Sunday, October 18, 2009

No Good Options for Specialists

I just received this e-mail from the Heart Rhythm Society:
On Wednesday, the Alliance of Specialty Medicine (the Society is an active member of the Alliance), as well as the American Medical Association and nine other medical societies attended a meeting with the following officials: Senate Majority Leader Harry Reid (D-NV), Senate Finance Committee Chairman Max Baucus (D-MT), Senate Health Committee Member Chris Dodd (D-CT), White House Chief of Staff Rahm Emanuel and Office of Health Reform Director Nancy-Ann DeParle. During the meeting it was announced that S.1776 will serve as the Senate vehicle for eliminating the SGR formula and lay the foundation for establishing a new Medicare physician payment system. This new proposal will be incorporated into broader health care reform legislation.

The Society encourages Senators to support S.1776 as an important first step toward the establishment of a stable physician update mechanism. However, the details of this new system have not been determined. (emphasis mine)

The Senate is expected to start voting on S.1776 as early as Monday evening. The Senate will vote four times. Following Senate rules, the first three votes will be procedural requiring 60 votes. The Senate will then vote for passage of the SGR repeal bill, which requires only 51 votes. In exchange for repeal of the SGR formula, the Senate Leadership has asked physician groups to support health care reform legislation that is currently moving through the Senate.

While the Society supports the repeal of the SGR formula, we are concerned with several other provisions proposed in the Senate Finance Committee health care reform legislation, such as mandatory pay for performance, payments cuts to physicians who exceed resource use benchmarks, preferential payment for primary care and placing payment system decisions in the hands of a new Medicare Commission composed of 15 unelected individuals.(emphasis mine, again)
I would favor letting the SGR formula cuts go through and let Congress deal with the consequences. The other "deals" they want in return for abolishing the SGR payment formula are more concerning to me in the long run.

More on ther Heart Rhythm Society's "concerns" here.



shadowfax said...

You suggest that we docs reject the "deal" of the SGR fix for the other changes (primary care bonus, P4P, etc). But I think it's the proverbial "offer you can't refuse," in the sense that the physician payment reforms (bundling is the one that scares me) will be imposed one way or another. The SGR fix (which was coming anyway) is being held out as the spoonful of sugar to make this possibly bitter medicine go down. But if we refuse, they'll just shove it down our throats anyway.

DrWes said...


In retrospect, as the AMA releases its one-sided TV ad today that discusses none of the down-sides of S. 1776 for doctors, we find that this bill was really created as a sneaky 'accounting trick' to offload $200 billion in costs from the already bloated $900B Baucus plan.

Keith said...


I would agree the that the idea of bundling payment for certain services is worrisome. We had this before and it was called capitation and we all know how well that worked out for physicians.

We have shared the same concerns about how this system will cut the pie up as well (correct me if I am wrong).

As for primary care payments, I would point out to you that under the SGR system, there has been a massive cost shifting effect to specialty services by virtue of the fact that specialist are increasing in numbers; PCPs are not. Also there has been numerous additions of codes for specialty services that did not exist when the RBRVS system was created, disproportionally going to specialty services.

The SGR was supposed to constrain the cost of physician services, but has not done so because the RBRVS committee, that is entrusted with determining what codes are created and what they will be paid, is largely packed with specialists. I would be very happy to have specialty services carved out to a separate SGR along with one for primary care services. The result would be a falling conversion factor over time for specialty services and a rising one for primary care. It is the bundling of primary care into the bigger physician pool that has led to many of the problems that exist in primary care compensation (as well as other mostly cognitive specialites) and it is time to rebalance the distribution of payments. After all, have not many of your services in essence taken away payments to primary care over the years since many were created and priced since the RBRVS system was first created? In essence, primary care and other cognitive specialties have been subsidizing payments to cardiology and other procedure driven specialties by virtue of this cost shifting.

We in primary care have no similar new codes to counterbalance this, which is why you will find the absolute costs of cardiology, radiologic, and other services have far outstripped payments to primary care. You must have some sense of fairness left in you as to this argument, I hope. The only other plausible atand is to assume that primary care is no longer necesary or valuable and deserves to have compensation cut. Unfortunatley many studies show the opposite, proving time and again that patients fare better and care is delivered for less cost with a healthy primary care system.

Once again, every other country in the developed world has a higher number of primary care docs than specialists and deliver care for greatly reduced cost to their entire population (not just the one who can afford insurance). We are the only ones that have the proportions the other way around, and this is largely because we are the only ones that have a very profit driven medical system that is largely designed to overtreat the patient, even when we cannot prove the benefit of what we are doing (just as long as insurance covers the cost of these worthless treatments).