Trendspotter:Healthcare Reform Is First Step To Shore Up Deteriorating System

By Ken Terry

Many pundits have weighed in on the likely consequences of not passing healthcare reform, which is expected to come to a head within the next few days. But a recent blog post by Matthew Mintz, MD, an internist in Washington, DC, puts things in perspective for physicians.

Judging by his essay, Mintz is neither a Tea Partier nor a single payer advocate like those who belong to Physicians for National Health Program (PNHP). Both the Tea Party and PNHP oppose the reform bill—the former because it would expand government intervention in healthcare, and the latter because it fails to put government in charge of healthcare. Mintz is not concerned that the proposed legislation would give the government too much power; rather, he worries that, in the absence of reform, the healthcare system will continue to deteriorate. In fact, he believes that while the reform bill deserves to pass because it expands insurance coverage, healthcare will decline even if it's adopted. What’s missing, he says, are more stringent cost control measures and a plan to increase the supply of primary care.

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Writes Mintz: “Though our dysfunctional system and plans for reform may not affect you now, things will get worse. Without addressing costs, premiums will continue to go up and even more patients will lack the ability to afford health care coverage. Without addressing the bureaucracy of insurance paperwork and the pay disparity between specialists and primary care physicians, students will continue to go into non-primary care fields and current primary care doctors will retire. In addition, our nation is only getting older and fatter, and thus sicker and more expensive.”

Despite the shortcomings of the reform bill, Mintz views it as an essential step toward providing everyone with high-quality care at an affordable cost. If the legislation is voted down, he points out, Congress will probably not revisit the issue for a long time to come. By then, he says, things will be so bad that everyone will be demanding reform.

I agree with Mintz on the politics of reform, and I also concur that the system’s decline will accelerate unless the federal government takes decisive action. But several elements in the bill could help slow cost growth. One is the proposed Independent Medicare Advisory Board, which would theoretically have more power than the current Medicare Payment Advisory Commission (MedPAC) to make changes in Medicare reimbursement. While the proposal has elicited strong opposition from the healthcare industry, including medical societies, it's needed because Congress is too political to make the required cost-cutting decisions. The problem with the proposal in its current form is that it takes hospitals, physicians, and drug companies off the table for the next decade. So it would not have much practical effect unless later legislation gave the independent board real authority.

Another provision in the bill would encourage the formation of accountable care organizations – combinations of hospitals and physicians that would share in whatever savings they produced for Medicare by improving coordination of care. Most likely, big healthcare systems would take advantage of that opportunity. There are also demonstration projects for payment bundling and enhanced home care for chronically ill seniors. Many hospitals are already preparing for payment bundling—which would provide a single payment for multiple kinds of services, such as acute and post-acute care—by employing more physicians.

Last but not least, the Senate bill that forms the backbone of the final reform legislation places 1 to 2 percent of hospitals’ Medicare reimbursement at risk for meeting quality and efficiency targets. While the bill is not specific about physician incentives, it proposes studying physician utilization patterns before deciding how much of your reimbursement to put at risk.

As for increasing the attractiveness of primary care to young doctors, the bill would shift some Medicare funds from specialists to primary-care physicians—a direction in which CMS has already started moving.

Needless to say, the AMA and many specialty societies oppose most of these initiatives. So if Washington is really interested in cost control, it’s unlikely to get much help from physicians. And yet, if both public and private health spending growth is not restrained, an increasing percentage of patients will no longer be able to afford your services.

Trendspotter: AMA To Give Small Practices a Helping Hand in Launching EHRs

By Ken Terry

Small physician practices are less likely than big groups to have electronic medical records—and there’s a reason that goes beyond cost. They lack the resources and the technical knowledge to implement these complex systems. The support and training that vendors offer is frequently inadequate, especially for physicians who aren’t especially computer-savvy. And the vendors freely admit that they don’t have sufficient staff to cope with the expected influx of new EHR buyers who want to show meaningful use by 2011, when the government incentives start flowing.

Under the HITECH provisions of the American Recovery and Reinvestment Act (ARRA), the government is required to create health IT regional extension centers (HITRECs) across the country to help up to 100,000 primary-care physicians install EHRs in their practices. The Office of the National Coordinator for Health IT has allocated nearly $600 million for this purpose, and 60 HITREC grants will be handed out by the end of March.
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Some healthcare systems are taking advantage of the Stark exception to subsidize EHR purchases by non-employed staff physicians, and far more are trying to get their employed practices online. But in either case, the demands of working with a multitude of small practices to implement EHRs exceeds the capacities of most hospital IT staffs. Moreover, the hospital IT people have expertise in inpatient systems but know little about ambulatory-care EHRs.

