PNHP

Uwe Reinhardt’s timely comments on ACOs and P4P

Uwe Reinhardt’s timely comments on ACOs and P4P

Pay for Performance Extends to Health Care in Experiment in New York

By Anemona Hartocollis
The New York Times, March 30, 2015

(A)ccountable care organizations are appearing around the country for Medicare recipients, with mixed results. New York, which has the country’s largest Medicaid budget, is committing more than $1 billion a year for five years to the experiment.

“If we succeed, patients will be more likely to get the right tests and medicine, doctors will benefit as we simplify the business side of their practices, and businesses will benefit as we hold down health-care cost growth,” Sylvia M. Burwell, secretary of the federal Department of Health and Human Services, said this month in New York City, during a visit to promote accountable care organizations.

In the future, if the experiment works, providers may be paid solely based on outcomes rather than volume of services, with better-performing groups earning more than those whose patients are in worse shape.

Perhaps the most unusual alliance is one that brought together more than 1,000 primarily Hispanic doctors serving Upper Manhattan and the South Bronx and Asian doctors working in the Chinatowns of Manhattan, Brooklyn and Queens; and North Shore-Long Island Jewish Health System, a hospital chain that serves a largely middle-class population. The nonprofit venture they formed, called Advocate Community Providers, counts more than 770,000 patients, by far the most of the 25 groups taking part in the program.

The force behind this group is Dr. Ramon Tallaj, a former health official in the Dominican Republic who moved to the United States in 1991.

But some of the Medicaid panel members questioned the logic of having such a large, diverse group of doctors and patients like Dr. Tallaj’s, without any obvious connections among them.

“What’s the glue that holds them together?” asked Stephen Berger, a panel member and investment banker.

The sheer size of the group could also make it complicated to track patients and determine who deserves credit for any improvements in their health. Patients may continue to see any doctor they wish, even if that doctor is not in the group.

Likewise, Dr. Tallaj acknowledged that if his patients did well, he could reap the benefits even if he had not seen them, though he said that was not his motivation.

Uwe Reinhardt, a health economist at Princeton, thought the idea was not as promising as some had hoped. “People thought there was maybe more waste than there actually really is,” he said.

Dr. Reinhardt was also dismissive of performance bonuses for doctors. “The idea that everyone’s professionalism and everyone’s good will has to be bought with tips is bizarre.”

http://www.nytimes.com/2015/03/31/nyregion/pay-for-performance-extends-to-health-care-in-experiment-in-new-york.html

Comment:

By Don McCanne, M.D.

Value rather than volume. Quality rather than quantity. Paying for performance. Reducing costs by eliminating wasteful services. Making providers accountable and rewarding them based on the value of their services. These concepts have become memes in the political and policy communities yet with very little in the health policy literature to confirm that these should be the driving principles behind health care financing reform, though there are quite a few studies that confirm that these concepts lead to mediocrity, at best.

It is urgent that we reconsider these concepts since in two weeks the Senate is expected to pass H.R. 2 which is designed to change payment methods from fee-for-service to models of payment that instill these ideas that are more rhetoric than science-based policy. Yet the rhetoric is leading to implementation of the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). These will have a major impact – more negative than positive – on the actual delivery of health care services.

Who is behind this meme-driven revolution in health care? Much of the academic policy community. Legislative and administrative staff members. Politicians. Representatives of vested interests that will benefit from these changes. Well-meaning consumer organizations. Although some are driven by greed, most are on meme-fed autopilot and have gathered in lemming fashion charging forward to a goal in which utopian perceptions will be dashed by the reality of plowing into the shoals of flawed policy.

Although it is quite disconcerting to read the meaningless rote responses of some of the more noted representatives of the policy community, we do have the comfort of of being able to hear from some of that community who bring us reality by questioning these conclusions that are based more on wishes than on objective evidence.

One of those on whom we can rely is Uwe Reinhardt. His brief comments in this article should give the Senate pause as they consider H.R. 2. Current political activity seems to be based on the concept that these flawed policies can eliminate much of the wasteful health care services provided. As he tells us, the problem with that rationale is that there is not nearly as much waste as has been thought. The initial results of experimentation have confirmed that there just is not that much recoverable by attempting to reduce or eliminate care that is not beneficial.

Perhaps Uwe Reinhardt’s most important lesson is in his comments about paying for performance: “The idea that everyone’s professionalism and everyone’s good will has to be bought with tips is bizarre.” What could be more fundamental than the ethical foundations driving the practitioners of the healing arts? The policy people have it all wrong, and they do not seem to understand why.

Why We are Fighting for a Single-Payer Healthcare System

By Terence Redmond McAllister, M.D., and Leann DiDomenico McAllister
Physicians Practice (Baltimore), March 16, 2015

Currently there are a few TV ads — TD Bank’s Bank Human Again and Nationwide’s In the Nation campaigns, most notably — that focus on how “human” they treat their customers. We weep with sad recognition when we see these ads as they are a stark reminder of the inhumane treatment we providers receive from insurance payers on a daily basis.

