Thursday, September 24, 2009

New Pay System For Docs Likely

Two things have caught my attention this week on the health reform front:

1. Sen. Max Baucus says he plans to increase the subsidies available to lower-income individuals who would be hit hardest by his plan. As it stands, a person making as little as $32,500 a year (300% of the federal poverty line) would have to spend about $4,224 of personal income, pretax, out of pocket, before being eligible for any subsidy. And even then the subsidies are paltry. I haven't seen the details of what Baucus now proposes, and the New York Times is pulling the old "not immediately clear" business, so we'll see what he comes up with. But he told the paper "that he wanted to reduce the maximum amount that moderate-income Americans would have to pay in premiums ... to less than 12 percent of income." Not much; still incredibly unfair to lower-income people to force them to buy something they can't afford. So let's not get too excited. But at least it's a start.

Perhaps more interestingly ...

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2. An amendement from Sen. Maria Cantwell would change how physicians are paid -- dramatically and in unspecified ways. As Sara Michael noted in her post yesterday, the Cantwell amendment "would incorporate a quality measure" that would penalize doctors for "low-quality" care. But what does that mean? Beats me. There's no definition for it in the amendment; Cantwell would assign the HHS secretary to define it. By 2014, the secretary would "provide, to the extent feasible, information to physicians about the value of the care they provide," according to the amendement. If I'm reading this right, all physicians who take Medicare would get a letter in the mail in 2014 telling you whether you're any good or not. A report card, basically. Before then, expect FURIOUS lobbying over the details.

I agree in principle that the volume-over-quality method of paying physicians is nonsensical. I think most physicians would rather work in a system where they are paid for the quality of care they provide -- the better the care, the higher the pay. Ken Terry has some interesting news to report on the subject of phyician-payment, too.

But the devil has always been in the details. Who decides what "quality" is? How does that translate into higher pay? Are physicians providing better quality, by deifnition, if their patients are healthier? Of course we can all see the flaws in that line of thinking. There is also evidence-based medicine and most pay-for-performance programs pay doctors for demonstrating that they have followed evidence-based medicine protocols. But that raises questions, too, about how physicians would make that demonstration and which protocols to use. The results of Medicare's new P4P program were decidedly mixed, and that was only a small pilot.

So here is my question, folks: Do you agree that physician payment models need reform, and if so, how would you do it? Are specialists paid too much? Primary care too little? How do you crack the volume vs. quality problem -- or do you disagree that it is a problem. How should quality be defined, and by whom?

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