantage plan.

3. Raise Medicare’s costs by driving more patients into private Medicare Advantage plans. Private plans have already cost Medicare an excess of more than $282 billion since 1985. Mandatory deductibles and reduced access to physicians in traditional Medicare will drive more patients into private Medicare Advantage plans, which are more costly than the cost of caring for patients in the traditional fee-for-service program. Although Obamacare was supposed to reduce the amount the private plans are overpaid (the “Medicare cuts” in Obamacare), these have been mostly offset by “adjustments” and “quality awards” by the Department of Health and Human Services.

4. Undermine Medicare’s popular support by requiring higher income seniors to pay higher premiums (means testing). Under means-tested premiums, higher-income individuals will be required to pay larger premiums, undermining the support of this influential group for Medicare program. Although the income subject to extra premiums is high, it can always be reduced in the future.

5. Ending the SGR should cost $20 billion, not $210 billion. These drastic measures aren’t even necessary. According to Bruce Vladeck, a former top administrator at Medicare, “Since the Sustainable Growth Rate (SGR) was implemented in 1998, total Medicare physician expenditures have exceeded the allowed amounts by only $20 billion (on a total of almost $1 trillion). To recoup that all in one year would require a 21 percent reduction in fees for one year. And those reduced fees would then become the base for payment levels in all subsequent years. In a rational world, Congress would write off the $20 billion as a relatively small policy error and establish a more realistic prospective formula. But under Congressional budget rules, the cost of doing so is not $20 billion, but $20 billion per year, compounded by inflation, times 10 years.”

6. The GOP sees this bill as a step towards their longer-term goal of turning Medicare into a voucher program for private plans, shifting more costs onto patients. Rep. Mick Mulvaney, R-S.C., a staunch conservative, told the Washington Post he is supporting the bill because it will lead to much greater savings beyond the traditional 10-year time frame for estimating costs. Newt Gingrich stated the GOP’s goal succinctly in 1996: “Now, we don’t get rid of it [Medicare] in round one because we don’t think that that’s politically smart, and we don’t think that’s the right way to go through a transition. But we believe it’s going to wither on the vine because we think people are voluntarily going to leave it — voluntarily.”

7. Other features:

Continues funding for safety-net programs
* Two-year extension for CHIP
* Two-year ($7.2 billion) extension for Community Health Centers

Restricts abortion, adds funds for war
* Makes Hyde Amendment permanent law. Since the ACA is a permanent statute, any amendment to any part of the ACA becomes part of U.S. Code.
* $94 billion in additional military spending in an “off-budget account.”

Dr. Ida Hellander is director of health policy and programs at Physicians for a National Health Program.

Get rid of insurers to give care to all

By Ewell Scott, M.D.
Lexington (Ky.) Herald Leader, Letters, March 24, 2015

Thanks to Gov. Steve Beshear’s foresight and preparation in creating a state-run health insurance exchange, rather than leaving it to the federal government.

Kentuckians who purchased policies with subsidies will not be at risk to lose coverage, if the U.S. Supreme Court shuts down subsidies in states that don’t have exchanges. Nationally, some 8 million patients may lose coverage. Even though Medicaid has its problems in terms of its managed-care manipulations and low compensation rates, the coverage is better than none at all.

However, the Affordable Care Act, even fully implemented, will not achieve the goal of affordable, universal health insurance. Some 30 million will remain uninsured.

The system we now have is grotesquely expensive and complicated. We spend 17 percent of our gross domestic product on health care. Other countries do it for 8 percent to 10 percent of GDP, and do it better. We can improve by expanding Medicare for all of us and eliminating private health insurance companies.

By so doing, enormous savings would occur. High deductibles, enormous co-pays and exaggerated medication costs would be eliminated. It is possible. Think about it. House Resolution 676, now introduced in Congress, will do it.

Dr. Ewell G. Scott resides in Morehead, Ky.

