AMA – The Moral Healthcare Blog

Primary care still waiting on ACA Medicaid pay raise – amednews.com

If the states manage to screw this up, and prevent pay improvement for primary care, it could jeopardize the success of the ACA…

Washington Primary care physicians who qualify for higher Medicaid payments under the Affordable Care Act might not see these rate increases as quickly as anticipated this year.

The Medicaid program has had a long-standing reputation for paying doctors at rates far below what Medicare pays for the same services. The ACA aimed to address this problem by directing states to bump rates for primary care services provided by primary care doctors up to 100% of Medicare rates for calendar years 2013 and 2014. Because the final rule on the provision was issued in late 2012 with an effective date of Jan. 1, many family doctors were hoping to see an immediate boost in their claims payments. However, “there could be a lag of several months even from now” for the enhanced Medicaid rates to take effect, said Jeffrey Cain, MD, president of the American Academy of Family Physicians.

Some physician organizations are concerned that states are missing the opportunity to prop up primary care because they aren’t moving quickly enough to pay these higher fees.

Several administrative steps are needed first at the state and federal levels, said Neil Kirschner, senior associate of regulatory and insurer affairs for the American College of Physicians. States have until March 31 to modify their Medicaid plans accordingly and submit those changes to the federal government, which then has an additional 90 days to approve the plans. “It’s unclear how many states have done that,” he said.

In recent letters to the National Governors Assn. and the National Assn. of Medicaid Directors, the American Medical Association and other organizations representing primary care doctors called on states to enact the pay bump expeditiously and engage in active communication with physicians to notify them about the timing of the pay increase.

With the ACA provision in effect for only two years, any implementation delays will make it harder for the government to collect data to see if patient access is improving by raising Medicaid payments, Kirschner said. The longer states take, the longer physicians must wait for these enhanced payments, which could affect decisions whether to take new Medicaid patients, he said.

Primary care still waiting on ACA Medicaid pay raise – amednews.com

Next Steps in Healthcare Reform: Repealing IPAB and SGR

Medscape: When Medscape interviewed AMA CEO Dr. James Madara in April, he reiterated the AMA’s support of the ACA, but he stressed that like all things, it’s a work in progress. Now that the law has been upheld, what are the next steps to improving the healthcare system? What areas of healthcare are in most need of improvement?

Dr. Lazarus: We think the things in the act that we’d like to get rid of, like IPAB, would help. We would like to see comprehensive medical liability reform, which we think would help on the cost side and bring down the cost of care. We would like to see a repeal of the SGR in Medicare. And we, in our own strategic planning, are looking at new delivery and payment models that will work better, both for physicians and patients. We think this will give physicians more satisfaction in whatever kind of practice situation they’re in, and it will enable them to deliver better care to patients at a reduced cost. We need to have time to do that. It’s a 5-year plan, and we’re excited about that part of our strategic plan.

Medscape: Do you have any parting thoughts on the future of medicine and the ACA?

Dr. Lazarus: This is something that we had been working on for a long time. We had been advocating for health insurance coverage for all Americans for many years, and we were pleased with the outcome. It gives us at least a roadmap to where we’re going. It eliminates the uncertainly about where things were going. As the law is implemented, we’ll see what other changes need to take place. But we were pleased at the outcome.

AMA – AMA votes to continue commitment to health system reform

AMA – AMA votes to continue commitment to health system reform:

AMA votes to continue commitment to health system reform
Outlines details to guide efforts toward making the health system better for patients and physicians
For immediate release:
Nov. 9, 2009
HOUSTON – The American Medical Association (AMA) House of Delegates today voted on health system reform policies, reaffirming the AMA’s commitment to health system reform. The AMA’s House of Delegates is the nation’s broadest, most inclusive assembly of physicians and medical students. Delegates representing every state and medical specialty debate and vote on behalf of their physician peers.
“Now is a defining moment in the history of the AMA,” said AMA President J. James Rohack, M.D. “In a democratic process, the AMA House of Delegates today voted to continue AMA’s commitment to health system reform for patients and physicians. The time to make health system reform a reality is now.”
The AMA reaffirmed its support for health system reform alternatives that are consistent with AMA policies concerning pluralism, freedom of choice, freedom of physician practice and universal access for patients. It also outlined specific elements it will actively and publicly support and oppose as the health system debate continues.
The AMA’s support for H.R. 3962 and H.R. 3961 remains in place.
“H.R. 3962 is not the perfect bill, and we will continue to advocate for changes that help make the system better for patients and physicians as the legislative process continues,” Dr. Rohack said.”

