Post-Election Health Policy - Impact on Physicians


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Presentation by MMS President Bruce Auerbach at a meeting of the NE Society for Healthcare Strategies

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Post-Election Health Policy - Impact on Physicians

  1. 1. Post-Election Health Policy: Impact on Physicians Bruce S. Auerbach, MD President Massachusetts Medical Society •No stakeholder group in health care is more aware of the problems in health care than physicians. •We have no monopoly on this, but we experience its strengths and weaknesses every day, in a very direct, almost intimate way. •Physicians are both Republican and Democrat – maybe more Democrat here in Massachusetts. •But regardless of how we vote, where we live or where we work, we are fundamentally conservative people – we need to feel assured something new will work, before we use it. •We’re not likely to take a chance on something new, just because it’s new, because peoples’ lives are at stake. This applies to technologies, and it applies to health policy too. 1
  2. 2. •Physicians tend to fall into 3 camps. •A small group that wants us to go back to the good old days •Another small group that wants us to leap into a full-blown single payer system •Then, there is a vast middle ground of physicians who believe that while the health care system has its good elements, it is somewhat dysfunctional too. They looking for the areas to improve what’s dysfunctional without harming what works. •Three different approaches, but what we have in common is we all want change. •We know that costs cannot keep rising like this forever. •We know that while the quality of our care is higher than ever, it could be a lot better. •In the past, we did not embrace the imperative to control costs. But that is changing. •In the past, we did not embrace the quality imperative as well as we could have. But that is changing, too. •You could argue that we should have come to this point sooner – and I may not argue with you – but the point is, we’re here at the table. We want to work with you to make health care better. 2
  3. 3. Starting Points • Reduce variation • IT adoption • Payment reform • Transparency • Performance measurement – Scientific validity • Cost control •We accept the stipulation that reducing unnecessary variation in health care is critically important. It will save costs, improve outcomes, and it may save lives. •We accept the idea that full scale adoption of information technology – in big hospitals and small practices – will help get us there very quickly. •We accept the assertion that reimbursing hospitals and doctors solely on the volume of work they do is not applicable in all settings. We need payment reform. •We accept the transparency imperative. We’re not afraid of having our outcomes available for the public to see. It’ll keep us on our toes, and it will reinforce the trust that must be present between every doctor and patient. •We accept the notion that at least some of our compensation should be based on how well we do our jobs. •This could be where many of us in this room may part ways. •We insist that such performance measurement systems – and performance based payments – must be scientifically valid. •We do not accept badly designed systems that are literally worse than the problem itself. •We have proven that we will do what it takes to fight badly designed systems. We have gone to court to correct a particularly bad system that its sponsors have been unwilling to change on their own. •We don’t think it has to be perfect before it’s rolled out. You do have to start somewhere, as my friends among the health plans are fond of saying. But wherever we start must be scientifically valid – and we have published detailed explanations of what that means. They’re available on our website. •We accept that we bear some responsibility for controlling costs. But we don’t have as much control over costs as some would have you believe. •There’s an old saying that most of medicine flows from the pen of the doctor – or at least the modern equivalent of the pen. But that’s a gross oversimplification of why health care has become expensive. 3
  4. 4. Schroeder S. N Engl J Med 2007;357:1221-1228 •According to Michael McGinnis in a very famous article published in Health Affairs six years ago, our health care system has only a limited ability to reduce premature death and improve overall well-being. •Put another way, if every American were to receive timely, error-free medical care tomorrow, the number of early deaths in America would not be reduced by very much. •The top factors by far -- behavior and genetics – have seven times the impact on health status over medical care alone. •At our Shattuck Lecture a year ago, Steve Schroeder asked, if that’s the case, why do we spend so little on health prevention? Good question – we could spend days answering that. •Since I only have 20 minutes today, I can short-cut that discussion by telling you that if the new administration were to bestow its blessing today on a massive funding of preventive care, the physician community would be one of the first in line to support it. •Not just prevention, either. 4
