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Commission Tackles Physician Payment Reform

Apr 6, 2012

By Steven Schroeder, MD

How physicians are paid and what services they choose to recommend are key drivers of today’s escalating health care costs. The Society for General Internal Medicine (SGIM) has convened an independent commission to assess physician payment and physician-influenced expenses as well as issue recommendations on how to reform physician payment to restrain health care costs while at the same time optimizing patient outcomes. The 13-member National Commission on Physician Payment Reform will work together over the upcoming year, with a final report expected in early 2013.

Payment incentives and systems directly impact medical services that physicians provide as well as the overall approach to their patients. For example, the current fee-for-service system aligns payment with services provided rather than overall care outcomes. While the Commission will examine existing formulas that determine physician payment, such as the Resource-Based Relative Value Scale (RBRVS), we will also investigate promising payment methods that could lead to higher quality of care and better patient outcomes. More specifically, the Commission will evaluate optimal incentives and safeguards surrounding the three principal forms of physician payment: fee-for-service, capitation, and salary, as well as variations of these forms such as episode-based payments, global payments, pay-for-performance and partial capitation that attempt to incorporate quality into the equation.

The Commission appreciates that many have already put considerable effort into payment reform. We would like to complement, not duplicate, these efforts. We will review new approaches in the Affordable Care Act designed to constrain costs, including bundled payments and Accountable Care Organizations, as well as disincentive payment strategies that penalize providers for avoidable costs. We will also draw on the factual findings of The Medicare Payment Advisory Commission. A key difference is that the National Commission on Physician Payment Reform will look at the entire physician payment system, including both public and private payers.

The Letterman Approach to Cost Awareness

Apr 6, 2012• 3

By Christopher Moriates, MD

Who doesn’t love a Top 10 list? Creating them is an art form. So when it was formally proposed by Dr. Brody in 2010 in the NEJM that each specialty create their own “Top 5 list” of unnecessary care, it seemed like a straightforward – if not downright provocative – suggestion.

“The Top Five list would consist of five diagnostic tests or treatments that are very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered. In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit,” he wrote.

And yet, thus far the only groups that have seemed to have taken him up on the suggestion have been the primary care specialties of Internal Medicine, Family Medicine and Pediatrics – notably amongst the least compensated fields in health care.

This is a great start, but c’mon guys, where are the rest of you? Dr. Brody wrote you a “prescription.” We have a term for your behavior: “noncompliance.”

Not to say that there hasn’t been some progress. The ABIM Foundation has indeed put together an impressive list of organizations participating in their “Choosing Wisely” campaign. They also have begun to be instrumental in funding projects towards this goal. Costs of Care has highlighted far-reaching areas of non-value-based care, including a recent thoughtful essay about robotic surgery. We must now consolidate on these small gains and move this forward across all specialties in medicine.

HealthTech: Glen Tullman, AllScripts

Apr 6, 2012• 1

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Matthew Holt interviews Allscripts CEO Glen Tullman at HIMSS12. Tullman recaps what happened this year at his company and explains how Allscripts can help small companies innovate.

Will Doctors or Patients Bend the Cost Curve?

Apr 6, 2012• 44

By Davis Liu, MD

The American Board of Internal Medicine (ABIM) and nine other professional medical societies announced that doctors should perform 45 tests and procedures less often than currently done because there is no good medical evidence that they add any value. Specifically, a xray or other imaging for low back pain in an otherwise healthy individual or an EKG as part of a routine physical, just add a lot of unnecessary cost to the health care system as a whole and don’t provide doctors or patients any meaningful information that would be helpful in improving health or arriving at the right diagnosis and treatment.

The ABIM partnered with Consumer Reports to create a new campaign called Choosing Wisely and are joined also by collaborators like employers (the National Business Group on Health, the Pacific Business Group on Health), hospital safety (the Leapfrog Group), and labor unions (SEIU). The mission is simply to have doctors and patients deliver and receive care that is medically necessary, based on evidence, avoids harm, and minimizes duplication.

The real question is – will it work? Will doctors follow what their professional societies recommend?

Though Choosing Wisely is a laudable attempt to make medical care better quality, the truth is doctors won’t likely follow these guidelines from their medical societies. If it was that easy, we would not have this problem! Even today, it is still a challenge for the medical profession to have all doctors wash their hands correctly every patient every time, get immunized routinely against influenza, or even not to prescribe antibiotics for coughs, colds, and bronchitis due to viruses! What is more disturbing is that doing these basic interventions did not impact a doctor’s income. Some on the list of Choosing Wisely, however, will.

Why the Fragility of Health Outcomes Research May Be a Good Outcome for Health

Apr 5, 2012• 1

By David Shaywitz, MD

Durably improving health is really, really hard.

I’ve discussed this in the context of drug discovery, which must contend with the ever-more-apparent reality that biology is incredibly complex, and science remarkably fragile. I’ve discussed this in the context of patient behavior, focusing on the need to address what Sarah Cairns-Smith and I have termed the “behavior gap.”

Here, I’d like to focus on a third challenge: measuring and improving the quality of patient care.

I’ve previously highlighted the challenges faced by Peter Pronovost of Johns Hopkins in getting physicians to adhere to basic checklists, or to regularly do something as simple and as useful as washing hands, topics that have been discussed extensively and in a compelling fashion by Atul Gawande and others.

Several recent reports further highlight just how difficult it can be not only to improve quality but also to measure it.