Now that the American Society of Anesthesiology has voted to support the House Bill, we now have an AMAZING NINE OF of the TEN largest physicians organizations supporting reform.

Even if you take out the AMA and AOA as a friend suggested because they are multispecialty groups, we have 8 of the ten largest physician specialty organizations supporting reform. The American College of Radiology is still against it, the American College of Emergency Physicians (# 9) has still not committed and the American College of Cardiology ( which I’m pretty sure is # 10) is on board.

That’s about as close as you can get to running the table with physicians groups.

Tort Reform does not necessarily equal caps

From the AMA.

Tort reform may still be coming, per President Obama’s Address last week. While caps are still the AMA’s favorite remedy, in this recent letter they outline some other considerations…

Alternative Reforms

While the AMA continues to advocate for proven reforms like MICRA, we are also committed to finding innovative solutions to the broken medical liability system such as offering of grants tostates to pursue alternatives to current tort litigation. These alternatives include:

• Health Courts. Health courts would provide a forum where medical liability actions could be heard by judges specially trained in medical liability matters and who hear only medical liability cases. The AMA developed and adopted health court principles in 2007 to assist state and local governments, insurers, hospitals and other entities interested in exploring this option for medical liability reform.
• Early Disclosure and Compensation Programs. Under an early disclosure and compensation model, providers would be required to notify a patient of an adverse event within a limited period of time. Notification does not constitute an admission of
liability. Providers offering to compensate for injuries in good faith would be provided immunity from liability. Payments for non-economic damages would be based on a defined payment schedule developed by the state in consultation with relevant experts and with the Secretary of Health and Human Services (HHS).
• Administrative Determination of Compensation Model. A state’s administrative entity would be charged with setting a compensation schedule for injuries, resolving claims for injuries, and establishing compensation based on the patient’s net economic loss, subject to periodic payment and offset by collateral payments from sources such as insurance.
• Expert Witness Qualifications. Several states have amended the statutory qualifications for those who may serve as medical expert witnesses at trial. Some states (e.g., Georgia, Texas, and Illinois) have created additional standards that medical expert witnesses must meet in order to ensure the testimony juries receive is presented by an individual with particularized expertise in the matter in question.

The AMA is committed to finding a solution to the challenges of the broken medical liability system, including federal reforms based on proven state solutions like California and Texas as well as alternative liability reforms like health courts. The AMA also supports protecting patients’ access to care by working in concert with
state medical associations to enact and defend strong medical liability reform laws.

AMA Conference Call on HC Reform

The AMA is doing regional conference calls on health care reform. The one for my region (PA, NY, MA, maybe others) was tonight. I gather it was the first one they’ve done so far, but they indicated they would be doing more.

On the call for the AMA were Immediate Pat president Nancy Nielsen, Jim Wilson, Political Education Programs Manager, and Richard Deem, Senior VP for Advocacy.

I was pretty pleased with the call and the positions that the AMA seems to be taking, so you may be pleasantly surprised.

The call started with some comments by Dr. Nielsen, then questions from the group (transcribed for the AMA reps, who read them to us), and a brief closing statement.

Dr. Nielsen opened with a discussion of HR 3200, presumably because of the push back the AMA has gotten from its more conservative members. HR 3200, in its original release addressed in positive ways, many of the AMA’s highest priority goals. These included extended coverage for the uninsured, preserved choice of health insurance plans, fundamental Medicare reform including elimination of the SGR, encourages mangament of chronic diseases and coordination of care, increased payment to Primary Care Physicians with no reduction in fees to specialists.

The things in 3200 the AMA wants changed: addition of Medical liability reform; change in plan for public option fees to be 5% above medicare; and restrictions on physician ownership of hospitals.

Ammendments introduced so far include “modest” liability reforms (AMA speak for anything that is not “caps” on damage awards), including encouraging states to give incentive payments for certificate of merit and “early offer” programs, and she reaffirmed, essentially, that we’re all about caps at the AMA. Also ammended, public plan participation by physicians will not be mandatory and public plan fees will be negotiable and not fixed to medicare rates.

Compromises still being sought include, in the Senate HELP committee: Public Plan similar to HB 3200; negotiated payments; the plan must be self sustaining, and compete on a “level playing field.”

