Reinhardt's lament

Anybody see Uwe Reinhardt's post in the New York Times Economix blog this morning? Reinhardt, a healthcare economist at Princeton, responds to a recent Peggy Noon column, called Common Sense May Doom ObamaCare, with a depressingly dead-on list of what constitutes "common sense" thinking about health reform.

The list basically boils down to: Americans don't want any limitations on what treatments they may have; if their doctor says they should have it, then they should, whatever the cost and however unlikely it is to provide very much relief. On the other hand, people should not have to pay for this themselves. Other people should pay. And yet the government shouldn't spend more money on healthcare or raise anyone's taxes. Got all that?

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He's right, of course. People can't have everything for free. That's why it is so disingenuous of the president to keep telling everyone, "If you like what you have now, you can keep it." He's saying, "Hey Everyone: We're gonna change healthcare, which constitutes one-sixth of our economy, but don't worry -- you won't have to change unless you want to." That's not being honest. And it's not persuading people. What we have now is an unsustainable addiction to unnecessary and expensive care.

The question is: How do we break the addiction? One way is through a government board of medical experts who would decide for everyone what treatments are cost-effective, a la England. I don't think Americans will accept that.

Another is by devising a privately run system that makes real headway in moving people off their employer-subsidized care and into insurance plans in the individual market. People would choose whatever plan they want, getting help, presumably, from some government-run online marketplace that simplifies the choices. They would pay for it with a combination of their own money and government subsidies. The public money would come from taxes on employers (who would no longer have the need to cover their employees). If people want the expensive Cadillac plans, fine, but they have to pay for it, because the subsidy would be based on their income, not the plan they choose. When they see the price tags they might realize the benefits of more cost-effective care, but for those who don't mind digging deeper, I say go for it -- as long as it's their nickel.

You could also give real teeth to the Medicare payment commission's recommendations, which would not only save Medicare money but also provide cover to private insurers looking to cut their own costs. And such a reform would not necessarily preclude, at some future point, the addition of a "public option."

Let's have debates on reform

With it now clear that Congress is not going be voting on any particular version of healthcare reform until after the summer recess (it must be nice having a "summer recess," btw), and with polls showing public support quickly waning for what's fast becoming known as "Obamacare" (whatever that means), I'd like to propose a series of televised debates on the subject between the president and whomever the Republicans want to put up.

I will even volunteer to moderate.



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I'd like to know how, precisely, the president proposes to slow cost growth while covering about 47 million more people, without affecting the quality of care for people who already have coverage, or raising middle class taxes. Seriously, I don't understand most of the bills that are being floated by the various committees, and I follow this stuff closely. For example, yesterday we learned that conservative Democrats managed to "cut" $100 billion out of one of the House bills while also getting promises that rural hospitals won't see their Medicare rates drop. Set aside the Washington inside baseball for a moment. Assuming this is the idea that makes it through the House, I'd like to know: Where is this $100 billion? Are these real or phantom cuts? And that's just the tip of the iceberg.

So it's time, I think, for the president to quit making stump-style speeches and just put his cards on the table. Is it too much to ask for him to get specific and just tell us what he wants to do?

I have questions for Republicans, too. Do they have any ideas at all about how to reform healthcare? Anything? OK -- tort reform. I'll give them that. Anything else? They're terrific at shouting "socialism" but what do they actually propose? They ran Congress and the White for six years, and we got, what, exactly, out of them (other than tort reform) in the way of health reform ideas?

So it seems to me that both sides have a lot of explaining to do. Let's do it right by having a series of presidential-style debates, on different aspects of healthcare reform.

What questions would you ask the president or Republicans, if you had the chance?

UPDATED POST: Red Flags rule enforcement

UPDATE: Thanks to an anonymous reader for alerting me to today's FTC announcement that, in fact, the deadline has again been extended for compliance with the Red Flags identity theft rule.

The FTC is giving creditors more time to develop policies. Now, practice have until Nov. 1, 2009 to comply. So, as it turns out, Saturday Aug. 1 is NOT the deadline, as I initially indicated below. But still read on for some other good information -
assuming you'll eventually have to comply!


The deadline for complying with the FTC's new Red Flags rule for preventing identity theft is fast approaching.

