Dec 09
8
HR 3962: A Path to Progress or Paucity?
The House of Representatives passed HR 3962; now the bill moves to the Senate.
The consequences of this vote, whether yea or nay, are likely to fundamentally alter the fabric of healthcare and the lives of physicians in many ways.
There are a number of things to like in this bill. First, eliminating the ability to deny health coverage based on health status or preexisting conditions is laudable and necessary.
Second, provisions that promote the evidence-based practice of medicine are not only good but also essential.
One potential consequence of this reform is that disenfranchised specialists who can no longer make a go of their former practices may attempt to recast themselves as primary care physicians in order to receive federal grants and stipends. Although this may be an excellent move for some, prudence is required to ensure that standards of care are met and maintained.
One of the items with the greatest potential for correctly rewarding desired healthcare delivery in this bill is a clause to revamp the relative value units (RVUs) of the Medicare fee schedule. The American Medical Association/Specialty Society Relative Value Scale Update Committee, or RUC, have been wholly preempted by the specialist and subspecialist, with hardly a voice for primary care represented. This is a fundamentally necessary change if the Centers for Medicare & Medicaid Services (CMS) is to receive balanced and appropriate recommendations regarding the values of services rendered.
Unfortunately, when it comes to payment revisions, the language in the bill states that CMS “may hold such hearings, sit and act at such times and places, take such testimony, and receive such evidence as the Commission considers advisable.” This allows CMS to decide when it will hold hearings on Medicare payment issues, if it decides to hold hearings at all. A decision not to hold hearings preempts input from physicians and allows political cronyism and backdoor politics to hold physicians hostage in the payment model.
Funding pilots of the Patient-Centered Medical Home is also worthwhile. I am troubled, however, that even those in government who champion this seem to have a very cursory understanding of the ramifications of this pilot. They don’t seem to comprehend how extensive are the requirements placed on primary care offices. Furthermore, funding of this pilot is in a precarious position, given the overall state of the deficit spending of our government.
Relief for the states from the unfunded mandate future of Medicaid is also appropriate. Because of the severe shortage of primary care physicians, an increase in Medicaid rates is essential. This will help prevent Medicaid from becoming a Soviet-style program in which the goal of the program is met because the government decrees that all have coverage, even though not everyone is able to actually get care through the program.
3962 will establish a commission to recommend changes in the quantity and specialty distribution of health professionals, to recommend new and expanded programs for the delivery of primary care. Oddly, the legislation gives no mention to primary care being represented on the commission. Given the close nature of the vote and the divisive tones in the healthcare debate, I foresee this commission being emasculated or its recommendations ignored, co-opted, or corrupted to political agendas.
This bill provides annual and lifetime caps on how much families or individuals would be required to pay for healthcare so that no American has to declare bankruptcy due to healthcare expenses. This is a commendable provision.
However, in practical terms, the fact that the same entity which created the Alternative Minimum Tax set these terms borders on comedic. This will place an unfunded mandate either upon the hospitals and physicians who care for patients suffering catastrophic medical conditions or upon the American taxpayer. To my knowledge, the future costs of this clause have not been incorporated into the Government Accountability Office’s calculations of the cost of the overall bill.
The health exchange concept is not without merit. However, I fear that its functioning relies on too many preconditions, which can be changed by the Department of Health and Human Services or later congresses, or perhaps even an “Exchange Czar” to the detriment of the practice of medicine.
Similarly, the “nonpunitive” incentives for successful participation in the Physician Quality Reporting Initiative process must be viewed with a jaundiced eye. Experience to date with the participation requirements and the whims of the mandarins who deem participation as “successful” or “unsuccessful” are not encouraging. Effective 2012, the bill would enable the government to reduce payment to physicians for nonreporting or “unsuccessful reporting.” The legislation as it currently exists does not appropriately account for health status and socioeconomic factors of patients when reviewing physicians. Small practices may be disproportionately negatively affected by their patient mix and outcomes while trying to provide access and improve quality.
It is very telling that Congress failed to fix the Sustainable Growth Rate (SGR) formula for setting Medicare’s physician payment rates abomination prior to this vote. To our faces, congresspeople tell physicians that they view this formula as flawed and that they support changing it. However, when a vote on this reached the light of day, political gamesmanship and public posturing snuffed out the measure easily.
If this process fails to implement meaningful medical liability tort system reform, the economics clearly mandate system-wide failure of the healthcare delivery system in America. The unaccounted costs of the bill as it currently exists cannot be counterbalanced without a dramatic reduction in the expenditures on defensive medicine. With the macroeconomic repercussions of this plan, the savings from defensive medicine will be required in order to have an iota of a chance of funding healthcare.
Ultimately, these reforms as proposed in 3962 may serve as the first paragraph in the final chapter of the primary care physician. If I am overstating this, then why does the bill specifically exempt hospitals and hospice providers for up to 4 years from payment reductions but leaves physicians with the SGR reductions and vulnerable for more? Physician payments are one of the few areas in which the government can recoup “savings” to diminish the cost of the legislation.
Should this legislation be enacted, perhaps all will have coverage but few will receive the care that they expect and require. The ultimate decision now lies with 100 Senators. Time will tell whether it is successful or whether the day will come when there aren’t 100 primary care physicians practicing in the country. Reform is desperately needed, but as of this writing, this bill doesn’t fit the bill.