Read more here: http://www.kentucky.com/2015/03/23/3764427_letters-to-the-editor-march-24.html?rh=1#storylink=cpy

SGR Fix: APMs threaten physician burnout (RAND)

Effects of Health Care Payment Models on Physician Practice in the United States

By Mark W. Friedberg, Peggy G. Chen, Chapin White, Olivia Jung, Laura Raaen, Samuel Hirshman, Emily Hoch, Clare Stevens, Paul B. Ginsburg, Lawrence P. Casalino, Michael Tutty, Carol Vargo, Lisa Lipinski

RAND Corporation, March 19, 2015

The project reported here, sponsored by the American Medical Association (AMA), aimed to describe the effects that alternative health care payment models (i.e., models other than fee-for-service payment) have on physicians and physician practices in the United States. These payment models included capitation, episode-based and bundled payment, shared savings, pay for performance, and retainer-based practice. Accountable care organizations and medical homes, which are two recently expanding practice and organization models that feature combinations of these alternative payment models, were also included. Project findings are intended to help guide efforts by the AMA and other stakeholders to make improvements to current and future alternative payment programs and help physician practices succeed in these new payment models.

Physician Incentives and Compensation

Practice leaders described transforming certain practice-level financial incentives (especially those concerning cost containment) into internal nonfinancial incentives for individual physicians, choosing instead to appeal to physicians’ sense of professionalism, competitiveness, and desire to improve patient care. Common nonfinancial incentives included performance feedback and selectively retaining or terminating their physicians based on quality or efficiency performance.

Generally speaking, alternative payment models had negligible effects on the aggregate income of individual physicians within our sample.

Physician Work and Professional Satisfaction

Within our sample, alternative payment models had not substantially changed how physicians delivered face-to-face patient care. However, the overall quantity and intensity of physician work had increased because of growing patient volume expectations and ongoing pressure for physicians to practice at the “top of license” (e.g., by delegating less intense patient encounters to allied health professionals), which was described as a potential contributor to burnout because lower-intensity patients could be an important source of respite for busy physicians.

Additional nonclinical work, particularly documentation requirements, created significant discontent. Physicians recognized the value of documentation tasks that were directly related to improvements in patient care, such as identifying patients with diabetes to facilitate better management of all patients with this condition, but they disliked the extra burden generated when documentation requirements were perceived as irrelevant to patient care.

Most physicians in practice leadership positions were optimistic and enthusiastic about alternative payment models, while most physicians not in leadership roles expressed at least some level of apprehension, particularly with regard to the documentation requirements of new payment models. Overall, even these physicians seemed to believe that major changes in payment methods would continue and acknowledged that some changes were useful. Nevertheless, their attitude was frequently one of resignation, rather than enthusiasm, because their day-to-day work life was more difficult and included burdens they did not believe would improve patient care.

Factors Limiting the Effectiveness of New Payment Models as Implemented

Physicians and practice leaders described encountering three general types of operational problems in new payment programs that limited their effectiveness and sapped physicians’ enthusiasm for them.

First, physicians and practice leaders participating in a variety of alternative payment models described encountering errors in data integrity and timeliness, performance measure specification, and patient attribution (the process by which patients are assigned to a specific physician or practice). These payment models shared characteristics that might have made errors more likely: They were administratively more complex than FFS payment; some required payers to develop new measurement systems; and some were deployed for the first time quite quickly, without a “dress rehearsal” in which errors could be corrected before payments were on the line.

Second, physicians had a variety of concerns about the implementation of performance and risk-adjustment measures underlying PFP, shared savings, and capitation programs. Broadly speaking, these concerns stemmed from a sense that the multiplicity of measures within and across programs could distract physician practices from making the changes to patient care that were actually the ultimate goal of many payment programs.

Third, the influence of uncontrollable, game-changing events in shared savings and capitation programs (e.g., the introduction of very high-cost specialty drugs) sapped physician practices’ enthusiasm for these payment models. Finally, some physicians reported that they could not understand exactly what behaviors were being encouraged or discouraged by certain performance-based payment programs—even after seeking clarification from payers.