This means creditors — including most medical practices — must be able to spot the warning signs, or so-called “red flags,” of identity theft and have a process for preventing and responding to identity theft.

Have you developed a policy yet? Read more
If you've been dragging your feet and need some help, here are some really useful tools to get you started. Here, you'll find a Red Flags identity theft policy, board resolution, and contract addendum. And here you can access a Red Flags identity theft affidavit and notification of suspected identity theft form.

For more, go to our Red Flags resource page.

And please feel free to offer your insights on this new requirement. Does your practice have a policy in place? Any tips or advice for other practices?

Podcast: urgency for healthcare reform

"There's a feeling of some urgency that we do need reform."

That's from Dr. Ted Rosen, a professor of dermatology at Baylor University and editorial board member and frequent contributer of Consultant magazine. In the first of three podcasts, Dr. Rosen begins to offer some of his views on healthcare reform.

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Dr. Rosen lists a few areas needing to be formed, among them cost containment, quality of care, access to care, and availability of insurance.

To listen to this podcast, which is hosted by our sister publication -- and later the entire series called "What do the Washington healthcare reformers have in mind for you and your patients?" -- visit Consultant Live.

Feel like listening to a couple more podcasts? Check out our interview on the Red Flags rule -- which goes into effect Aug. 1 -- and a discussion on the EHR stimulus plan.

Hurdles to healthcare reform

Just as most people have ideas of how to fix the healthcare system, nearly everyone has thoughts on what’s standing in the way of real reform.

Time magazine today lists the five biggest hurdles to healthcare reform:
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1. Curbing costs – Skyrocketing costs were a major justification for the overhaul, but Democrats on Capitol Hill are instead struggling to find ways to save money in the long run.

2. Raising revenue – While much of the reform would be paid for by fines, reduction in Medicare payments, and corporate and foreign tax changes, there’s still a shortfall that needs to be funded and several options are being floated.

3. Coverage questions – How do add coverage for nearly 50 million uninsured Americans? Enter the controversial public plan or the proposal to broaden Medicaid guidelines.

4. Personal touch – President Obama has left the details up to Congress, and some say he isn’t offering enough guidance. Health reform needs stronger involvement from the White House.

5. Public perception – Americans are growing more and more skeptical that Obama can implement reform in the next four years.

Surely, the list could go on. Last year, we explored our system’s biggest problems – and some fixes. What do you see are the greatest hurdles?

Docs and Twitter

Since joining Twitter a few months ago, we have watched our network grow and each day the Twitterverse is abuzz with interesting links and insights, many of which are from doctors.

I recently began to wonder how and why doctors use the social media. Somehow docs are finding time to pound out – in 140 characters or less – updates on what they are doing, links to articles they read, or re-tweets (resent tweets) of others' Twitter updates. Read more

(Right now, I am putting together a podcast on the topic and interviewed a couple doctors about their Twitter use. The American Medical News also had an interesting story on it.)

Many doctors seem to be sending out links and news items, while others are broadcasting the minutia of the day. One doc we follow and whom I interviewed, sends sometimes a dozen updates in a day, some of which offer a glimpse into the daily grind:
“ahead of schedule for a change”
“in office. there are already four people waiting at the door and it looks like all of them are waiting for me”
“time for bed”

Another doc told me it builds a community among physicians and others, and that often medicine is far from the tweet topics. And that Twitter is the new blogging.

Should docs use Twitter? If you’re a tweeter, why? How do you balance building a community with divulging too much personal information (on your or patients)? And how do you find the time?

What Obama Thinks of Doctors

Did anyone notice that President Obama seemed to be calling American physicians hucksters last night? I wouldn't have believed it myself if I hadn't heard it with my own ears. A reporter asked if he'd be willing to "guarantee" that the government wouldn't prevent patients from gaining access to particular treatments. The president said no, he would not. Then he said:

"Right now, doctors, a lot of times, are forced to make decisions based on the fee payment schedule that's out there. So if they're looking and -- and you come in and you've got a bad sore throat, or your child has a bad sore throat, or has repeated sore throats, the doctor may look at the reimbursement system and say to himself, "You know what? I make a lot more money if I take this kid's tonsils out."

