Health Care Payment Reform

I  interview physicians every week, and I often have the same thought as Dr. Matthew DiPaola expresses in a recent blog post.

The sense of dreary inevitability about the health care system that too many doctors walk around with these days must end.  Doctors, it’s time to take ownership of your profession…before someone who cares much less than you, does.

Many are uninformed about health care policy and seem beaten down by the system, as if they are powerless to do anything about it. This strikes me as troubling because the truth is physicians are the only ones that can save the system. Ultimately, health care happens through interactions between physicians and patients, and any health care reform ideas that physicians do not buy into will be sabotaged either overtly or covertly by their actions.

Thus, the future of the health care system depends on leadership from physicians. True, they did not sign up to be health policy leaders; their job is to be physicians. But no patient signs up for a broken leg; when a leg breaks, the patient takes immediate action to get it fixed so normal activities can resume.

More physicians need to take immediate action to fix the health care system (both in their daily patient care decisions and in advancing policy changes that can save the system) so they can practice medicine in a healthy health care system.

The role of doctors in health care reform cannot be overstated–and yet it is rarely mentioned.

Arnold S. Relman, MD, has a valuable perspective in today’s New England Journal of Medicine.

Mayo Clinic points out a problem with health care reform proposals on the table.  Since President Obama likes to highlight Mayo as an example of the way health care should be delivered, the nation’s health care payment system needs to support its high-quality, low-cost model.

According to a story on Minnesota Public Radio:

Mayo contends that there can’t be any real reform unless Medicare starts rewarding systems that provide quality health care at reasonable prices.

Sen. Max Baucus wants his health care bill to include changes to the Sustainable Growth Rate folly. Does he have an idea of how to do that? I’m eager to see what happens here.

In opening remarks, Baucus identified a major challenge going forward.

I want to acknowledge up front that we did not do as much to correct the payment of doctors—especially as I would have liked under the incredibly misnamed sustainable growth rate (SGR). The SGR needs to be fixed permanently. I look forward for further progress on this.

Today is a big day in health care, as the Senate Finance Committee starts marking up Sen. Max Baucus’s health care proposal.

Here’s what the American Medical Association thinks about the proposal. It’s not surprising to see AMA trying to protect physician incomes, of course. But its list of concerns suggest that the association is unwilling to support some of the basic tenets of health care  payment reform.

For example:

• AMA opposes mandatory participation in the Centers for Medicare and Medicaid Services Physician Quality Reporting Initiative. While PQRI is flawed in execution to date, quality reporting and accountability are essential to payment reform.
• AMA opposes payment reductions for physicians identified as high-resource users. Efficiency is not important in the country with the world’s highest health costs??
• AMA opposes budget neutral financing for primary care bonus payments.  How will primary care pay be raised in relation to other specialties if all specialties make more money?

Senator Max Baucus’s health care proposal would provide financial incentives to hospitals and physicians willing to work together as accountable care organizations. Here’s what is required, according to his proposal:

To qualify as an ACO, an organization would have to meet at least the following criteria: (1) agree to become accountable for the overall care of their Medicare fee-for-service beneficiaries; (2) agree to a minimum three-year participation; (3) have a formal legal structure that would allow the organization to receive and distribute bonuses to participating providers; (4) include the primary care physicians for at least 5,000 Medicare fee-for-service beneficiaries; (5) provide CMS with information regarding primary care and specialist physicians participating in the ACO as the Secretary deems appropriate; (6) have arrangements in place with a core group of specialist physicians; (7) have in place a leadership and management structure, including with regard to clinical and administrative systems; (8) define processes to promote evidence-based medicine, report on quality and costs measure, and coordinate care; and (9) demonstrate to the Secretary that it meets patient-centeredness criteria determined by the Secretary, such as use of patient and caregiver assessments or the use of individualized care plans.

And here is how incentive payments would be determined:

To earn the incentive payment the organization would have to meet certain quality thresholds. In determining the quality of care furnished by an ACO, the Secretary would be required to use measures such as: (1) clinical processes and outcomes; (2) patient and caregiver perspectives on care; and (3) utilization and costs (such as rates of ambulatory-sensitive admissions and readmissions).

We have not been hearing enough about what physicians think about the health care reform debate, so yesterday’s New England Journal of Medicine was especially interesting to me.

I was surprised by the survey results that a solid majority of physicians support a public option to increase competition competition for private insurers. I probably should not have been; physicians are getting increasingly frustrated with dealing with private insurers–apparently so frustrated that they are willing to take lower rates from Medicare (or other public insurance) than bear the costs of dealing with private insurers.

Even more interesting was another Perspective piece in yesterday’s New England Journal. The findings of another survey suggest to me that physicians’ low profile in the health care debate does not indicate apathy. Some interesting findings:

• 78 percent of respondents said that addressing societal health policy issues is in the scope of professional obligation of a physician.

• About 73 percent  said physicians are obligated to care for the uninsured and underinsured.

• 54 percent said they were morally opposed to using cost-effectiveness as a factor in deciding which treatments a patient should receive.

Are hospitalists a part of the solution to the problems caused by America’s fragmented health care system? Bob Wachter thinks so, and I think he might be on to something.

Wachter, chief of the division of hospital medicine at University of California-San Francisco, says:

…since hospitals are the target of most robust quality reporting, pay-for-performance, and patient safety mandates, hospitalists share their worldview on these issues as well. If I’m getting money from my hospital, I damn well better help the hospital achieve excellent performance on publicly reported hospital quality data, “no pay for errors”, Joint Commission National Patient Safety goals, patient satisfaction scores, readmission rates, and the other scary things that keep my hospital CMO up at night.

In other words, well-organized hospitalist programs share their hospital’s accountabilities.

I wonder if hospitalists, generally speaking, are in leadership positions in which they can maximize the shared accountabilities that lead to better quality and lower cost care. Your thoughts, please?

My “Practice Matters” column in Oncology Times received a bronze award in the Regular Department category of the American Society of Health Publication Editors annual competition!

Actually, I tied with McKnight’s Long-Term Care News but still…  First place went to American Medical News and second to Modern Healthcare, so I’m in good company.

Four of my other clients–HealthLeaders, Physician Executive, Nephrology Times and Neurology Today–also won awards!!!

Dr. Ron Paulus, chief technology and innovation officer at Geisinger Health, tells me that Geisinger is working on a model to encourage patients to comply with physicians’ orders–because patients tell physicians what orders they want to receive.

It seems to be working. Here’s what he says:

We know that many patients don’t actually follow the advice that they’re given by their physician, and our belief is that’s not because those consumers are stupid or mean-spirited. They’re actually very smart and they have a lot invested in their own health, obviously. We felt that there was a disconnect between what that consumer may be desiring and what it is that is being prescribed.

So we developed a mechanism, a touch screen-based questionnaire method, to elicit what kinds of interventions patients with coronary artery disease might be willing to undergo. Would they be more interested in drug therapy, or more interested in diets, or more interested in exercise?  And we also asked them questions, including, “I don’t want to do anything about my care.”

We think it’s very, very important to elucidate those preferences so that the doctor/patient interaction can focus on education, counseling, advice, and mutual engagement around what the right strategy is in caring for this particular patient’s disease.

…This whole area of activation and preference-eliciting is trying to make sure that the clinician and the clinical team and the consumer patient and his or her family or loved ones are all on the same page together. They all understand their mutual responsibilities, and they’re working toward a common outcome goal, where that consumer is engaged and willing and eager to follow that plan to achieve better health.