The AMA is trying to help fill the gap by creating a new web portal that will “provide physicians access to information, products, services, and resources to help facilitate medical practice and ease adoption of health information technology.” While the AMA will give doctors access to e-prescribing and lab ordering applications via the portal, now in beta test mode, AMA’s partner, Dell Perot Health Care Systems, will help physicians implement their EHRs. According to Dell Perot, the AMA will initially offer its member an Allscripts EHR, and it appears that other products will be made available later.

No pricing was available at press time. But, since Dell Perot will host the EHRs on a remote server, upfront and maintenance costs will be lower than they would be if the program and the patient data were hosted on an in-office server.

The big question is how effective Dell Perot can be in working with small physician practices. Both companies have extensive experience in helping hospitals set up and integrate their systems, and Perot—which merged with Dell last year—has also done a lot of outsourcing work for hospitals. The company has also been helping some big healthcare systems, such as Memorial Hermann in Dallas and Tufts Medical Center in Boston, ramp up EHRs in the offices of affiliated physicians. But small independent practices outside the orbit of a healthcare system present a different set of challenges.

In an interview with Physicians Practice, Jamie Coffin, vice president of Dell Healthcare and Life Sciences, pointed out that Dell has helped computerize lots of small businesses in non-medical fields. Of course, that doesn’t mean too much, because EHRs and healthcare are much more complex than, say, a bookkeeping system in a restaurant chain.

Part of the small-practice solution, Coffin indicates, is to use remote training and support tools. Dell Perot will install the hardware, do a “brief touch” in the practice to get the software running, and then follow up online. This does not leave much room for change management or handholding, and practices that cannot figure out how to use the software quickly might drop it, as many have before. But based on Dell Perot’s success to date in working with healthcare systems, they’re hopeful that this approach will also click in private practices.

In any case, Coffin points out, the AMA-Dell venture will fill a need as physicians scramble to show meaningful use. “The real question is whether EHR vendors can scale to the number of installations they have to do over the next 36 months,” he says. “It’s not a cost question for them, it’s an issue of whether they can scale to the demand. They’re going from 1,000 implementations a year to 10,000-20,000 or more. That’s one reason why they’re looking at companies like Dell and Perot.”

A little more liability premium relief

The pain of high medical liability insurance premiums continued to ease a bit for most physicians — but perhaps not for long. An annual survey found that 94 percent of premiums are holding steady of dropping this year, according to American Medical News.

But despite the dips, they are still inflated after the rate hikes in the early 2000, insurers say. And this relief could be short-lived.
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According to the Medical Liability Monitor survey, 58 percent of premiums had no change (up from 50 percent last year), 36 percent of premiums fell (down from 43 percent). Two years ago, a full 16 percent of premiums went up, so increases have slowed.

At the same time, jury awards are climbing steadily, so it won’t be long before rates rise again, insurers say.

The news of this survey comes just as I am researching for an upcoming story on how to keep malpractice lawyers at bay. Several pieces of advice I’ve been told so far revolve around treating the patient with respect and setting a tone in the office that makes the patient feel valued and comfortable. Little things mean a lot, consultant Judy Capko said. Even eye contact and friendly body language can go a long way.

Here’s a recent column with 10 ways to keep lawyers at bay, and look for more in the March issue.

Physician payment formula update

The House approved legislation this week preventing the 21 percent Medicare payment cut, and fixing the overall payment formula.
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The bill revamps the formula for basing payments on the sustainable growth rate, which has resulted in potential cuts to physicians for the last seven years. Each year, the Congress has stepped into stop the cuts, but have yet to fix the system.

This step is expected to cost about $210 billion over ten years. That fact, but that the Senate rejected a similar law, makes it unclear if this measure will actually become law.

The new target for payments would be the gross domestic product plus 1 percent. Preventive care and E&M services would be GDP plus 2 percent, according to American Medical News story.

Now the Senate can either take up the House bill or reconsider its own bill which foundered last month after some noted the bill would raise the federal deficit. WSJ blog notes that when the Senate bill failed, Sen. Reid said the Senate would go to a one-year fix instead.

Update: AMA keeps support of House bill

The AMA voted yesterday “reaffirming the AMA’s commitment to health system reform,” meaning they decided to retain their support for the House bills.

“H.R. 3962 is not the perfect bill, and we will continue to advocate for changes that help make the system better for patients and physicians as the legislative process continues,” AMA President J. James Rohack, MD, said in a statement.