Now, that may be the right thing to do. But I'd rather have that doctor making those decisions just based on whether you really need your kid's tonsils out or whether it might make more sense just to change -- maybe they have allergies. Maybe they have something else that would make a difference."


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Got that?
You're "forced" to make decisions based on the fee schedule, and you're unnecessarily removing children's tonsils(!) just to make a buck. Fear not, however, because "part of what we want to do is to free doctors, patients, hospitals to make decisions based on what's best for patient care."

Well. That is quite a statement. I wonder what you all think of it: Are you indeed performing unnecessary procedures because of the fee schedule? Have you ever said to yourself something like "You know what? I make a lot more money if I take this kid's tonsils out," and then done so, needlessly? What other unnecessary and potentially dangerous procedures have you performed on children, just because you'd "make a lot more money"? (Don't worry; it's an anonymous forum.) Do you find that statement insulting? Is anyone concerned that the President of the United States thinks that this is what you do?

Advice from an overweight doc?

What does it mean when the doctor clearly can’t follow the doctor’s advice?

Pediatrician Perri Klass explores the issue in a NY Times column this week. She struggles with her weight, but then she faces giving advice to an overweight 8-year-old. Read more

She asks: “How on earth, I was thinking, am I supposed to give sound nutritional advice when all they have to do is look at me to see that I don’t follow it very well myself?”

Doctors, of course, are human, and struggle as everyone does with finding free time. And as Klass says at the end of the column, “If this were easy, I would be thin and fit.”

But does it make it harder for an unfit doctor to dole out healthy lifestyle advice? Or does the doctor have the advantage of personal experience and compassion for the patient struggling to be healthy? In the end, does it matter at all to the care of the patient whether the doc exercises and eats well?

In our recently-completed Great American Physician survey, which will run in an upcoming issue, we found most of you do think the doctor has some responsibility here. In fact, 90 percent say it’s important to set an example for patients.

Although most of you eat well and exercise fairly regularly -- and I talked with several docs who lift weights, walk, and practice yoga -- 45 percent of you admit your body mass index is a bit higher than it should be (and 13 percent say much higher). A quarter of respondents don’t eat right most of the time, and 3 percent smoke cigarettes.

But does it matter?

Someone gets it right for a change

Jacob Weisberg of Slate explains why the mantra "If you like your current health care, you can keep it, period" -- a phrase President Obama repeats often and which might be the only thing Democrats and Republicans agree on in the health reform debate -- is exactly the wrong way to go.

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And here I was thinking I was all alone in the wilderness.

Weisberg argues correctly that "we're missing the boat most completely by sticking doggedly with a workplace-based system that no longer makes sense." Amen, brother. He argues, as I have, in favor of the bill known as the Wyden plan, and nicely explains how it works.

The president could explain all this to the American by saying something like this: "Sorry, folks, but you will have to change your health plan. That's the bad news. The good news is that you won't be forced into any particular plan (like you probably are now at work) but instead will have a range of options. You'll get government assistance to help pay for it (in lieu of your current employer subsidy), and because you'll be buying insurance in the individual market, you'll also get to decide what to buy. If you like your current plan, you'll be able to choose something very much like it, and you'll probably be able to keep your current doctor. If you want the Cadillac coverage, you'll have to pay more out of your own pocket. But it's your choice. You can also change your mind, so if you're not happy with the plan you pick, just fire 'em and pick a different plan, just like you could with your car insurance. Again, it's your choice."

Now that would be change I could believe in.

Physicians not getting contracted fees

The American Medical Association has just posted its insurer report card, with detailed data on how the payers are treating physicians. It lists only a handful of national payers, plus Medicare.
(The AMA's efforts dovetail with Physicians Practice's own PayerView report with more payers.)
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Of particular interest in the AMA report: The contracted fee schedule match rate -- how often did actual payment match the what the physician is supposed to get contractually? -- ranged from a high of 98% to a low of 72%.
Make sure your posters don't just accept remitted fees. Use systems that check to make sure you get what you deserve.

GOP docs challenge AMA support

The AMA's endorsement last week of the House Democrats' healthcare bill no doubt raised some eyebrows. And sure enough, a group of Republican physician congressmen is challenging the position.