From coding policies that have nothing to do with NCCI edits to time-consuming phone trees that lead to underpaid, overworked customer service people who hang up on us, we are done with the soul-crushing daily abuse we endure for our crust of bread.

Speaking of which, we were shocked by how much positive press Aetna Chairman and CEO Mark Bertolini, a man who reportedly earned $30.7 million in 2013, received when he raised his employees’ minimum wage to $16 per hour. He might as well have said, “Let them eat cake.”

Bertolini has a long history of putting profits ahead of patient care. Even though fair wages are newsworthy, we see Aetna’s announcement as little more than a PR campaign.

As single-payer healthcare becomes a real possibility, Bertolini is using his fair-wage pledge as a way to win approval from the providers and patients who have been abused for years by his business practices.

While media outlets were focusing on Aetna increasing the wage rate floor for all of its employees to $32,000 a year, many missed the bigger story that the U.S. wastes $375 billion a year due to insurance-related paperwork. It’s worth saying again, so we will: Insurance wastes $375 billion each year.

For readers who might not know the administrative nightmare that is the insurance payment system in the U.S., here are a few recent examples from our practice:

• Eight months ago a small error occurred, technical or human is unclear, were the subscriber’s name was placed where the patient’s name should have appeared on the electronic claim. Today, after four written appeals and a dozen phone conversations, the claim has still not been paid.

• A six-month-old claim has yet to be paid by an insurer who keeps telling us the member’s policy terminated on 11/30/2014. The date of service was 11/29/14 when the policy was active. We’re not sure exactly how many conversations we will have to have with the payer to convince it that November 29 does, in fact, come before November 30.

• One payer is trying to take back money on a claim that is over a year old and was appropriately paid the first time. We have sent two written appeals and tried calling (but failed to successfully navigate the phone tree) to no avail.

We recognize that many of you, our peers, lean conservative. Like you, we’re not interested in taking vows of poverty. As we’ve written before, our goal is to earn a good living for ourselves while keeping work/life in balance and delivering the best primary care that we can. But even the most conservative of you can see that there is a significant different between earning a living and making millions a year and huge profits for investors. For us, the health insurance companies are the problem. The solution is single payer.

We are tired of hearing ourselves complain about the insurance companies and so we’re doing something about it.

Just this month, we both became members of Physicians for a National Health Program (PNHP). PNHP is a single issue organization advocating a universal, comprehensive single-payer national health program. PNHP has more than 19,000 members and chapters across the United States.

We are not naive; we know that single payer has its own issues. Whatever concerns we have, though, pale in comparison to the $375 billion dollars that the insurance industry steals from patients and providers on an annual basis. Overpaid insurance company executives will have to find a new way to steal from the American people. It’s time for single payer.

The authors reside in Massachusetts. Practice Notes is a space for commentary and news on practice management and healthcare policy. Opinions expressed by guest bloggers are their own, and do not necessarily reflect the views of Physicians Practice, its staff or editors.

http://www.physicianspractice.com/blog/why-we-are-fighting-single-payer-healthcare-system

Two week ‘doc fix’ reprieve gives us time to protect Medicare

Senate to Take Up Medicare ‘Doc Fix’ Bill After Recess

By Siobhan Hughes
The Wall Street Journal, March 27, 2015

The Senate will take up legislation to replace a formula for reimbursing doctors who treat Medicare patients when the chamber returns from a two-week recess, Senate Majority Leader Mitch McConnell (R., Ky.) said early on Friday.

The House had one day earlier passed the bill in an overwhelming 392-37 vote. Supporters had hoped the Senate would take up the measure before a two-week spring that begins once the chamber adjourns Friday.

“We’ll turn to this legislation very quickly when we get back,” Mr. McConnell said. “There’s every reason to believe it’s going to pass the Senate by a very large majority.”

Dr. Robert Wah, the president of the American Medical Association, said his group was “extremely disappointed” that the Senate vote was delayed and said that physicians would face a “devastating” cut when the current patch expires just days from now.

The Centers for Medicare and Medicaid Services has said that it takes a minimum of 14 days to pay claims from doctors. Lawmakers expect that if Congress acts soon enough the government would be able to make payments without imposing the pay cuts.

One possible wrinkle is that Mr. Reid appeared to request votes on a limited number of amendments related the legislation. Mr. McConnell said that he would “be discussing the way forward” with Mr. Reid.

http://www.wsj.com/articles/senate-to-take-up-medicare-doc-fix-bill-after-recess-1427452707

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AARP Statement on House Passage of Medicare SGR Reform Bill

AARP, March 26, 2015

AARP applauds the House for its bipartisan work on the Medicare Access and CHIP Reauthorization Act of 2015 (H.R. 2) that permanently replaces the Sustainable Growth Rate (SGR) formula. However, we remain concerned that Medicare beneficiaries are unfairly shouldering more than their fair share of the cost of the SGR “Doc Fix,” and we urge further improvements as the bill moves to the Senate.