Consider the recent JAMA article (abstract only) by Lindenauer et al. analyzing why the mortality rate of pneumonia seems to have dropped so dramatically from 2003-2009. Originally, this had been attributed to a combination of quality initiatives (including a focus on processes of care) and clinical advances. The new research, however, suggests a much more prosaic explanation: a change in the way hospitals assign diagnostic codes to patients; thus, while rates for hospitalization due to a primary diagnosis of pneumonia decreased by 27%, the rates for hospitalization for sepsis with a secondary diagnosis of pneumonia increased by 178%, as Sarrazin and Rosenthal highlight in an accompanying editorial (public access not available).

Health Care Law Supporters Ought to Be Sentenced to Serve as Governors

Apr 5, 2012• 10

By Sen. Lamar Alexander

During the debate two years ago over the health care law—which I called an historic mistake because it expanded a health care delivery system we already knew was too expensive, instead of taking steps to reduce its cost two years ago—I suggested to our colleagues on the other side of the aisle who were supporting it that, if they voted for it, they ought to be sentenced to go home and run for governor and see whether they could implement it over an eight-year period.

Governors have long wrestled with the rising costs of Medicaid, paid for partly by the states according to rules set in Washington, and the question of how to deal with public education, especially higher education. Some 30 years ago, when I was a young governor, I was still struggling with the fact that at the end of the budget process, we had money either to put into higher education or into Medicaid – but the rules from Washington said it had to go to Medicaid.

I remember going to see President Reagan and asking: ‘Why don’t we just swap it, Mr. President? Let the federal government take all of Medicaid. Let the states take elementary and secondary education.’ That didn’t happen, and gradually, the increasing Washington-directed costs have distorted state budgets so much that now 24 percent of the state budgets go to the Medicaid program.

Because of the health care law, we are going to add 25.9 million more Americans to Medicaid, according to the Medicaid Chief Actuary.

Our former governor, Governor Bredesen, a Democratic governor, estimated that between 2014 and 2019 the expansion of Medicaid would add $1.1 billion in new costs to the state of Tennessee.

Jack Cochran, The Permanente Federation

Apr 5, 2012• 2

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The Permanente Federation is the national organization for Kaiser Permanente’s doctors. In this interview taken at HIMSS12, Executive Director of the Federation Jack Cochran gives an overview of transitions physicians are undergoing in the workplace. He also debunks what he says is the biggest myth about patient to doctor emails.

The Magic of Doing One Thing at a Time

Apr 5, 2012• 2

By John Halamka, MD

I’ve previously written about multitasking and work induced attention deficit disorder.

I’ve also written about the burden of having two workdays every 24 hours – one for meetings and one for email

Yesterday, I was sent a post from the Harvard Business Review that summarizes these issues very well.

It highlights the problem and a series of solutions.

Nearly half of employees report the overwhelming stress and burden of their current jobs, not based on the hours they work, but the volume of multitasking – too many simultaneous inputs in too little time. They’ve lost the sense of a beginning, middle, and an end to their day, their tasks and their projects. There is no work/life boundary.

As a case in point, I’m writing now while doing email and listening to a Harvard School of Public Health eHealth symposium. Am I being more productive or just doing a greater quantity of work with less quality?

The author of the post points to evidence that multi-tasking increases the time to finish a task by 25%. He also notes that our energy reserves are depleted by a constant state of post traumatic stress induced by our continuous connectivity.

He suggests three strategies:

1. Rather than multi-task, reduce meeting times to 45 minutes, leaving 15 minutes for email catchup and transition.

Everyone Should Learn the Entrepreneurial Method

Apr 5, 2012• 4

By Saras Sarasvathy

When I was a teenager, the older women in my family taught me to cook. I learned it was traditional not to add salt when cooking lentils, because it would slow down the cooking. For some reason, perhaps the sheer pleasure of being difficult, I insisted on taking two identical pots and cooking identical quantities of lentils, one with salt and one without. That caused quite a bit of a stir, and not only because I proved that the salted lentils cooked just as fast. On the one hand, my mother, grandmother, and aunts sensed more difficulties were to come. On the other, they knew they’d participated in something different and important: a scientific experiment.

The women in my family were courageous, smart, and resourceful. They knew many things: useful wonderful things. For the most part, their knowledge was received knowledge, knowledge they’d been given, not figured out on their own. This is a common situation. The idea that anybody can be taught to figure things out, that there is a logic to discovery and invention, would have struck our ancestors as radical and strange. Until quite recently — until science education became institutionalized and widespread — the creation of new knowledge depended on either genius or luck.

Pay for the “A”

Apr 4, 2012• 5

By DINOSAUR MD

Medicine is simple and straightforward; except when it’s complex and nuanced.

Medical diagnosis is a simple matter of taking a history, performing an examination, and reviewing the results of ancillary testing; except when it’s a complicated case of eliciting subtle nuances from the patient in both the interview and the exam, and interpreting multiple pieces of conflicting data.

Medical treatment is a straightforward affair of providing appropriate treatment; except when there are multiple treatment options with unclear risks and benefits, technically challenging surgical or other procedures to perform, not to mention fully informing the patient and family about all of those treatment options, risks, and benefits, plus eliciting and answering all their questions.

Nothing to it.

Notice, though, that the key ingredient here is DIAGNOSIS. Performing a flawless appendectomy won’t do a thing for an ovarian cyst, nor will a PPI prescription do much for an acute coronary syndrome. Performance measures that look at treatment without addressing diagnosis are somewhere between misguided and ludicrous.

Why does American medicine have this so bass-ackwards? Follow the money. Thanks to the specialty-heavy RUC, the commission that sets fees for various procedures, doing something — anything — is paid far more handsomely than thinking (even thinking about what to do).