Pay For Performance

Improve-Don’t Destroy-Medicare

The recently passed House of Representatives “doc fix” is a warning and should serve as an inspiration to forge ahead in improving and expanding Medicare for all.  Instead of sticking with the necessary goal of repealing the Sustainable Growth Rate (SGR) the Republican lead House has started on its quest to privatize (cost-shift back to out-of-pocket expensing) Medicare and cut back on Medigap benefits. Those of us who are concerned about the health care of everyone in our country need to get serious about the job of improving Medicare even before we move into universal coverage. We could start with proposals for quickly eliminating the donut hole in drug coverage. That, combined with eliminating the proscription against negotiating prices with the pharmaceutical industry, would offer affordable availability of even the specialty drugs for cancer, hepatitis C, multiple sclerosis, rheumatoid diseases, etc.  A quick fix should be made to the physician payment system until workable substitutes for our present volume based system can be developed under a single payer plan. That fix could be a simple up-adjustment of evaluation and management codes and down-adjustment of procedural codes with a budget neutral end point. And we could stop wasting time, money and other resources on the present catch-word pay-for-performance and pay-for-value experiments. Attention could be focused on mental health and long term care needs. Expandable systems could be developed for these areas even before Medicare moves to universal coverage. We should also be making the necessary changes to eliminate the need for Medigap policies, Part D coverage, and Medicare Advantage Plans. Not solely related to Medicare but open to immediate action would be improvement in the recruitment and financing of the primary care pipeline from first year medical students through residency training programs. We could also take a few steps back to re-think the present electronic medical records push and its Meaningful Use regulations. This has been a poorly thought out, expensive, provider exhausting  effort with a huge disconnect between the stated goals and the existing technology and financing resources.

We should be improving Medicare, not destroying it. We should all be putting pressure on our Congressmen and administration to eschew any actions that disregard the above goals.

Congressional Committe Eyes Medicare

Again, a congressional committee is studying a fix to the Medicare Sustainable Growth Rate (SGR) problem. Last year’s attempt led to a three committee compromise plan that never came before congress for a vote. The plan was an over-reaching attempt to change the entire physician compensation system. This produced a minefield that incorporated concepts that, so far, have proven to be ineffective and/or expensive, viz., using controversial guidelines to guide the already failed pay-for-performance mantra and tying payments to physician participation in alternate payment models (APMs) such as patient centered medical homes (PCMHs). So far this latter entity has been ill-defined and unsuccessful even though, in the future, thoughtful development may make this a viable optional medical care delivery system. Rather than attempt to re-write all of Medicare it would be wiser for the committees to focus on two rather simple things that they have been unable to accomplish: repeal of SGR and revision of the flawed RBRVS payment system. This latter contributes to the present inappropriate physician payments and to the demise of primary care. For a discussion of a quick fix for both of these problems read…http://wp.me/p4MwV3-4j

Can Physician Performance Be Measured?

In response to Comments in Becker Hospital Review I received these questions:

“Dr. Dave – I’d be interested in what outcomes you’d measure that really matter in the care of patients. And, what you’d suggest for a delivery and payment model(s).”

I submit the following answer:

I don’t know what background you are coming from. I’m a retired family doc with 27 years in private practice, 10 years working in and running a (salaried) rural health clinic and 7 years (salaried) doing urgent care in a >200 docs physician owned medical clinic and 6 years part-time in a low income clinic.

When talking about “measuring outcomes” remember the old saying (falsely attributed to Einstein) “Not everything that counts can be counted, and not everything that can be counted counts.”  What are outcomes;  mortality rate, days of pain free existence, avoidance of bankruptcy, peace of mind, years of life lost due to premature mortality (YLLs), years lived with disability (YLDs), healthy life expectancy (HALE) ?  And to whom do we attribute increase and decrease; the patient, which doctor, an institution, the system, society?  And, again, can numbers represent compassionate, concerned, competent care?  So what does it mean to “measure”?

There are numerous problems with current pay for performance problems. One of the biggest problems is thinking that any sense can made of the current Rube Goldberg system of Obamacare plus >2000 insurance carriers. Any real solutions need to benefit every single person in our country. Pretending to measure performance in medical care is a political diversion of both CMS and the insurance companies.

As far as I’m concerned putting all physicians on salary with reasonable negotiations is the only way to help gain control of medical costs and create the leverage for improving quality by eliminating incentives for cursory encounters and unnecessary medical procedures.

Pay-for-Performance is a poisonous concept whose unintended consequences are far greater that any conceivable benefits. System improvement and re-development of the culture of a medical “calling” and ethos of peer responsibility are essential. So-called P4P and quality improvement efforts cannot begin to deal with the multitude of problems that face us.

We can’t (and shouldn’t) go back to a Dr. Welby picture but we don’t have to keep going in the wrong direction.

I’m in favor of a single payer system (improved Medicare for All). I’m also in favor of starting that improvement now.  And I’m in favor of medical care reform in many areas (physician, hospitals, pharmaceuticals, medical appliances, costs, integrity, transparency, etc.)  A single-payer system would require a tremendous amount of work to create the needed reforms  but it’s the only system that can have the muscle to overcome the self-interest of the powerful stakeholders and ensure compassionate, competent, and cost-effective care for  everybody.

I invite you to visit my blog site (HC-Reform) and “Like” what you like. For our present discussion I would start with Pay-For-Performance (http://wp.me/p4MwV3-m).

Dr. Dave