Sunday, April 12, 2015

Medicare SGR Replacement Bill: "An Unwarranted Role of Medical Specialty Boards"

From Merrill Goozner at Modern Healthcare Magazine:
"The law not only scraps the sustainable growth-rate formula for physician payment, it consolidates the diverse programs for rewarding or penalizing physicians. The CMS no longer will calculate separate payments for reporting quality measures, improving performance or meeting meaningful-use standards.

Instead, the CMS will substitute a composite MIPS score for each physician participating in the Medicare program. When measured against clinical peers, a physician's score could result in the agency rewarding or penalizing him or her up to 5% of annual revenue starting in 2020. That rises to 9% of revenue for 2022 and beyond.

While the program is designed to be revenue-neutral, it allocates $500 million for rewards, just in case a majority of physicians turn out to be like the kids at Lake Wobegon and achieve universally high composite scores.

The overall score will be based on how well participating physicians perform in four separate categories: quality measures (30% of the total); resource use (30%); achieving meaningful use (25%); and clinical practice-improvement initiatives (15%). Each component will be determined by agency rulemaking and stakeholder input.

But some stakeholders are being given a greater say in the process (others are invited to participate, of course). The law, for instance, asks “eligible professional organizations” to recommend quality measures for use in the program. It defines eligible professional organizations as “nationally recognized specialty boards of certification.”

It also says physicians can achieve the maximum score on the clinical practice-improvement component by being part of a certified medical home or “comparable specialty practice.” The law gives “eligible professional organizations” the ability to make that determination. The bill also mentions “practice assessments related to maintaining certification” as one way to achieve a maximum clinical practice-improvement score.

The special role given physician specialty boards in the SGR replacement bill heightens the stakes in the recent controversy swirling around the costly and complicated recertification process at the American Board of Internal Medicine, one of the largest boards in the nation. A rival group is seeking to substitute continuing medical education credits for recertification test-taking, which the ABIM and patient and consumer advocacy groups oppose.

The flare-up has brought some of the more unsavory and unscientific aspects of the self-regulating physician recertification process to light. A recent New England Journal of Medicine perspective by ABIM critic Dr. Paul Teirstein of the Scripps Clinic noted that the latest studies have shown no relationship between physician recertification and performance on quality measures—the very task given to certification boards in the SGR replacement bill.

Teirstein also accused the ABIM of being “a private, self-appointed certifying organization” that charges exorbitant fees “unfettered by competition” for its products and tests.

The certification boards aren't major powerhouses on the Washington lobbying scene. Last year, for instance, the ABIM spent only $160,000 on the lobbying firm of Mehlman Castagnetti Rosen Bingel & Thomas, according to Senate lobbying records. But that firm's chief healthcare lobbyist, Dean Rosen, once served as an adviser to then-Senate Majority Leader Bill Frist (R-Tenn.), and apparently still has good connections with the staffers who drafted the language of the SGR replacement bill.

As we editorialized here two weeks ago, a permanent end to SGR is the right thing to do. And creating MIPS to replace multiple rewards programs will lessen the administrative burden on physicians and physician practices, and incentivize them to move toward value-based care payment models.

But other stakeholders will need to remain vigilant to ensure that self-interested physician specialty boards don't play an outsized role in setting the parameters of the program—especially when it comes to determining what constitutes quality and clinical-practice improvement."
This is horrible. Our government is about to authorize the use corrupt and completely unaccountable certifying organizations to serve as a metric with which to determine the "value" of health care for our patients and remuneration for working physicians nationwide. In fact, the certifying organizations the bill authorizes are being sued in federal court for possible anti-trust violations. How embarrassing would our U.S. Senators look in the eyes of seniors everywhere if that suit is found in favor of the plaintiffs?  The whole Medicare SGR Replacement Bill, H.R. 2, would fall apart.  Are our U.S. Senators really ready to put their political careers on the line for one flawed bill? (Note the senators who were lobbied were never privy to this pending lawsuit.)

(To think that the policy divisions of our sub-specialty medical societies are also complicit in this scheme is even more appalling.)

