Payment Reform: One Primary Care Physician's Response

The last post on the Boston Globe's coverage of payment reform generated a number of responses, but one seemed to capture the sentiments most accurately. With permission of the author, here it is for your consideration:

"You should know that if Massachusetts does try to balance the health care budget on the backs of the primary care physicians (which this ultimately amounts to), I, for one, will be out. I submit that many of my colleagues will do the same. 

Try to institute a similar payment system for attorneys, accountants, dentists and/or other similarly trained professionals and see what happens. Although the health care payment system certainly has socialist leanings, we're not quite at the point that they can mandate where I do business. 

Let the hospital executives, insurance executives, the office of HHS, professors of health policy, patient advocacy groups and anyone else that feels empowered to infringe upon my rights as a small business owner find someone else to use as slave labor or provide the patient care themselves."

-  A Massachusetts PCP

Will "Global Payments" Help or Hurt Patient Care?

The mid-term elections are over; the 2011 legislative session is on the doorstep; and the policy wonks and MA political junkies are salivating in anticipation of possible legislation on payment reform -- the final frontier in health care reform.


Countless hours have been spent in ballrooms discussing the nuances, implications and nitty-gritty of payment reform, and this week was no different.  The Boston Globe covered the most recent gathering -- the Massachusetts Health Policy Forum.  The article is worth the two-minutes to read to hear multiple opinions on the topic. More importantly, you should note that nearly every "stakeholder" is quoted including a hospital executive, an insurance executive, the office of HHS, a professor of health policy, and a patient advocacy group. 


Who's missing? ... a practicing physician ... again. This seems to be the theme of these efforts: Bring everyone into the discussion except those most critical cog in the entire system. Hopefully that will change soon.

Best Quote from the Article: "The autonomy of decision-making is going to be diminished on an individual level’’ and moved to teams." - Gary Gottlieb, MD; CEO, Partners HealthCare, Inc.

Response to Quote Question: Who will be responsible for making care decision with patients when health care is a "team" (aka committee) effort?

Poll: Will "global payments" compromise patient care?

*** PUBLIC COMMENT ON PAYMENT REFORM ***

   ** SAVE THE DATE **

State's Health Care Quality and Cost Council
to hold Public Forum on Payment Reform 

Members of the Massachusetts Health Care Quality and Cost Council (HCQCC) and its Committee on the Status of Payment Reform Legislation (the Committee) will host a public forum in Shrewsbury on Thursday, December 2nd.  Members of the public, including but not limited to, advocates, consumers, providers, employers, health plans and the press, are encouraged to attend.  

WHAT:	Public Forum on Health Care Payment System Delivery Reform
WHO:	Massachusetts Health Care Quality and Cost Council Health care industry stakeholders
WHEN:	Thursday, December 2, 2010 12:30 p.m. - 2:30 p.m.
WHERE:	UMASS Medical School -- Hoagland Pincus Conference Center 222 Maple Avenue Shrewsbury, MA

Physician-Industry Relationships Debated on AC360

Here's an excerpt of an exchange between a reporter from ProPublica (of recent repute for spearheading the initiative to consolidate data on payments to physicians), a former pharmaceutical sales representative who became a whistle-blower and Dr. Tom Stossel from Harvard Medical School / Brigham & Women's Hospital.  


Interesting exchange ... be sure to vote after viewing the video!

Who won the debate?

Put Doctors on Salary, Part 2

The previous post generated some consternation among several readers (for good reason). Here's a (somewhat) related article published in Fierce Health which highlights that independent practices earn more than their hospital owned counterparts. No wonder policy wonks, more likely to be from academia and academic hospitals, suggest everyone should be on salary: They can better control costs (aka your income) and preserve critical services (aka their income).

Clearly we're setting up for a significant power struggle in MA since ~60% of physicians are part of small independent practices yet legislators have decided that more consolidation in the form of ACOs is the solution to controlling costs. 

There's more money in independent practices...sort of

October 29, 2010 — 11:35am ET | By Dan Bowman

Apparently it pays--quite literally--to be part of an independent physician practice as opposed to a hospital-owned practice. According to a Medical Group Management Association survey presented at the group's annual conference in New Orleans earlier this week, the median total revenue at independent practices per full time physician in 2009 was just over $780,000, vs. roughly $448,000 for hospital or integrated delivery system-owned practices, a 44 percent difference reports Medscape Medical News.

But those numbers don't necessarily indicate that independent practices are more lucrative than their hospital/IDS-owned counterparts. Rather, hospital/IDS-owned practices tend to "reallocate income and costs," say the authors of the Cost Survey for Integrated Delivery System Practices: 2010 Report Based on 2009 Data.

"Everyone talks about how hospitals lose money on their own practices," MGMA president and CEO William Jessee said at a press conference. "And yes, they have lower revenue than non-hospital-owned practices, but a lot of this comes from how they account for the revenue. For example, a non-hospital-owned practice may account differently for the ancillaries they purchase, so there are some accounting differences."

