Archive for August 2011

Déjà vu all over again, the Medicare physician fee debate is back

Last month’s debate on the U.S. debt ceiling brought to light the ugly side of how we finance the nation’s operations, and as lawmakers move forward on a deal to reduce the deficit, they will inevitably turn their eyes to one of the country’s biggest expenses: Medicare. Federal spending for fiscal year 2010 totaled $3.5 trillion and Medicare comprised 15 percent of the total amount.

However, with crisis comes opportunity and a convergence of factors may make this the time to address a structural deficit in how the country pays physicians and other providers for the services they provide to Medicare beneficiaries.

Under the debt deal, a 12-member joint committee has until Thanksgiving to formulate a plan to cut at least $1.2 trillion in spending over the next 10 years. Then, recommendations made by the so-called “supercommittee” must go before Congress and pass by a simple majority in both chambers by Christmas. If the committee can’t agree on cuts or Congress fails to pass them, a series of across-the-board reductions would be triggered. One cuts pay to Medicare providers by up to 2 percent starting in 2013, which experts estimate would add up to around $12 billion.

While a reduction of any amount hurts, there is a bigger problem on the horizon: the Medicare physician payment formula, known as the Sustainable Growth Rate or SGR. Under the SGR, a across-the-board 29.5-percent cut would take effect on Jan. 1, 2012.

Every congressional budget cycle since 1997 has included a reduction in Medicare payments that has eventually been modified. Since 2002, Congress has stepped in 12 times to stop the cut, including four times last year. And each year that Congress provides a temporary patch, the price tag gets steeper. According to the AMA, if Congress were to wait until 2016 to eliminate the SGR, the combined price of providing temporary patches and fixing the structural problem would approach $600 billion.

Now it boils down to deficit reduction; if Congress doesn’t address the broken SGR in some way, it will continue adding to the deficit. This gives the argument to repeal the SGR strength it hasn’t had in previous years.

The real value of the supercommittee is that there are no restrictions on what they can recommend to cut or how it scores savings; its jurisdiction gives the 12 members the ability to find offsets for other spending in all areas of government. By virtue of normal committee jurisdiction, fixing the SGR—a Medicare Part B issue—would usually mean finding offsets only within Medicare Part B, and that hasn’t been possible without hurting the program. Similarly, the supercommittee could recommend federal medical liability reform and score those savings toward deficit reduction.  

Late last month, the American Medical Association and 10 specialty societies (including AAFP) sent a video to Congress on the need for full repeal of Medicare’s flawed Sustainable Growth Rate formula. At just over two minutes long, a combination of text and eerie techno-classical music sets the scene: “By acting now, Congress can preserve access to care for people on Medicare and reduce Medicare spending by hundreds of billions of dollars. Or it can put off a solution…again.” Weaving through charts and graphs, they make the golden deficit-reduction argument, ending with the final statement: “Stop digging the hole. Pay the bill. Repeal the SGR.”

[Can’t see the embedded video above? View here: http://youtu.be/jNmuyZWi3qc]

The AMA proposes a three-pronged approach: repeal the SGR; provide five years of stable payments with positive annual updates; and transition to a broad array of payment and delivery innovations.

AAFP outlined similar asks in a letter sent to supercommittee members last week. First, stabilize Medicare payments to physicians by repealing the SGR, and specify a payment rate for the next 3 to 5 years with a 3-percent higher rate for primary care physicians delivering primary care services. Second, avoid making reductions in Graduate Medical Education, especially GME payments for primary care education and training, to protect the physician workforce.

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Help wanted: Send us your ideas for the Primary Care Rescue Act

As a die-hard fan of the Texas Longhorns, I have no shame in telling you that after last year’s 5-7 record, I was glad the college football season was over. Even though I’m a self-admitted policy wonk and political news junkie, I was equally relieved—even somewhat jubilant—when the 82nd Texas Legislature finally closed up shop and went home. If you followed the frustrating struggle to balance the state budget without additional revenue, and witnessed the resulting cuts to higher education, public education, and health and human services, you might have been just as ready for it to end as I was. At least when they’re not in session, they can’t do any more damage, right? Now is not the time to bury our heads in the sand. In fact, the legislative interim is perhaps our best opportunity to formulate and articulate our most effective arguments for renewed investment in Texas’ primary care infrastructure. We can document the ill effects of the drastic reduction in state support for graduate medical education, especially in family medicine residency training, and we can illustrate the broken promise of access to primary care physicians for underserved communities made manifest by the 76-percent cut to the state’s Physician Education Loan Repayment Program.