Increased Stress and Time Pressure

New nonclinical work for physicians was almost universally disliked, especially when there was no clear link to better patient care. For example, frustration was common when physicians believed they were being asked to spend more time on documentation solely to get credit for care they had provided already. Overall, increased stress on physicians might directly harm the quality of patient care and might also serve as a marker that physicians are concerned about the quality of care they are able to provide.

Full report (142 pages):
http://www.rand.org/content/dam/rand/pubs/research_reports/RR800/RR869/RAND_RR869.pdf

Comment:

By Don McCanne, M.D.

HR 1470, which Congress is scheduled to approve in only two days (March 26), would replace the flawed Sustainable Growth Rate (SGR) method of determining Medicare payments with a new Merit-based Incentive Payment System (MIPS). MIPS introduces considerable administrative complexity which would be a great burden to physicians, but the legislation allows physicians to opt out of MIPS by joining Alternative Payment Models (APMs) such as Accountable Care Organizations (ACOs) or Patient Centered Medical Homes (PCMHs). This RAND study of APMs reveals that physician members of APMs are at very high risk of BURNOUT.

Some believe that the onerous structure of MIPS was designed specifically to drive physicians into APMs, especially ACOs. But is moving from burnout to burnout really progress?

From the report: “(physicians’) day-to-day work life was more difficult and included burdens they did not believe would improve patient care.” Further: “Overall, increased stress on physicians might directly harm the quality of patient care and might also serve as a marker that physicians are concerned about the quality of care they are able to provide.”

This legislation will require physicians to submit to MIPS requirements or join an APM, in either case incurring a high risk of burnout. But health care should really be about the patient. Well, this does affect patients, but in a bad way. Stressed-out physicians unintentionally provide lower quality care. This is the exact opposite of the intent of this legislation, assuming that higher value is intended to represent higher quality.

Supporters say that getting rid of SGR is not only worth the legislative compromise, but that the new MIPS provides the additional benefit of improving quality, not to mention some CHIP funding being thrown in as well. As we have seen, quality will likely be worse instead because of the inevitable burnout. But now the supporters are responding with the usual: “perfect being the enemy of the good,” “art of legislative compromise,” “bipartisan support,” “making sausage,” and “must move on to other priorities.”

It’s tempting to tell them what to do with their sausage, but, above all, we should speak out loudly on behalf of our patients. This legislation will make health care worse. With only two days left and the steamroller in full momentum, can we do anything to prevent this injustice about to be inflicted on patients and their health care professionals?

Grover Norquist sees bipartisan doc fix deal as ‘model of success’ in privatizing Medicare

By Kay Tillow
Daily Kos, March 23, 2015

House Speaker John Boehner (R-Ohio) and Minority Leader Nancy Pelosi (D-Calif.) have worked out a deal, a permanent “doc fix” that would repeal automatic cuts in Medicare payments to physicians. Their bipartisan solution, if enacted, will plunge a stake into the heart of traditional Medicare, according to health policy expert Don McCanne, M.D., of Physicians for a National Health Program.

Social Security Act amendments passed more than a decade ago once again threaten to slash Medicare payments to physicians, this time by 21.2 percent, as of April 1, 2015.  These provisions require automatic cuts based on a formula called the “sustainable growth rate.”  

Each time these cuts threaten to kick in, Democrats and Republicans alike look for a solution to stop the harmful cuts. Now Boehner and Pelosi have agreed on a permanent solution, a plan that stops those cuts, but at the unacceptable price of inflicting devastating damage on Medicare.

The Boehner/Pelosi-backed bill, H.R. 1470, “SGR Repeal and Medicare Provider Payment Modernization Act of 2015” is cosponsored by progressive James McDermott (D-Wash.), anti-Medicare Republican Paul Ryan (R-Wis.), and seven others from both parties.  The bill would replace the current formula for physician reimbursements with a new Merit-based Incentive Payment System (MIPS).

MIPS is an administrative nightmare, says McCanne.  