In a letter sent Friday to the AMA, 12 members of the GOP Doctors Caucus expressed their disappointment for what they called a "blanket endorsement" of America's Affordable Health Choices Act or 2009: Read more

"Several important principles that you have strongly advocated for in the past are missing from the bill, such as liability reform, Medicare payment reform, and antitrust issues. This inherently jeopardizes the well-established relationship that exists among the over 250,000 members of the American Medical Association and their patients.”

It looks like the group’s real concern lies in the proposal’s public option. The AMA has traditionally been a conservative group and support of a government-run health plan was a bit controversial.

(The GOP Doctors Caucus was formed in March to boost Republican physician influence, according to an American Medical News story. Most of the docs in Congress are Republicans, and health reforms are being heralded by Dems and the administration, so I am guessing there isn’t a Democratic counterpart to this group?)

Here’s the end of the letter: “... we fully believe that the AMA has lost touch with the vast majority o f physicians in this country. We therefore urge the AMA to reconsider its support for H.R. 3200.”

Do you agree? Who is rightfully representing the voice of the physician in this debate?

And finally, considering the discussion here lately about docs and the AMA, check out a recent Physicians Practice story on whether associations are worth joining.

The culture gap in healthcare

In a NY Times column this week, Pauline Chen, MD, tells the story of two Asian-American sisters, both infected with hepatitis B and one of whom is suffering from liver cancer.

The family would later discover that all six siblings contracted hepatitis B, which predisposes people to cirrhosis and cancer, from their mother, who died of liver cancer. Two brothers also later died of the disease.

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Hepatitis B is more common among Asians, and Chinese are at highest risk, Chen writes. But it seems clinicians the family members had seen earlier weren’t more aware of health risks of Asian-Americans.

Although this has been changing in recent years, and medical schools have been responding with “cultural competency” curricula, a level of cultural understanding seems critical for the health of the patient and the relationship between patient and doctor.

We addressed cultural competency in an article about how it can improve patient care and build your business.

Without some level of awareness of cultural differences, Chen points out:
- Clinicians could miss important medical implications
- The healthcare worker may risk alienating the patient
- The patient’s perception of the care may also be effected

Considering physicians' time constraints, it’s hard to know everything about everything. But, Arthur Kleinman, physician and professor of medical anthropology and psychiatry at Harvard Medical School, tells Chen: “What you don’t want is doctors carrying around plastic cards listing the five things you need to think about when you see, for example, an Asian-American patient.

“What you want is the ability to inquire, to ask questions.”

Have you had experiences like this that tested your cultural competency or prompted your practice to make changes? Is it possible to have a full awareness of cultural differences?

Will Congress have to give up Medicare payment control?

It’s quite a perk and a campaign tool for Congress: setting Medicare reimbursement rates for their local hospitals, doctors and home healthcare centers. (Take, for example, Alaska Republican Ted Stevens who managed to secure a permanent 35 percent increase in Medicare payments for Alaska physicians. How’s that for constituent services?)

Now, President Obama is considering taking that power away from Congress, potentially shifting the control to an independent entity, according to the Washington Post.

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An advisory group might be better willing and able to tackle the skyrocketing Medicare spending. The House’s healthcare proposal announced this week, which Bob blogged about yesterday, doesn’t include ways to stem future Medicare costs.

But opponents argue that Congress will be held accountable, even if the power is taken away, so they should be able to protect the interests of their constituents. What do you think?

(Of course, Medicare reimbursement and reform has been a never-ending debate. In the meantime, check out our story on how to actually make it work for you.)

How Much is Your Life Worth?

What's a QALY? It's an acronym for Quality-Adjusted Life Year: a unit of measurement designed by economists to calculate how much value "a generic human life" has based on how many years the person probably has left -- and the "quality" of those years -- compared with someone of ordinary health. It's a chillingly straightforward formula that is used in many countries to determine whether to pay for a particular treatment: if the treatment costs X and delivers Y benefit, is it worth it? If the benefit is that it extends your life by a year, but no more, and costs, say, $50,000, is that a good deal?