And now is the time to begin preparations for a major initiative in the next legislative session. In the late ’80s, rural medicine in Texas was in terrible need of state investment. Health care organizations and advocates rallied around a broad set of goals encompassed in what was called the Omnibus Rural Healthcare Rescue Act, which the Legislature passed in 1989. The law created the Center for Rural Health Initiatives and the Office of Rural Health Care, and it contained tort reforms, benefits for rural hospitals, several reforms to strengthen the state’s trauma care infrastructure, and new recruitment and training programs for primary care physicians. Family medicine won funding for third-year clerkships, among other valuable reforms.

As our state demographics change, and following the decision of the 82nd Legislature to withdraw almost 80 percent of its investment in programs intended to increase the state’s primary care workforce, we believe primary care in Texas is in desperate need of something like that landmark omnibus package of reforms and initiatives. Let’s call it the Primary Care Rescue Act. Obviously we would want to include the restoration of state support for GME, especially the funds that go directly to family medicine residency programs through the Texas Higher Education Coordinating Board. Also we would include full restoration of funds for the Statewide Primary Care Preceptorship Program, and the Physician Education Loan Repayment Program. But what else should we include?

We wish to engage you—the membership of TAFP—in this endeavor from the very beginning. What state reforms would make your practice easier, more efficient, and provide better care for your patients? What kind of administrative simplification requests should we make in state programs? What about managed care reforms? Would a standardized pre-authorization process help? Standardized contracts? Real-time claims adjudication? What could the state do to make primary care more attractive to medical students?

The sooner we can begin to craft a set of reforms to use during the election cycle, the more likely our success becomes. Remember, politics drives the process that sets policy. That’s why we want to hear your ideas for the Primary Care Rescue Act. Use this space, here on the blog, to comment with your ideas, and we’ll pay close attention to the discussion. If you’d rather send us your ideas individually, feel free to e-mail me, Jonathan Nelson, at jnelson@tafp.org. Or you can e-mail Tom Banning at tbanning@tafp.org, or Kate Alfano at kalfano@tafp.org. However you choose to share your ideas, we are eager to hear them. The legislative interim can be a time filled with promise and hope, and it’s the perfect time to lay the groundwork for big initiatives in the next session. Let’s take advantage of that opportunity.

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Asking for honest feedback – what did you like (or not like) about AS social media?

This Annual Session ushered in a new era of communication, and we asked members to interact with us, their fellow attendees, and their colleagues from around the state and country. Now that the dust has settled on a busy conference filled with CME, business meetings, and special events, we want to encourage you to continue the commentary.

So…what did you think? How were our posts/pictures/tweets? What can we do to improve our communication and interaction with you? And, in a very simple sense, what did you like or not like about our effort (so we can be better next time)?

TAFP's Kate Alfano and video wizard Herb Holland after the conclusion of the live stream

As a recap, the total effort centered around the Annual Session Social Media Portal – http://tafp11.txfamilydocs.org/ – a page within our TXFamilyDocs.org blog. We had an ASSA Flickr stream updated nightly, as well as a daily news wrap. Staff tweeted more frequently than posting on Facebook, but that goes along with the urgency of the platforms.

The highlight of the conference was our live stream of the lecture “Know Before You Sign! What to Look for in a Physician Employment Contract, Including Employment by Non-Profit Health Corporations.” Though it occurred from 5:15 – 6:15 p.m. on a Saturday afternoon, we had about a dozen viewers join us live, and we continue to have hits on the archived video on our Ustream channel: http://www.ustream.tv/channel/texas-academy-of-family-physicians. We even received a shout-out from Dr. Sevilla on his Family Medicine Rocks blog for this effort.

As fleeting as it seems, there is a certain longevity to social media tweets and posts, and I encourage you to revisit them. There is still time to upload pictures to our Flickr account (become a member and join our group: http://www.flickr.com/groups/txfamilydocs/), and it only takes a minute to scroll through our tweets and Facebook posts.

And, as mentioned above, this conference provided the building blocks for what we hope will be a larger effort to draw in our members and connect them beyond the walls of a host hotel. Watch as we work to further integrate all of our social media platforms at future conferences, and also please continue sending your suggestions. That’s the beauty of social media – it’s not about the person with the account password, it’s an fluid stream of interaction constructed for and by its contributors.

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ASSA Flickr Stream

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