Expensive consultants will game the system bringing in additional incentive payments while those who work with disadvantaged patient populations will find it difficult to score higher points, predicts McCanne. Those who serve less wealthy populations will see negative payment adjustments by up to 9 percent.

MIPS robs from the professionals who are trying to make the system work for their patients and gives the spoils to those who likely have consultants to show them how to game the system, says McCanne.

MIPS will apply only to traditional Medicare, promoting an exodus of physicians from traditional Medicare into the private for-profit Medicare Advantage plans.

The deal would also reward remote patient-monitoring and telehealth as clinical practice improvement activities, reports Darius Tahir of Modern Healthcare. That can create big bucks for health information technology but does not portend well for patients who need hands on caring professionals.

According to The Hill’s Scott Wong and Peter Sullivan, the deal will be paid for through a combination of means testing — that is, making wealthier seniors pay more for Medicare — and reforms to the supplemental health insurance plans known as Medigap.  

Medigap policies would have to make the patients pay the first $250, providing the “skin in the game,” that ugly, inhumane concept so popular with insurance companies. The further means testing of Medicare threatens its broad based popular support as a benefit for all.

“The increased beneficiary cost-sharing included in the SGR reform proposal could work hand-in-hand with the larger House GOP Medicare plan by prodding seniors to choose the lower-cost private Medicare plans envisioned under the budget blueprint. That would advance their long-held goal of turning Medicare into a privatized, means-tested welfare program and getting the government out of the health insurance business,” reports Harris Meyer in Modern Healthcare.

Grover Norquist, founder of Americans for Tax Reform and known for wanting to shrink government small enough to be drowned in a bathtub, likes the Boehner-Pelosi deal.  Norquist says the “doc fix” deal could be a “model of success” for a larger entitlement deal.

The bill, negotiated in secrecy, is being steamrolled and is predicted to come to a vote this week.  Those who cherish Medicare as our nation’s best yet health program should sound the alarm.  A stab in the heart of Medicare is not a compromise but a complete and disastrous sell-out.

Kay Tillow is a leader of Kentuckians for Single Payer Health Care and the All Unions Committee for Single Payer Health Care–HR 676. She resides in Louisville.

http://www.dailykos.com/story/2015/03/23/1372791/-Grover-Norquist-sees-bi-partisan-doc-fix-deal-as-model-of-success-in-privatizing-Medicare#

Proposed SGR deal would advance GOP goal of privatizing Medicare

By Harris Meyer
Modern Healthcare, March 18, 2015

The proposed bipartisan House deal to repeal and replace Medicare’s hated sustainable growth-rate physician-payment system offers Republicans a chance to make two significant benefit changes they’ve long sought. Now it remains to be seen if they can accept and lock in that victory. 

It also raises the question of what Democrats, if they help enact the SGR bill, would have left to offer when Republicans come back the next time—probably quite soon—with more and bigger demands to revamp and reduce Medicare spending.

The deal crafted by House Speaker John Boehner and House Minority Leader Nancy Pelosi would pay for a $70 billion portion of the SGR overhaul partly by increasing Part B premiums for higher-income beneficiaries and requiring those with Medigap supplemental coverage to spend at least $250 out of pocket before coverage kicks in, according to Modern Healthcare’s Paul Demko, who first reported the details last week. 

Even though President Barack Obama previously proposed similar Medigap changes in his 2016 budget, senior advocacy group AARP expressed “very serious concerns” about those changes and the increased means-testing of premiums. Some Senate Democrats also voiced reservations. 

The Center for American Progress (PDF) has cautioned that revising Medicare supplemental coverage rules to impose higher costs on seniors would hurt lower-income beneficiaries. It urged that any such changes be applied using means-testing, sparing beneficiaries at lower income levels. Beyond that, AARP and other groups that support Medicare fear that too much means-testing could erode political support for the program among middle- and upper-middle-class Americans.

But Boehner and the conservative Americans for Tax Reform see the measures as an important first step toward dramatically restructuring Medicare. Meanwhile,House Republicans separately unveiled their 2016 budget proposal that would transform Medicare into a defined-contribution voucher program (which they call premium support), convert Medicaid into a capped state block-grant program, and repeal the Affordable Care Act.