  5. 5. •Chronic disease management - asthma, diabetes, high blood pressure, obesity. •Let’s look at diabetes alone: Simply ensuring that a diabetic has timely, regular H1aC tests, and timely eye exams, would reduce blindness, hospitalization, cardiac events, stroke, amputations, and the list goes on. •However: our system rewards heroic, episodic care above all. Preventive care gets little, and frequently, no funding. •Our system has devalued primary care so much that many of our young doctors don’t want to become internists, or family practitioners – even if they were inclined to do when they started medical school. •There are enough pediatricians – for now – but if things don’t change, maybe we’ll see a crisis in that specialty too. •It has gotten so bad that there is a terrible crisis in the shortage of primary care physicians – here and across the country. More than higher costs, this shortage threatens the terrific gains we made in Massachusetts to insure everyone. •If it happens here, with our medical legacy, imagine what would happen if this experiment is exported to other states, where their health care infrastructure isn’t like ours. It would be a disaster. •Preventive care is actually more expensive in the short run. I can’t list any studies proving that this will save money in the long run, but it’s worth the gamble. And – even if we do spend more – it’s for the right reason. To keep you out of the hospital. 5
  6. 6. Physician Workforce Study • Internal medicine • Family medicine • New: Oncology, neurology, and dermatology • Continuing: – Emergency medicine – General surgery – Neurosurgery – Orthopedics – Psychiatry – Urology – Vascular surgery •There is a long punch list of things physicians want addressed in the new administration. •We are very worried about the condition of the physician workforce – not just here in Massachusetts, but across the country. •For years, we have seen predictions of a severe shortage of physicians by the middle of the century. That is now coming true. •For the last seven years, our medical society has conducted a comprehensive study of the physician workforce in our state. We survey practicing physicians, chiefs of hospital medical staffs, and others, about their ability to retyain and recruit physicians in Massachusetts. •Every year, we identified between 6 and 12 physician specialties with labor shortages. Three years ago, we identified an emerging crisis in the primary care labor force. Today this “emerging” crisis is here, it is now front and center. •But as you can see here, it is only two of the 12 specialties that are under stress. That is why a workforce strategy targeting only primary care will fail. This goes beyond primary care – it goes to some of the core specialties in medicine. •The causes are very complex, and the answer may NOT be simply adding more physicians. That could be a never-ending spiral. We need to look at systemic reforms that make the best use of our resources, and encourage the marketplace to allocate our resources more equitably. 6
  7. 7. Medicare •Medicare is an example of what works, and doesn’t work, about our health care system. •Medicare successfully made health care accessible to every senior citizen in America. •By its sheer size, Medicare brings the flaws of health care system in very sharp focus. •One problem is rising costs. If left unchecked, Medicare could bankrupt our federal budget and our society. •So for the last 8 years, Congress has tried to control the growth of Medicare spending by using a detailed formula that has stipulated a cut in physician payment rates by about 5% each year, since the beginning of the decade. •These cuts are based on faulty, outdated assumptions, and would be devastating to physician practices nationwide. The problem needs delicate micro-surgery, but instead we had an attempted amputation. •In every year but one, Congress intervened at the last minute – sometimes after the last minute – to block the payment cut. Because of federal “pay-go” rules, the cut didn’t go away, it was deferred until a date in the future. •This has happened year after year, and the day of reckoning was pushed deeper and deeper into the future. And the size of that future cut grew each time. •This past year, the payment cut was delayed 18 months (instead of 6 months or 12 months). Finally, Congress has plans to develop a long- term fix to this Medicare payment problem in the new administration. •Physicians are very supportive of this effort, and we expect to be at the table helping Congress and the administration develop a system that will work. 7
  8. 8. Defensive Medicine •Another thing we can look at to control costs is the cost of defensive medicine. •Tomorrow, our medical society will release a report on the cost of defensive medicine in Massachusetts. Conventional wisdom is that malpractice reform will make only a small dent in controlling costs. •Our report states that defensive medicine wastes between 8% and 15% of the health care dollar. It’s a huge proportion of our spending, and it’s more easily corrected than some of the other approaches we’re discussing. 8