You might say "Yes, of course, a year of my life is worth that." But here's the catch: The entity that gets to answer the question is not the person whose life is at stake; it's the one paying the $50,000. In a publicly financed healthcare system, it would be answered, most likely, by a panel of economists and physicians appointed, probably, by the Secretray of Health and Human Services. In England, for example, this panel is called the National Institute for Health and Clinical Excellence, better known by the Orwellian acronym NICE.

I think this concept is coming soon to the United States. We will all know what "QALYs" are, and how to calculate them. Check out some of the commentary and coverage of health reform ideas that we've published.

So, how does the QALY formula work?

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In a much-discussed article in the New York Times (to be published this weekend in the Times Magazine), bioethics professor Peter Singer explains it. He says that "The dollar value that bureaucrats place on a generic human life is intended to reflect social values, as revealed in our behavior." Since most people would pay almost anything to save their own lives, he explains, the bureaucrats instead start by examining how much people are willing to pay to reduce the RISK of their own death.

He goes on:

"How much will people pay for air bags in a car, for instance? Once you know how much they will pay for a specified reduction in risk, you multiply the amount that people are willing to pay by how much the risk has been reduced, and then you know, or so the theory goes, what value people place on their lives. Suppose that there is a 1 in 100,000 chance that an air bag in my car will save my life, and that I would pay $50 — but no more than that — for an air bag. Then it looks as if I value my life at $50 x 100,000, or $5 million."

How do you value the life of someone with a disability versus someone who doesn't have a disability? That's in there, too. He acknowledges the obvious flaws in this system but dismisses them are mere inconveniences.

How does all this sound to you? I'm no pollyanna: I understand that every system of allocating a resource (like healthcare) amounts to rationing when the demand for it is greater than the supply of it. America rations healthcare by price, through a bad facsimile of a free-market system known as the "large group market," paid for mostly by employers. The question is who should do the rationing, and how? Any sensible discussion of health reform must begin with that question.

An Awful Proposal from the House

So, a few questions for the House Democrats and the president concerning yesterday's House proposal to raise taxes on rich folks and the upper middle class to pay for healthcare reform:

1. Mr. President, you said, in praising the proposal, that it "will lower costs, provide better care for patients and ensure fair treatment of consumers." Why does something that will lower costs require the raising, by House estimates, of "more than $1.2 trillion over the next decade." Something that lowers costs makes it cheaper, no?

2. The new "surtax" combined with the expected expiration next year of the Bush tax cuts, will push the highest federal tax rate to 45 percent. Add state and local taxes, and some people will now be paying most of what they earn to the government. Is that what you meant by "fair treatment"?


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3. The new tax hikes would affect 2.1 million taxpayers, according to the Tax Policy Center. The money raised would be used to cover 37 million uninsured Americans. That means that EACH of the 2.1 million Americans will be, in essence, paying for the healthcare of almost 18 people. Is THAT what you meant by "fair treatment"?

4. The House bill would require everyone to carry insurance coverage, offering tax credits to people making as much as 400% of the federal poverty level -- $43,000/year for an indivdual. The penalty for noncompliance is 2.5% of income. So a young, healthy, self-employed person making $43,001 a year would pay a penalty of $1,075 for not buying coverage. On the individual insurance market, such a person would expect to pay between $2,200 and $3,200 yearly for low- or no-deductible coverage. He would get none of the rich people's money. Given the choice to pay the $1,075 penalty or two or three times as much for coverage he would probably rarely need, which do you think he would choose?

This House plan is not likely to pass. The Senate isn't interested. But the Senate has its own bad ideas. The only good idea on health reform that I've heard is from Sen. Ron Wyden, an Oregon Democrat. See my columns on the subject here and here

Currently, his proposal is being ignored, perhaps because Republicans have belatedly said they could get behind it. (Where were they three years ago?) Maybe we'll get lucky: The House and Senate will fail to agree on a plan, or that whatever they agree on will be distateful enough to moderates in the Senate to sustain a filibuster. Then, next year, maybe they can get it right.

Essay: An unusual charitable contribution

Urologist Neil Baum submitted this essay recently, and we thought it was great. Please read his full essay here about his unusual payment option for a payment, and join in the discussion.