The increased beneficiary cost-sharing included in the SGR reform proposal could work hand-in-hand with the larger House GOP Medicare plan by prodding seniors to choose the lower-cost private Medicare plans envisioned under the budget blueprint. That would advance their long-held goal of turning Medicare into a privatized, means-tested welfare program and getting the government out of the health insurance business.

Some conservatives clearly were thrilled at the prospect of advancing their Medicare overhaul goals through the SGR bill, and urged other conservatives to accept the added 10-year costs to the federal budget and pass it. “I could care less about the 10 years,” Ryan Ellis, tax policy director of Americans for Tax Reform (which is headed by conservative stalwart Grover Norquist), told the National Journal. “You would never measure entitlement reform in a 10-year window.”

Follow Harris Meyer on Twitter: @MHHmeyer

http://www.modernhealthcare.com/article/20150318/BLOG/303189965

Harris Meyer oversees news and feature coverage for the magazine. Meyer has covered healthcare and law since 1983, most recently as a freelance writer for Health Affairs, Kaiser Health News, the Oregonian, Medscape and other publications. He previously served as law editor at the Daily Business Review in Miami; a staff writer at the New Times alternative weekly in Fort Lauderdale, Fla.; senior writer at Hospitals & Health Networks; national correspondent at American Medical News; and health unit researcher at WMAQ-TV News in Chicago. Meyer has a bachelor’s degree in communications from Northwestern University. In 2000 he was a winner of the Gerald Loeb Award for Distinguished Business and Financial Journalism. He joined Modern Healthcare in 2013.

Fed war on health care spending abuse needs to include Medicare Advantage

Commentary: Obama administration bragging about anti-fraud efforts, but Center report showed bigger dollars are being lost elsewhere

By Wendell Potter
Center for Public Integrity, March 23, 2015

The Obama administration went to great lengths last week to inform us that it recovered $3.3 billion in fraudulent payments to Medicare health care providers in fiscal year 2014. Officials even went so far as to give an advance copy of their report to The Wall Street Journal, which, like the Center for Public Integrity, has been investigating Medicare fraud and abuse.

In a story that appeared in the Journal before the official release of the report, WSJ reporter Stephanie Armour wrote that the recovery “was part of an effort by the Obama administration to improve enforcement and prevent abusive billing practices.” That effort is run jointly by the Department of Health and Human Services the Justice Department.

HHS secretary Sylvia Burwell was quoted in the story as saying that “we’ve cracked down on tens of thousands of health care providers suspected of Medicare fraud,” an effort she said is helping to extend the life of the Medicare Trust Fund.

That’s good news, of course. Taxpayers benefit when doctors and other health care providers get caught trying to rip off the government.

But when it comes taking on big and well-connected insurance companies that have been ripping off the Medicare program for years, the administration has been far less aggressive in catching, much less punishing, the abusers.

As the Center for Public Integrity reported last week, officials in the Obama administration were advised as long ago as 2009 that a formula the government uses to pay private insurers that participate in the Medicare Advantage program “triggered widespread billing errors and overcharges” that waste billions of tax dollars every year.

There was no press release issued by the administration about that 2009 report; in fact, the administration buried it. The report probably never would have surfaced at all had the Center for Public Integrity not filed a Freedom of Information request seeking records going back several years regarding payments to Medicare Advantage plans.

The Medicare Advantage program is a privately run alternative to standard Medicare. Close to a third of Medicare-eligible Americans are now enrolled in insurance company-operated Medicare Advantage plans. People enrolled in these plans typically pay less out of pocket for their care—which explains their appeal—but also typically have a smaller network of providers to choose from.

As Center reporter Fred Schulte explained in his March 13 story, the federal government pays these private health plans a set monthly fee for each patient based on a formula known as a risk score. Risk scores were put in place by the government to measure the state of Medicare Advantage enrollees’ health. “Sicker patients merit higher rates than those in good health,” Schulte wrote.