Is this what our patients need? Are we, the front line working physicians, going to allow the self-serving money trail of government grants to determine what constitutes quality care for our patients and "value" for  our health care system?

All physicians AND their patients need to stop and pick up the phone Monday morning. Call BOTH your Senators and flood the switch boards. Tell them to vote "NO" on the Medicare SGR Replacement Bill (H.R. 2).

Unless, of course, you think $2.3 million dollar condominiums with chauffeur-driven BMW 7-series town cars is how our nation should define health care "value" in the years ahead for our Medicare patients.


Addendum: Here's even more lobbying to CMS that pushed for ABMS "board certification" to be the only board used for CMS's Physician Compare website in Sept 2014.


Illuninati said...

Dr. West, what is the role of the AMA in all this? I'm retired but would have remained in the AMA if they had not helped Obamacare along with the raid on the Medicare piggy bank. Are they still working on the wrong side?

DrWes said...

Illuminati -

The AMA is a complicit bystander who is using their lawyers to defend the ABMS in the lawsuit against them.

Anonymous said...

This is the icing on the cake. I have "voluntarily" certified in Internal Medicine twice and twice "involuntarily" in Geriatrics.
I am appalled by the revelations in this blog and in multiple national publications of the abandonment of its members by not only the ABIM,AMA and the American College of Physicians.
An AMA response on this blog site mocked a physician responder for a lack of knowledge of ACA and insurance.
This very organization has survived as its membership dwindled by selling rights to the CPT.
It controlled the RUC that conducted its deliberations with greater secrecy than the Consistory of Cardinals in their selection of the Pope.
The only factions who were unrepresented in the crafting of the ACA were physicians and their patients.
The AHA, Insurers and big pharma had already cut deals that despite their protests will increase their revenues (Steven Brill:Bitter Pill).
Where were the AMA, ACP and the rest.
The ACP blog like a pom-pom waving cheerleader cheered it on. It's Form 990s also disclose salaries for its physician and nonphysician officers far in excess of incomes that we internists can ever achieve.
The mandates within the SGR will add to the cost of practice and the punitive penalties will drive many away.
The Hippocratic Oath stressed the primacy of the patient-physician relationship. The new medical "professionalism" espoused by hypocrites of our organizations who have put their vested self interests ahead of those they supposedly represent. In addition like infectious organisms they have infected the very soul of medicine

Anonymous said...

As an interventional cardiologist, I have decided NOT to place carotid stents, NOT to perform TAVR, NOT to perform alcohol septal ablation, NOT to perform ASD closure, NOT to perform mitral clips, NOT to perform mitral or aortic balloon valvuloplasty; however, every ten years I must become an expert in all these procedures that I have decided to avoid such that they are concentrated in a small number of other interventionalists in our group. I thought that I was doing the right thing which is what the ACC recommends. As a patient, would you rather have your procedure completed by someone who has only done a total of ten in the last five years.

The ABIM punishes me for this virtuous behavior by subjecting me to a test that requires me to be an expert in procedures that I don't perform. The interventional cardiology board asks me to size an aortic valve balloon. I don't do this procedure so how would I know. Of course, I can go to a university sponsored program in some far away town for a large sum of money and memorize superfluous information to regurgitate on a test .

This is the end result of a one size fits all bureaucracy. They say to allow procedures to concentrate in the hands of a few then penalize those that comply with their edicts.

Medical Quack said...

Congress can't model laws anymore..period and will they fund the former agency "Office of Technology Assessment" that used to be around to help them with technology! What's up with that? I was hoping that Defense Secretary Ashton Carter might have some power of persuasion as he worked for the agency at one time when it was funded and now look where he's at:)

A couple of former CMS employees have both told me that both HHS and CMS have relied on the "mentored" models that United Healthcare helps them build, and to that I say "no surprises" there. If you have time to look around and read a bit you do find some real similarities. The problem is they can't model anything different in Congress either, very scary indeed. The Center for American Progess aka the CAP is creating policy these days too, not the agency and that's where old Dr. Zeke Emanuel hangs his hat to by the way:) He loves UHC and Optum, he writes about it all over the web:)