While AARP commends the House of Representatives for working together in a bipartisan fashion on this SGR bill, we are concerned that Medicare beneficiaries will now face higher out-of-pocket costs, including higher premiums and reduced coverage through certain Medicare Supplemental (Medigap) plans. The typical senior on Medigap is not wealthy—nearly half have annual incomes of less than $30,000.

AARP wants a permanent solution to the SGR formula, one that achieves a balanced and fair solution for all stakeholders—Medicare beneficiaries, physicians and other health care providers, insurers, and drug companies. AARP is ready to work with the Senate to improve this important bill.

http://www.aarp.org/about-aarp/press-center/info-03-2015/statement-house-passage-sgr-reform-bill.html

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Letter to Speaker John Boehner and Democratic Leader Nancy Pelosi

From Joe Baker, President
Medicare Rights Center, March 25, 2015

We are grateful to the House Republican and Democratic leadership for working to develop an SGR compromise. The SGR formula is fundamentally flawed, and permanent changes to the Medicare reimbursement system are long overdue. Yet, H.R. 2 does not represent a fair deal for people with Medicare—expecting too much from beneficiaries in return for too little.

We are concerned with the offset provisions in H.R. 2, including proposals to scale back comprehensive Medigap coverage and to increase costs for those already paying higher Part B and Part D premiums. The clients we represent include those beneficiaries whose Medicare cost sharing will be altered by the offsets included in H.R. 2. In particular, we are most troubled by the provision to prohibit Medigap plans from covering costs up to the Part B deductible, starting in 2020 for newly eligible Medicare beneficiaries.

We fundamentally disagree with the premise that Medigap “first-dollar” coverage should be undone as a means of controlling health care service utilization. Decades of empirical research consistently demonstrates that, while higher out-of-pocket costs certainly deter health care utilization, it deters utilization of needed care as well as unneeded care indiscriminately. Additionally, research consistently supports what we know to be true through our experience serving people with Medicare: health care providers—not beneficiaries— order services and ultimately drive utilization trends.

Medigap provides health security and peace of mind to beneficiaries living on fixed incomes. The value of Medigap to people with low- and middle-incomes is its predictability. Planning for the expense of a monthly premium is doable, but the same is not true for the unexpected cost of a deductible. This security is critically important to the 40% of Medigap enrollees with incomes below $30,000. We believe comprehensive, “first-dollar” Medigap plans should remain available to future retirees.

At the same time, additional income-relating of Part B and Part D premiums concerns us. These provisions in H.R. 2 represent a sizable cost shift to select Medicare beneficiaries, and half of the total offsets included in the legislative package.

http://www.medicarerights.org/pdf/hr2-house-letter-032515.pdf

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H.R. 2 – Medicare Access and CHIP Reauthorization Act of 2015

  TITLE IV–OFFSETS

    Subtitle A–Medicare Beneficiary Reforms

      Sec. 401. Limitation on certain medigap policies for newly eligible Medicare beneficiaries.

      Sec. 402. Income-related premium adjustment for parts B and D.

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

Comment:

By Don McCanne, M.D.

The decision of the U.S. Senate leadership to delay consideration of H.R. 2 (the SGR repeal bill) until after they take a two week recess provides us with an opportunity to join with others in demanding removal of two provisions that would be very harmful to our traditional Medicare program – means-tested premiums for Medicare Parts B and D, and imposing deductibles for beneficiaries of Medigap plans.

Although some might argue that these changes are comparatively trivial, make no mistake about the intent of these measures. Speaker John Boehner stated on the House floor that H.R. 2 is the beginning of the process of entitlement reform. In stating that this is “about strengthening and saving Medicare,” he really means that it is about reducing the government funding of Medicare by shifting more of the responsibility of payment to the Medicare beneficiaries, eventually culminating in the premium support (voucher) model of privatizing Medicare.

Recent Quote of the Day messages have sounded alarms about two major concerns of the “doc fix” legislation: (1) the administrative burdens that will be placed on health care professionals by the Merit-based Incentive Payment System (MIPS) and the Alternative Payment Models (APMs), and (2) the efforts to push the traditional Medicare program in the direction of privatization.

Of these two, the administrative hassles of MIPS and APMs are the less urgent since precursors of these programs already exist. The existing Medicare reporting programs include PQRS, Meaningful Use, and Value Modifier. Alternative Payment Models include accountable care organizations (ACOs), patient-centered medical homes, and others. Merely eliminating MIPS and APMs from H.R. 2 will not adequately address these problems. They require much more work for a later date, hopefully leading to a single payer national health program.

On the other hand, eliminating means-tested premiums and mandated Medigap deductibles from H.R. 2 is an extremely urgent problem. We cannot allow incremental steps that shift more of the responsibility of paying for Medicare to the beneficiaries. AARP and the Medicare Rights Center agree. Sections 401 and 402 must be eliminated from H.R. 2.

Contact your Senators and urge other individuals and organizations to do likewise. Make telephone calls. Write letters. Send emails. Do it now.

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#