In terms of compensation, doctors working in independent practices earned close to 20 percent more than those in hospital/IDS-owned practices. On average, hospital/IDS-owned doctors took home $294,984, compared with $353,549 for non-hospital/IDS-owned docs.

The survey reports statistics from 1,003 practices nationwide.

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Put Doctors on Salary, Survey (by Commonwealth Fund) Says

Here's an interesting article that will surprise few that follow the Commonwealth Fund's work. For the unfamiliar, the Fund does extensive health policy research and is regularly commissioned by the states to support their policy development efforts. Familiar or unfamiliar, the article is worth reading since it gives a glimpse into an idea that, for better or worse, is gaining steam: End the independent physician practice and put everyone on salary.

The NY Times ran a story which mirrors this theme earlier this year and highlighted that "an increasing share of young physicians, burdened by medical school debts and seeking regular hours, are deciding against opening private practices. Instead, they are accepting salaries at hospitalsand health systems. And a growing number of older doctors — facing rising costs and fearing they will not be able to recruit junior partners — are selling their practices and moving into salaried jobs, too."

Apparently, the Commonwealth Fund decided to put some numbers behind the anecdotes. Note they do not list independent physicians on their list of groups surveyed. Makes you wonder...

Put Doctors on Salary, Survey Says
October 26, 2010

The healthcare system would be much improved if physicians were all on salary, according to results from a survey by the Commonwealth Fund.

"The way we currently pay for healthcare leads to unnecessary confusion and wide variation, and sometimes borders on chaotic," said Commonwealth Fund president Karen Davis, PhD.

"Experts agree that if private payers and public programs could come together and agree to pay the same way, and the same amount, we can improve the efficiency of our healthcare system, eliminate administrative waste, and create better experiences for patients," Davis said.

The Commonwealth Fund, a left-leaning think tank, and Modern Healthcare magazine commissioned Harris Interactive to survey healthcare academics and researchers; leaders in healthcare delivery, business, insurance, and other health industries; and key players in government, labor, and advocacy groups.

A total of 190 experts participated in the survey, which was conducted between Sept. 7 and Oct. 6. The results were summarized in a brief written by Kristof Stremikis, MPP, Stuart Guterman, MA, and Davis. All three authors work for the fund.

When asked whether they supported salaried medical practice with "appropriate rewards for quality and prudent use of resources," only 11% said they did not.

Nearly three-quarters (73%) said they supported salaried practice with rewards for both quality and resource use. The remaining 16% supported salaried practice with rewards for quality, "but not connected to prudent use of resources," the authors noted.

Nearly half of respondents (49%) agreed that it was "important or very important" for patients to choose services and providers on the basis of cost.

Respondents also agreed that the reimbursement system needs to be simplified.

"Currently, public and private health insurers engage in a complex and continuous process of negotiations with multiple healthcare providers to establish reimbursement rates for services," the authors noted. "This increases administrative expenses among payers and providers and leads to wide variation in prices."

Related to that, 56% of survey respondents said they supported replacing the current system with either all- payer payment rate setting or a single system of payment rate negotiation on behalf of all payers.

Another 23% of respondents supported letting each provider set its own prices, where insurers would pay the lowest price and patients would pay the difference in cost for seeing higher-priced providers.

Just 9% of respondents supported keeping the current system.

Survey respondents also supported several other changes to the reimbursement system, including "value- based benefit design," in which cost- sharing for individual services varies based on the established effectiveness and potential benefit of the treatment or service; and "reference pricing," in which insurers and public programs pay for a drug, device, or service based on the lowest price of equally effective treatments.

Just over half of respondents (53%) of also supported using tiered networks, in which premiums for enrollees would vary based on the level of spending by the hospitals, physicians, and other providers they used.

The survey also asked respondents about transparency in healthcare pricing. Nine out of 10 respondents agreed that it was important for the public to have information on clinical quality, prices, and patient experiences.

"Such information could be used to encourage physicians to meet local and regional benchmarks, allow public and private payers to become more prudent purchasers of care, and to empower patients to identify and receive care from high quality providers," according to a statement from the Commonwealth Fund, which also noted that the new healthcare reform law, the Affordable Care Act, contains provisions aimed at increasing transparency.

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The Happy Health Reform Cartoon

Via the Kaiser Family Foundation ... 10 minute animation devoted to helping average Americans understand health reform.  Interesting, but mostly a PR pitch for reform.  Lots of happy cartoon Americans tossing little coins in different directions (mostly at Uncle Sam) makes redistribution seem more fun. (It's also worth noting how rapidly Medicare cuts, a looming political and sustainability problem, are covered.) ... Nonetheless, the video's worth viewing:

Guest Post: Industry Funding of CME

The last post highlighted a Boston Globe article regarding the role of industry funding in continuing medical education ... in response to the Globe article, I receive this hypothetical interaction between a CME instructor and an attendee that I couldn't resist sharing:

CME REGISTRANT: "What are your credentials to teach this session?"