Schulte’s investigation into risk score payments last year uncovered evidence that the government has been overpaying private insurers for years. That’s because the risk scores can be manipulated by insurers to make it appear that enrollees are sicker than they actually are. Just last week, the Government Accountability Office estimated that “improper payments” to Medicare Advantage plans totaled more than $12 billion in 2014 alone.

When Schulte came across the unpublished 2009 report, he asked CMS why it was never made public.

The explanation he got was preposterous. According to a CMS spokesperson, the agency wanted to publish the report but was told it was too long, that to be considered for publication on a government-run research site, it would have to be “substantially shortened.” This despite the fact that some of the reports that have been published on that site are even longer than the one on risk score manipulation.

The story gets even more incredible. The CMS spokesperson said that “given competing workload demands we were not able to revise and resubmit the article.”

I don’t doubt that the folks at CMS were especially busy in 2009. That’s the year debate began on what would eventually become Obamacare.

To make Obamacare work, the administration needed to have the support of the insurance industry. Insurers had to agree to change many of their profitable but anti-consumer practices in exchange for billions of dollars in new revenue from the government.

Insurance industry lobbyists are among the most powerful and well connected in Washington. Could the administration have put the kibosh on the 2009 report because it didn’t want to jeopardize its relationship with insurers and put the reform law at risk?

We’ll probably never know. But if the administration is really as serious about reducing Medicare fraud as it said last week it is, let’s hear more from CMS about what it’s doing to end abuses in the Medicare Advantage program.

The Wall Street Journal reported that the owners of a home health care company that defrauded the government were recently sentenced to prison terms of up to 120 months each. How much do you want to bet that executives of Medicare Advantage plans that are overbilling taxpayers out of far more money will ever see the inside of a jail cell?

Wendell Potter is the author of “Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR is Killing Health Care” and “Deceiving Americans and Obamacare: What’s in It for Me? What Everyone Needs to Know About the Affordable Care Act.“

http://www.publicintegrity.org/2015/03/23/16942/fed-war-health-care-spending-abuse-needs-include-medicare-advantage

MIPS – Learn to live with it

Working Framework of SGR Package

House Committees on Energy & Commerce and Ways & Means, March 20, 2015

Repeal and Replace Medicare Physician Payment System. The legislation repeals the flawed SGR formula and replaces it with HR 1470, SGR Repeal and Medicare Provider Payment Modernization Act (replaces SGR with MIPS, the Merit-based Incentive Payment System)

Children’s Health Insurance Program (CHIP). This provision preserves and extends CHIP, fully funding the program through September 30, 2017.

Medicare, Medicaid, and Other Health Extenders. The legislation extends all of the extenders included in the Protecting Access to Medicare Act of 2014 (PAMA, the most recent SGR patch) in addition to funding for Community Health Centers through 2017.

Other Medicare Reforms.1) Medicare DMEPOS Competitive Bidding Improvement Act (HR 284). (2) The Protecting Integrity in Medicare Act (HR 1021).

Savings.

(1) Income-related Premium Adjustment. Starting in 2018, this policy would increase the percentage that beneficiaries pay toward their Part B and D premiums in two income brackets (roughly 2 percent of beneficiaries): for individuals with income between $133.5-160K ($267-$320K for a couple), the percent of premium paid increases from 50 percent to 65 percent. For those with income between $160-214K ($320- $428K for a couple), the percent increases from 65 percent to 75 percent.

(2) Medigap Reform. The proposal limits first dollar coverage on certain Medigap plans by prohibiting plans from covering the Part B deductible. Change applies only for future retirees starting in 2020.

(3) Increase Levy Authority on Payments to Medicare Providers with Delinquent Tax Debt.

(4) Hospital Update. Under current law, hospitals will receive a 3.2 percentage point adjustment in addition to their base payment rate in FY18. This policy would phase-in this update incrementally.

(5) Additional Medicaid DSH Savings.