  9. 9. Stand-Alone Solutions • Capitation • PMPM rates cannot keep up with costs • Global • Administrative cost Capitation shifting • Rate Setting • Re-regulation? • Single Payer • Systemic paradigm shift, but which system? • DON • Stifles competitive marketplace •That brings us to overall health care payment reform. •There is considerable interest in the physician community in examining a new way to compensate providers for the care they provide – and a new way for the nation to pay for it. •Standalone solutions have been proposed in the past, and each has been problematic. •The problem with capitation was that PMPM rates could not keep up with costs. The theoretical incentive to under-treat was more than our society could tolerate. •If you remember, the Institute of Medicine says that poor quality in health care comes in three forms – misuse, overuse, and underuse of care. Capitation encourages underuse. •Global capitation doesn’t reduce costs … it shifts administrative costs to physician practices, which are probably the LEAST equipped entity in health care to deal with the issue. We think that cost-shifting increases overall costs, worsens health status by reducing access, or both. •Rate setting at a global level introduces re-regulation … the top- down control of health care has its own problems. •Single-payer would cause a systemic paradigm shift, but would we want or tolerate the system we would get from that shift? •Determination of Need (DON) processes are cumbersome, overly political and stifle competition and innovation. 9
  10. 10. Prometheus Payment Evidence Informed Case Rate Model – A single risk adjusted payment across inpatient and outpatient settings to care for a patient with a specific condition • May improve quality, • Only 10 ECRs developed reduce administrative • Only in the modeling burden, enhance stage transparency • Limited data available to • Patient centered, build ECRs Consumer driven • Development time • Performance based – Still looking for pilot sites withholds – Prometheus Scorecard – Claims activity Evidence-Informed Case Rates: A New Health Care Payment Model, , Francois de Brantes,; Joseph A, Camillus, April 2007 Commonwealth Fund Publication No. 1022 Some of the most interesting solutions are comprehensive payment models that try to combine evidence-based medicine with aligned incentives and reasonable cost control. Some examples include: the Prometheus Payment Model, promoted by Francois DeBrantes and published by the Commonwealth Fund in 2007. This is a single risk-adjusted payment across inpatient and outpatient settings to care for a patient with a specific condition. 10
  11. 11. Blue Cross and Blue Shield MA Global capitation proposal for doctors and hospitals. Will consist of a flat fee per patient per year, age and sickness adjusted, with a bonus for improved care. • Quicker access to care • Details (Improved care?) via technology • May restrict patient • Home visits by nurses choice • Better coordination of • Physicians responsible care for costs they do not • Better care for chronic control illness • Increased administrative burden for physicians – Claims administration New therapy for old woes, Alice Dembner, 01/22/08, The Boston Globe •A global capitation proposal from Blue Cross Blue Shield of Massachusetts, introduced last year, but with little uptake so far. It’s essentially a flat capitated rate, with additional bonuses for improved care. •It has drawbacks, including the possibility of restricting patient choice, penalizing physicians for costs they do not control, and increasing administrative burden on physicians and hospitals. 11
  12. 12. The Advanced Medical Home Based on the principles of the Chronic Care model, uses evidence based guidelines and information technology to demonstrate use of “best practices” • Relationship based • Potential for gaming of system • Uses evidence based over or under utilization guidelines • Potential for less provider • Propose a fee for primary care access management • A variation of capitation • Purports to reduce wasteful • Potential for primary care spending on unnecessary physician shortage medical expenditures • Similar to successful European models The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of Health Care; Michael Barr, MD, MBA, Vice President, Practice Advocacy & Improvement; Jack Ginsberg, Director, Policy Analysis & Research. A Policy Monograph, American College of Physicians, 2006 Fundamental Reform of Payment for Adult Primary Care: Comprehensive Payment for Comprehensive Care; Alan H. Goroll, MD.; Robert A. Berenson, MD.; Stephen C. Schoenbaum, MD.; and Laurence Gardner, MD, 2006, Society of General Internal Medicine There’s a lot of talk about the advanced medical home. This vision of care, based on the model of chronic care management, is intuitively attractive to many people, because it appears to promote prevention, chronic disease management, collaboration, and communication. It appears to align the incentives of patients, payers and providers better than other systems in existence, or under development. At least a half-dozen pilot medical home projects are underway, or about to begin, in the area. Some are being developed by physicians, many by health plans. There are so many different approaches to this concept, and many of them are dramatically different form each other. I suspect that it will be a year or so before this new idea becomes more tangible; before we have a model that can be implemented. That’s just a few approaches… there are many more. 12
  13. 13. Post-Election Health Policy: Impact on Physicians Bruce S. Auerbach, MD President Massachusetts Medical Society •These comprehensive models may not be the magic solution. But they offer the good chance at addressing what we’re talking about today: •Reducing costs without cost-shifting •Improving quality •Promoting prevention •Promoting stability •And most important, improving health •The key point I want to leave you with: •Physicians are ready to step up and participate in these discussion. We are ready to help lead our health care system into the new era. 13