INSTRUCTOR: "I am a board-certified cardiologist and I have no financial conflicts to report"

CME REGISTRANT: "What will I be learning today?"

INSTRUCTOR: "Evidence-based best practices to open a clogged coronary artery. Let's begin. First, you hold the flint in your dominant hand and strike it sharply with the iron chisel until a sharp edge is fashioned. Be careful with the sparks and stone chips. This technique has been around a long time and is very well described....."

CME REGISTRANT: "What about angioplasty?"

INSTRUCTOR: "Ah, I see the catheter rep has paid you a visit. Angioplasty is a relatively new procedure and the risks are not yet fully understood, nor the long term outcomes. We have much more extensive experience with flint-making. The angioplasty companies are disease mongerers and by using the classical technique, you make a powerful statement that you cannot be bought."

CME REGISTRANT: "Please excuse me, I'm downloading intravascular ultrasound images on my iPhone for a case tomorow......"

INSTRUCTOR: "Please be sure to attend this afternoon's session where I will give an engrossing lecture, 'Fire: Going Beyond Sterilization', you won't want to miss it".

CME REGISTRANT: "Thank you...."

-Anonymous Guest

People Who Have The Most Expertise ... Are the People Who Work With Industry - Steven Nissen, Cleveland Clinc

The debate over the role of industry funding in continuing medical education (CME) continues on the pages of the Boston Globe this week.  

The article highlights a new company, Lighthouse Learning, that was formed by Dr. Martin Samuels, a neurologist from the Brigham & Women's Hospital and Harvard Medical School, who has a little experience in the field.  In fact, the article highlights that he was the medical director of M/C Communications until last year "when he said he decided that commercial support created an unacceptable conflict."


The curriculum will be developed by 11 specialists, many from Harvard, who will not be allowed to teach other courses funded by drug companies, "to further insulate them from industry influence."  


And the company's advisory board will also help them keep influence peddling in check. The board includes reputable names such as Dr. Joseph Martin, former Dean of Harvard Medical School, who will review the curriculum directors' other relationships with industry.  


(Note: Dr. Martin was also highlighted in a provocative NY Times article earlier this year which highlighted that under the new conflict of interest rules implemented at Partners HealthCare, Inc., he will no longer be able to accept the >$200,000 per year compensation for serving on the Board of Directors at Baxter International.  Interesting, that he will be watching over relationships at Lighthouse).


Non-MD, Dr. Eric Campbell, a vocal critic of industry, noted that Lighthouse may find it more difficult to separate themselves from industry influence than they expect.  He suggests "that companies can offer to pay doctors' tuition to attend certain courses, thereby exerting influence that way."



Oddly, in the article Non-MD-Campbell is noted for "specializing in conflict of interest" but seems unaware of the pharmaceutical industry's own conflict of interest policy, which states that:


"Financial support should not be offered for the costs of travel, lodging, or other personal expenses of non-faculty healthcare professionals attending CME, either directly to the individuals participating in the event or indirectly to the event’s sponsor (except as set out in Section 9 below). Similarly, funding should not be offered to compensate for the time spent by healthcare professionals participating in the CME event."

The final quote from Dr. Steve Nissen, who needs no introduction, sums up the issue quite accurately:


"The biggest name people, the people who have the most expertise and are going to draw an audience -- they are the people who work with industry."

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Banning Industry Sales Reps Increases Cost of Every Prescription by $5.18

Medpage Today puts an interesting spin on findings from a study about to be published in the Annals of Family Medicine.  Despite the headline, "Barring Drug Samples Boosts Use of Other Meds", which suggests a straight-forward response -- ban industry and get results -- the study actually tells a very different and more interesting story...

Study Results
After banning sales representatives and medication samples from their clinic, they found:

• That "aggregate levels of brand-name drug use didn't change significantly"
• A non-significant trend toward "reduced prescribing of branded anti-hypertensives and lipid-lowering drugs"
• That "branded drugs for respiratory disease declined significantly, by 11.34%"
• That "overall cost of prescription drugs were not reduced.  In fact, they increased by $5.18 per prescription per month immediately after the policy was introduced."

They speculate that the increase in overall cost of prescriptions was likely due to the loss of samples in the clinic, but go on to highlight that the cost of "lipid-lowering drugs were significantly reduced, by $0.70, per prescription per month."  It seems that the differential -- $5.18 increase vs. $0.70 decrease -- is sufficient to conclude that the policy hurt patients more than it helped them.

So, in short, the authors of th study found that the policy achieved one thing: It increase cost for patients.  The question that they did not address is "what impact did the policy have on patients?"  How well are the respiratory patients doing following the 11% drop in prescriptions for branded agents.  That's the interesting question given the push towards efficiency and quality moving forward.

References

Kristina Fiore, Staff Writer. MedPage Today. Barring drug samples boosts use of other meds. September 13, 2010.

Hartung DM, et al "Effect of drug sample removal on prescribing in a family practice clinic"Ann Fam Med 2010; 8: 402-409.

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