(6) 1 Percent Market Basket Update for Post-Acute Providers

http://waysandmeans.house.gov/uploadedfiles/bipart_topline_summary-032015_final2.pdf

****

What Measures Should Be Used to Evaluate Health Care?

By Melinda Beck

The Wall Street Journal, March 22, 2015

There’s little agreement among patients, providers and insurers

http://www.wsj.com/articles/what-quality-measures-should-be-used-to-evaluate-health-care-providers-1427079654

****

Primum Non Nocere: Congress’s Inadequate Medicare Physician Payment Fix

By Jeff Goldsmith

Health Affairs Blog, January 24, 2014

With this legislation, Congress is preparing yet again to enshrine in statute another payment strategy that is both unproven and highly controversial.

The proposed legislation casts in concrete an almost laughably complex and expensive clinical record-keeping regime, while preserving the very volume-enhancing features of fee-for-service payment that caused the SGR problem in the first place. The cure is actually worse, and potentially more expensive, than the disease we have now.

If we’re not sure new advanced payment schemes actually work, if we haven’t actually gotten them right, then we have no business compelling or incenting 680 thousand practicing physicians to use them. We’re not going to get clinical practice where we want it to go with an elaborate, individualized operant conditioning schedule with four domains and sixty eight “core measures”, and billions more spent on the IT systems and clerical support to document them. We need to reward teamwork, not box-checking.

It isn’t just physicians that should be guided by Hippocrates’ maxim, “First Do No Harm,” but our policymakers as well.

http://healthaffairs.org/blog/2014/01/24/primum-non-nocere-congresss-inadequate-medicare-physician-payment-fix/

****

Comment:

By Don McCanne, MD

We’re there. The SGR extension expires March 31, and Congress is leaving for a two week recess this Friday, March 27. Not only is there strong bipartisan Congressional support for HR 1470, the SGR repeal and replacement act, but there is also overwhelming support from the AMA and other physician societies and from other influential interest groups such as Families USA. The bill will pass this week.

The last two Quote of the Day messages have discussed some serious defects in this legislation, especially the problems with the Merit-based Incentive Payment System (MIPS). But that part of the bill is a given. What is new today is the one page summary of the intended amendments that will be added before enactment of the bill (see “Working Framework of SGR Package,” above).

Two items in these proposed amendments are of particular concern: 1) Means-testing of Medicare Part B and Part D premiums, and 2) Prohibiting Medigap plans from covering the Part D deductible.

Under means-tested premiums, higher-income individuals will be required to pay larger premiums, undermining the support of this influential group for the traditional Medicare program. Since they will be paying higher premiums, many likely would prefer to select their own coverage from a market of private Medicare plans – a goal of those supporting privatization of Medicare through the premium-support model of reform. Thus this provision would be a significant incremental step towards privatization.

Prohibiting Medigap plans from covering Medicare Part B deductibles expands the implementation of consumer-directed approaches to financing health care. It advances the conservative agenda of requiring more personal responsibility on the part of patients, often expressed by the repulsive “skin in the game” rhetoric. Much has been written about the potential adverse consequences of deductibles, but the more ominous portent of this measure is that it establishes the principle that all health care must conform with the consumer-directed model. As we have seen, the use of ever higher deductibles is rapidly expanding in employer-sponsored plans, and this opens the door for the same rapid increase in cost sharing to occur with Medicare.

But back to the basic bill – using the MIPS to replace the SGR. In the last two Quote of the Day messages it was pointed out what an administrative nightmare MIPS would bring us. What should be particularly alarming is that these new required administrative procedures have not been shown to either significantly decrease the volume of medical services, or improve quality – supposedly the two goals of payment reform.

As Jeff Goldsmith states about last year’s version of the same policies, “The proposed legislation casts in concrete an almost laughably complex and expensive clinical record-keeping regime, while preserving the very volume-enhancing features of fee-for-service payment that caused the SGR problem in the first place. The cure is actually worse, and potentially more expensive, than the disease we have now.”

Tune in to C-Span this week for the latest chapter in their epic fiction series: Democracy in America.