Paying for Primary Care

Bradley Flansbaum

Posted 3/5/12 on the Hospitalist Leader

I recently gave grand rounds at my hospital, and spoke on specialty over primary care dominance in the U.S. system.  I focused on the difficulties of care coordination, i.e., “the stress” of ambulatory practice, and touched the third rail of reimbursement and salary.  Surprisingly, on the latter point, I received little venom or push back from the specialists.  I was shocked–literally, and staved off my own electrocution.  Maybe we are accruing more evidence to support non-specialty practice and reality is setting in?

Despite that, at the annual AMA House of Delegates meeting, no other subject generates more sizzle than physician pay (putting the ACA aside).  However, given the national budget, no new money will enter the system, and solving the primary care provider crisis will entail multiple fixes:

  • Loan Forgiveness
  • Stipends and financial support
  • GME incentives, including lifting training caps
  • Restructuring office practice to improve quality of life
  • Utilization of midlevels and other venues of care to offload low acuity patient volume
  • A National Health Care Workforce Commission (currently without appropriations)

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The Math of E/M Coding: When Does 5=1?

Paul M. Fischer

My typical Medicare patient expects me to deal with 5 or more problems in a single routine visit.  There are usually around 3 old ones (e.g., diabetes, hypertension, hyperlipidemia) and at least 2 new ones (e.g., low back pain, fatigue).  For those who come with handwritten lists, there may be as many as 10, including every health question that has come to mind over the past 6 months (Should I take a holiday off of Fosamax? Should I add fish oil? Do I need another colonoscopy? Is the shingles shot any good?).

Physicians who do procedures get paid for each one done to a single patient on a particular day. Medicare’s rule for this – the Multiple Procedure Payment Reduction Rule (MPPR) – says doctors should be paid 100% for the first procedure and 50% for each subsequent procedure up to 5. However, for those of us whose work is primarily cognitive rather than procedural, there is an important exclusion:  the multiple-payment rule does not apply to E/M codes.  In fact, the definitions of 99213 and 99214 unambiguously state, “Usually the presenting problem(s) are of . . . complexity.” Note the “(s)”! It clearly creates a double standard that favors doing procedures and places thoughtful solving of patients’ problems at a disadvantage.

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Throwing Money the Wrong Way

Paul Levy

First posted 9/21/11 on [Not] Running a Hospital

I have talked a bit about using financial incentives to encourage doctors to do a better, more efficient, and/or safer job in practicing medicine.  I have been skeptical of this approach because I do not believe that doctors find such measures to be highly motivational.  In my former hospital, we stayed away from financial incentives and even discussion of finances when we were instituting changes in work practices that improved quality and safety and the work environment.  Instead, issues were framed in terms of the underlying values of doctors.

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How Obama Hits Health Providers in Deficit Plan

Merrill Goozner

First published 9/21/11 in The Fiscal Times

President Obama’s populist message on taxes was replicated on the health savings side of his deficit-reduction plan, which would cut spending on Medicare and Medicaid by $320 billion over the next decade and $1 trillion in the following decade.

The bulk of the savings would come from companies that provide goods and services to the programs. Payments to drug companies would be slashed by $135 billion by offering seniors in Medicare the same discounts currently mandated for poor people in Medicaid. An additional $42 billion in program savings would be achieved by reducing payments to nursing homes and home health care agencies.

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Doctoring Financial Incentives

Paul Levy

First posted 9/12/11 on Not Running A Hospital

Mixed results are reported in a recent paper entitled, “The effect of financial incentives on the quality of health care provided by primary care physicians.”  In the paper, Australian researchers collected and analyzed data from studies of incentive programs in the US, the UK and Germany.

As noted in this summary article by Reuters:

In those studies, researchers looked to see if financial incentives made a difference in how often doctors screened for different diseases, referred patients to follow-up care or achieved a certain health outcome — such as helping a patient quit smoking. Overall, the effects were mixed.

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Another Modest Proposal*: Paying for Physician Training

Paul Fischer

One of the main considerations in physician pay under CMS’ relative value system is the training required to complete a task. This is generally thought to be well understood but is, in fact. a quagmire of controversy.

Take for example the specialty of family medicine compared with dermatology, anesthesiology, or ophthalmology. Family physicians make between 1/2 and 1/3 of what these other specialties make, so one would think that there is a huge training difference. The truth is that each of the four require 16 years before medical school, 4 years of medical school, and 3 years of residency.  The 3 highly paid fields require 1 additional year in a transitional internship.  So the family physician education represents 23/24 or 96% of the length of education required for the others.  Since when is a 4% investment worth a 200% to 300% return?

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The Cost of Medicare: You Get What You Pay For

Caroline Poplin

First posted 8/26/11 on The Health Affairs Blog

Copyright ©2011 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.

In the battle over bending the cost curve in Medicare, a recent article in Health Affairs should set off alarms.  In it, Francis Lukas and colleagues describe the proliferation of new cardiac surgery programs—300 in 10 years–at exactly the same time that the number of cardiac bypass grafts fell.  Moreover, the new programs generally did not appear in rural areas, where they might have increased access for underserved populations: instead, they appear in markets that are already well resourced.

It would be nice if the new programs generated competition, particularly, given our urgent cost problems, price competition.  However the researchers found no evidence for this, and there is no reason to expect it: price competition is problematic in medicine, where because of varying degrees of market power, everyone outside Medicare pays a different price, and the uninsured pay the most.  More likely there is competition on perceived quality, where each program touts its new, expensive equipment and pricey, up-to-date facilities: the so-called arms race.

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