This vote comes after a group of disgruntled physicians challenged AMA’s endorsement of the House bill, which lacked several key provisions for physicians.The AMA also reiterated several items the organization plans to keep lobbying for, such as Medicare physician payment reform.

Push to overturn AMA endorsement of House bill?

For those not convinced that the AMA represents physicians’ priorities, there’s this: the AMA may be considering whether to rescind its support for the House healthcare reform bill in the face of pressure from some angry physicians.

The House bill did not have several elements some physicians say are critical: malpractice reform and a fix for Medicare reimbursements, for starters. Now some want the AMA to rescind its support, according to the WSJ.
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“Don’t give a blanket statement to a specific bill that contains provisions that violate AMA policy and interfere with the patient physician relationship,” Donald J. Palmisano, a former AMA president, tells the WSJ.

To be fair, the AMA’s support wasn’t entirely enthusiastic, and the organization said it recognizes “that more improvements are needed before a final bill emerges from a joint House-Senate conference committee.”

But, 10 of the 180 medical societies in the AMA’s voting body submitted a resolution Friday to rescind support. The 544 delegates are expected to vote today or tomorrow.

However, Fox News is reporting that according to one source’s e-mail, the disgruntled members have given up their fight to have the endorsement withdrawn.

Yes, AMA's endorsement was much-touted by Democrats pushing for the bill's passage. But, it passed, so what if the AMA does withdraw support? Perhaps it will affect lobbying efforts to improve the legislation as it goes to conference?

More H1N1 help

In an effort to improve the coordination of care this flu season, the AMA has launched a Web site (www.amafluhelp.org) they are calling the “nation’s first comprehensive Web-based patient flu health-assessment program.”

The idea is patients can assess the severity of their symptoms, and share their information online with their provider (both must register to use the system). There are also tools for physicians to help them monitor their patients’ symptoms, facilitate treatment, and manage the practice’s work flow. (The site is free, but physicians may decide to charge patients for online monitoring.)

The last part – managing the influx of patients this flu season – was the topic of this month’s podcast. And if you haven't already seen it, check out our H1N1 resource page.

Congress considering fix to Medicare payment formula

It looks like the flawed Medicare payment system is finally getting some serious attention.

Senate Democrats are planning a vote soon on a bill that would permanently eliminate the sustainable growth rate (SGR), the formula used to determine Medicare payment rates. As you probably know all too well, that formula has and will continue to threaten payment cuts each year. Congress usually steps in at the last minute to reverse the cuts, but a 21 percent cut was looming for 2010, and there has yet to be a permanent fix.
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The bill, introduced last week by Sen. Debbie Stabenow (D-Mich.) and separate from the main three health reform bills, would reset the SGR to zero for 2010 and beyond. This basically means it erases the $245 billion debt accumulated from last-minute fixes to avoid deep payment cuts, according to MedPage Today.

Among the major healthcare reform bills being worked out in Congress, the House bill scraps the SGR and later replaces it with the Medicare Economic Index, and the Senate Finance bill fixes it for just one year. That accounts for some of the cost difference between the bills.

The AMA, which supports the bill, launched a campaign last week including a television ad. “Congress can no longer put a band-aid on the problem,” AMA President J. James Rohack, MD, said in a statement.

But the cost (and the fact that the bill doesn’t really explain how to pay for the $245 billion) and the speed (it’s scheduled for a quick floor vote) has made some skeptical about this solution to the Medicare payment system.

So perhaps there are better ways to fix the SGR, but at least it's getting some real attention in Washington.

Obama rallies physicians for reform

It was a sea of white coats Monday in the White House Rose Garden as President Obama hosted a photo op with 150 doctors from around the country.

“Nobody has more credibility with the American people on this issue than you do,” Obama told the doctors, saying the “people who are most supportive of reform are the very medical professionals who know the health care system best.”
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Doctors surely see the need for reform every day. Obama noted, “They’ve seen far too much of the time they want to devote to taking care of patients spent filling out forms and haggling with insurance companies about payments. These doctors know what need to be fixed about our health care system and they know what health insurance reform will do.”

Besides taking a few minutes to reiterate what is in the proposals coming out of congressional committees, Obama was rallying support from the medical community. Last week, his campaign network Organizing for America, started raising money for doctor-themed ads.

A June poll found that almost 75 percent of Americans said they trust doctors to recommend the right course for reform, according to Politico. And Obama is counting on docs to speak out in support.

But clearly, not everyone in the healthcare community supports his plans, and there doesn’t seem to be consensus on what health reform should look like. In our own Great American Physician survey, we found most docs agree the system needs fixing, but the solutions varied.

What do you think of Obama's approach to rally physician support?

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.

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?