"I performed a neonatal circumcision in the office on a 7-day-old child. After the child was taken home, the parents called the office that there was excessive bleeding on the underside of the penis. I suggested that they compress the area with a sterile sponge for a few minutes and then call me back. When that suggestion did not solve the problem and the bleeding persisted, I requested that they bring the baby back to the office. Read more

Upon examination I noted a small blood vessel that was actively bleeding at the frenulum. This was easily controlled with a single absorbable suture and the baby was sent home.

I contacted the family multiple times during the evening to check on the baby and to reassure the parents that the child was going to be okay. The next morning I called the baby’s pediatrician and reported the complication and suggested that the baby come in for a CBC as several four-by-four sponges were soaked with blood with an estimated blood loss of 50 cc.

The baby was seen an additional six times in the office. At the last visit, nearly three months later, the parents pointed out a one- to two-mm area of adhesion between the glans and the ventral shaft skin where the suture was placed. I asked the parents if they observed his erection and if there was there any ventral curvature as a result of the adhesion. The parents said that his erection was straight without any angulation. I reassured them that this was of no consequence and that it would not affect his urination or his ability to have an erection. I also asked about the force and caliber of the urine stream and they indicated that it was also normal.

I submitted a bill to the parents. The parents responded with an e-mail note that they were unhappy and concerned about the adhesion and that they wanted to obtain a second opinion with another urologist. The note said that they were going to have added medical expenses, and as a result, they were “uncomfortable” paying the fee.

I called the family and asked them when they were going to obtain the second opinion and they gave me the date. I called the family after that date and they indicated that the pediatric urologist whom they contacted said that the tiny adhesion was of no consequence and he reassured the parents that nothing further needed to be done.

I told the family I was going to submit another bill, and I received a check for half the amount with a note on the bottom of the check as “payment in full for medical services.”

I called the family and politely informed them that I was not accustomed to negotiating my fees after the services are rendered and that I don’t allow patients to determine the value of my services. I told him that I would return the check and that he should do what he felt was appropriate.

After several weeks with no response, I contacted an attorney. I suggested that the attorney write him a letter requesting payment. However, I wanted to demonstrate that I wasn’t personally interested in receiving the money. Through the attorney I offered an alternative plan suggesting that the patient’s parents should make out a check to my synagogue’s social justice fund for the full amount and that the parents could use the donation as a tax deduction.

The check was soon sent to the synagogue and I received a nice note of thanks from the rabbi. I sent the baby’s parents a note thanking them for the donation and hoped that we could all put this behind us.

I believe this outcome was not only satisfactory to me, as I was not forced to have a patient determine the discount for my services, but also to the patient’s parents as well. It is another example of my wise mother’s advice: you can likely get your own way if you have more ways than one!"

On fighting sarcasm for the genuine

Sermo, the physicians discussion forum, and the AMA have been fighting.
The issues behind the hair-pulling are not nearly as interesting as Sermo's claim that 75% of physicians on its site aren't even members of the AMA. (The ever wry Dr. Bobbs commented to me that he's surprised 25% of physicians on Sermo ARE members.)

Which raises the question: How can physicians have influence if not through a major lobbying group like the AMA? Read more
One of my first columns for Physicians Practice asked why physicians don't more often try to change their situation, instead of allowing themselves to be victims.

But maybe the little victories are enough: The patient you help. The payer you influence.

In a post-modern society, are little, self-empowering actions all there is?
Obama ran and won on a platform of Hope -- which seemed mostly to mean a sense that every individual can impact the process. Do you buy it?

Multiple payers buy in on medical homes

Are the stars aligning for a robust medical home movement?

Pilot projects for the patient-centered medical home being launched in four states have what apparently most — if not all — other efforts lacked: involvement by multiple insurers, according to an American Medical News story.

Under the medical home model, patients have a central primary-care physician directing their care (aimed at improving quality of care and lowering costs), and docs are paid extra for coordinating care. Read more about the model and preventive care in a recent Physicians Practice article.
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The idea isn’t new, but has been gaining momentum. What’s needed for widespread adoption? Reimbursement reform and electronic records, pediatrician and medical home proponent W. Carl Cooley tells AMNews.

