Thursday, July 10, 2008

The Next Medicare Physician Fee Cut--17 Months, 20 Days, and 13 Hours to Go

The "Medical Home"--A real Solution?

Now that this year's fight over Medicare physician fees is all but over, it is important to turn to real solutions.

The recent Senate and House vote to kill the 10.6% physician fee cut only defers the problem for 18 months.

On January 1, 2010, the Medicare physicians are slated to get an automatic 21% fee cut!

More importantly, the Medicare physician fee structure is grossly out of whack with primary care docs starving under the current fee system.

In a recent post, I asked just what is the solution to this problem? I got a record number of replies from docs all along the lines that they are fed up with being underpaid by Medicare and they aren't going to take it anymore. If they have to go to a cash relationship with patients for the fees they deserve, or balance bill, so be it.

While their frustration is understandable, these aren't solutions. Collecting $350 upfront from a senior, as one doc suggested for a comprehensive visit, isn't progress.

So, we have 18 months to just keep heading toward the next cliff (this one twice as big at 21%), let the system degenerate (cash, balance bill, or a crisis in access as docs stop taking patients), or actually start taking some constructive steps forward.

It strikes me that the growing discussion over the "Medical Home" is a constructive one that we need to continue developing. The "Medical Home" isn't a new fee schedule, it's a new patient relationship structure that could be the foundation for real physician payment reform. Because the current fragmentation in the system is at the heart of the problem, I will suggest that it is structure that is more important than just fees toward the objective of better cost and quality.

In a recent post, I said it was the doctors that have to take the lead in the development in a new payment system for Medicare--and therefore the entire system since private pay is generally based on the Medicare structure. The politicians aren't going to do it until they get permission from the doctor lobby for a specific plan. As the recent House and Senate votes showed, the politicians are afraid of the docs--but not so afraid that they have been forced to come up with a real solution. The private payers aren't going to do it because they aren't going to unilaterally develop something the doctors will accept.

It is notable that the leading primary care physician organizations--Family Physicians, American College, and Osteopaths-- have gotten out front on this idea.

And to the health plans, you need to be encouraging real solutions because, as the recent votes made clear, the next 21% is going to come out of your hides if a real solution isn't found!

This from Wikipedia on the Medical Home:
Central to the Medical Home approach is the premise that patient-centered care requires a fundamental shift in the relationship between patients and their primary care physicians. There must be a higher degree of personalized care coordination, access beyond the acute care episode, and identification of key medical and community resources to meet the patients’ needs. However, the widespread adoption of information technology for care management and quality improvement along with adequate payment methods are essential. In the long run, the Medical Home is likely to result in savings to patients, employers, and health plans. Increasing the emphasis on primary care could produce large dividends throughout the health care system.

The concept of the Medical Home has evolved since its introduction by the American Academy of Pediatrics in 1967. It has gone from a specific place to receive care for children with chronic disease, to an entire system of providing care for all Americans. This concept shifts the paradigm from episodic acute care to a continuous comprehensive model.

The basic premise of the medical home concept is care that is managed and coordinated by a personal physician with the right tools will lead to better outcomes.

In 2007, the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association—the leading primary care physician organizations—released the Joint Principles of the Patient-Centered Medical Home. In this document they state the characteristics of the Patient Centered Medical Home:

  • Personal Relationship: Each Patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.
  • Team Approach: The Personal Physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing patient care.
  • Comprehensive: The personal physician is responsible for providing for all the patient’s health care needs at all stages of life or taking responsibility for appropriately arranging care with other qualified professionals.
  • Coordination: Care is coordinated and integrated across all domains of the health care system, facilitated by registries, information technology, health information exchange and other means to assure that patient get the indicated care when and where they want it.
  • Quality and Safety: Quality and Safety are hallmarks of the medical home. This includes using electronic medical records and technology to provide decision-support for evidence-based treatments and patient and physician involvement in continuous quality improvement.
  • Expanded Access: Enhanced access to care is available through systems such as open scheduling, expanded hours, and new options for communication between patients, physicians, and practice staff.
  • Added Value: Payment that appropriately recognizes the added value provided to patients who have a Patient-Centered Medical Home.
I don't pretend to be an expert in this area but Vince Kuraitis over at the e-CareManagement blog, who first pointed me in this direction, is and he has done a large number of posts on the issue. I encourage you to take a look.

But here is what I am arguably an expert on: Docs, you have 17 months, 20 days, and 13 hours until you get hit with an automatic 21% fee cut. You can throw all the tantrums you want and you will again almost certainly get the the politicians to put off the next cut. But you will still be stuck in the mud with the same out of whack fee structure.

Recent post: There Won't Be Any Health Care Reform Without Physician Payment Reform and There Won't Be Any Physician Payment Reform Unless the Docs Lead The Way
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