Are these latest pilots the answer? Here, the plans and the docs will track patient outcomes, sending the data to be studied and published, which shed some light on how much money the model can save.

What do you think of the medical home model? Is this development signaling payer buy-in? Will it work?

Hospitals attack physician-owned facilities

Having launched the week with gracious concessions to accept Medicare and Medicaid pay cuts for the sake of US healthcare, hospital organizations are now insisting on restrictions on physician-owned hospitals as part of the deal.

Traditional hospitals have long seen physician-owned centers as unfair competitors. (Here's a story with some history of the conflicts and new models for cooperation.)

But it's too bad, because what the healthcare world needs now is love sweet love. We need more integration, more cooperation, more information sharing, more seamless care -- and fewer grabs for power and cash.
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It's much too early to tell if these requirements will be built into final legislation, but the hospital lobbying groups are powerful. If you work in a physician-owned hospital or surgical center, it's time to start some lobbying of your own to prove the high quality, cost-effective care you deliver.
And, really, take the high road and show some love to your local hospital. It can work out well.

Time for clear talk on reform

When Obama visited the Middle East, pundits marveled at how he swept aside political platitudes for straight talk. For example, he called for an end to Israeli settlements while still insisting that Israel has a right to exist.
No duh.

That has long been the assumed basis of policy change in the Middle East, it's just that no one has wanted to say so out loud.
However, similar clarity seems to be lacking in debates around healthcare reform.

To wit, the "hospital industry" agreed this week to $155 billion in Medicare and Medicaid cuts over the next decade to pay for health reform.
Really?
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CMS can cut payments if it wants without the hospital industry's agreement. They've been doing it for years.

And it's not true that the hospital industry is accepting cuts. That makes them sound very nice and all that, but they expect to make the losses up as more uninsured patients get coverage under a government-supported health insurance plan.

For physicians to really buy in to health reform, I think they need to see that it will really mean better health for their patients. Not just a shift in how hospitals get paid and some sort of "kumbaya" posturing.

CMS' proposed payment shift

It looks like a boost to primary-care physicians could come at a cost to their higher-paid specialist brethren. CMS’ proposed 2010 physician fee schedule released last week would cut rates for specialists and imaging services, shifting the pay to primary care.

Organizations have been parsing through the regulation to see just how deep the cut would be for each specialty (cardiology: 11 percent, for example), while CMS says the regulation would increase payments to general practitioners, family physicians, internists, and geriatric specialists by 6 percent to 8 percent.Read more
To do this, CMS would eliminate payment for consultation codes, which are billed by specialists and paid at a higher rate than E&M codes. CMS says “resulting savings would be redistributed to increase payments for existing E&M services.” CMS would also refine practice expenses and revise malpractice premiums.

Overall, physicians’ payments would be slashed by a whopping 21.5 percent under the proposed regulation.

That is, unless Congress enacts legislation reversing the cuts, a strong possibility. The rates are updated each year based on the sustainable growth rate, which has yielded reductions for the last eight years. But, Congress has stepped in to avoid the cuts each year. (Meanwhile, specialists’ groups say they will lobby lawmakers to stop the cuts, according to the Wall Street Journal.)

Our own Pamela Moore addressed the threat of cuts last year and what docs should do if they are considering reducing their Medicare mix.

What do you think? Is this an effective way to close the pay gap between primary-care docs and specialists? Is this another sign the Obama administration is serious about primary care?

The regulations also included perhaps some good news for all. CMS proposed removing physician-administered drugs from the formula used to calculate the fee schedule, which has been long advocated for by the AMA and MGMA. (Cost hikes for outpatient drugs in recent years have outpaced other services, pushing spending levels above the target, according to AMA.) It wouldn’t prevent the 2010 reductions, but it would mean fewer years of negative updates.

All of that said, CMS is accepting comments until Aug. 31 and a final rule will be issued by Nov. 1. Congress, your move.

Welcome!

Hello and welcome to Practice Notes, a blog by Physicians Practice. Here, we will be bringing you news and commentary on practice management and healthcare policy issues.


We encourage you to contribute with comments and questions. And as always, please visit us at PhysiciansPractice.com for our regular journal articles, podcasts, tools, webinars and more.