In the Senate Finance Committee, the bipartisan “Gang of 6” are seeking compromise legislation, but we have not seen an actual bill yet. But all indications are that this bill will NOT fix SGR (only another one year fix, then replay the annual ritual of rganized medicine fightinng to fix this again. The AMA wants to fix this with Senate FLOOR VOTE. Also concerning are possible penalties for PQRI non participation and that we may end up with co-ops rather than PO/PP. Dr. Nielsen preemptively addressed the question of why the AMA has postioned itself where it has re: HB 3200: We need insurance market reform because insurance is tenuous to the public, it is tied to jobs, it is limited by preexisting conditions and because we all pay for care given to uninsured anyway. Getting rid of SGR is a big deal for the AMA as is avoiding other financial penalties (such as with PQRI) and we do all have to be worried about costs.

She also points out that we physicians are being dealt with very fairly in HB 3200: Hospitals are going to get cuts, home health gets cuts, as do others while physicians get $230 Billion (erasing SGR debt is part of this number, but also includes higher fees for PCPs including incentives for coordinating care and dealing with chronic care patients)

Why did AMA support HB 3200 so quickly? Dr. Nielsen said that early support means something and gives us more influence; we are working with leaders in both houses and they understand Medicare must be strong(!). The AMA did not “give away” support; it was negotiated and we got things: No mandatory participation in a public plan, more money.

She points out that ranting is not useful, quiet negotiation does and is working.

QUESTIONS FROM AUDIENCE:

Q: Socialized medicine!!! Slippery Slope!!!! (I paraphrased here.)
A: NO: Americans will not tolerate it. Expanding coverage is not socialism.

Q: Will there be rationing under Medicare or under any public option.
A: NO NO NO

Q: Wwhy support anything without “significant” liabilty reform?
A: We’re still fighting!

Q: How does AMA support 3200: It’s awful.
A: No, it isn’t. SGR!

Q: Can we have physician council to guide HC?
A: AMA may be filling this role in guiding legislation, but not clear if tere would be a way to do some far reaching council.

Q: Anything restricting physician patient relationship?
A: The AMA is FIRM in that there can be no interference in care decisions. CER will never mandate what a doctor may offer to a patient. MC is easier to deal with than PHIs(!!!), she said, from her perspective as a primary are physician. Less hoops with MC! We also want best evidence! Mr. Deem: No penalties on PQRI in HB 3200

Q: How can we support bill we haven’t seen? Aren’t we being used/abused?
A: Physicinas are necessary in this debate. Congress has brought actors together and said we are all in this together and we have to do this. NN thinks we are participating, not being used and we believe we have influenced the process significantly, but perhaps not on CAPS.

Q: HB 3200 better PCP fees?
A: Yes; also increased coordination of care fees.

Q: Did you read 3200?
A: Yes. We have a team that does that and they analyzed it. I have read it as well.

BIG POINT HERE: She calls out the BS email about he facts of HB 3200 as “outrageous,” and notes that the AMA has reviewed, and agrees with the rebuttal provided by politifact.com.

Q: Massachusetts seems to be working well except cost controls, what now?
A: We need to learn from MA; getting people in system but costs are big issue; bigger question is how do we come to grips with our responsibility as citizens and patients and physicians and insurers? MA has shortages in work force, nursing and derm and gen. surgeons; We don’t need to wait for workforce to be online before we reform HC; lead time too long for physicinas in particular. Choice of doctors and insurers key.

Q: 70-83% of peopple are satisfied with coverage; maybe they won’t be if we change things; maybe Congress will lower reimbursement after the bill passes?
A: We are all nervous; but we are also the unhappiest MDs in the world. Prez says you can keep what you have; AMA is concerned about this and we want to preserve choice.

Q: Will Public Plan crowd out private insurers?
A: Bill is written so choice to join PP is limited (to the uninsured, small businesses and some others) but this could change and we must be vigilant.

Q: Why should we trust this administration?
A: Trust but verify. This is about influence and we are critical to change. It is important for us to pay attention and focus on what we agree on, and not on divisive issues.
Mr Deem: Adminstration trying to fix/improve payment formula and did something about MD administered drugs that AMA has been asking for for 8 years and we are just now getting it.

Dr. Nielsen made the point here that Obama’s example of non-indicated tonsillectomy example. She thinks that was Really Bad; we know it is not like that; they got big push back.
[CMHMD: I actually agree that he really mangled this one; “inartful” was the kind way to put it, I thought.]

Q: Will there be an independent body, such as an uber-MEDPAC or IMAC, that will rule the roost?
A: Dr. Nielsen expressed concern that there seem to be expenditure targets for physicians, but not for any of the othr big players. She indicated the many if not all of these issues are “in process,” and the AMA is expressing our concerns.

Dr. Nielsen added that she thought a view expressed what she called a “minority view” of physicians is that an independent council would be better than dealing with congress. [CMHMD: I don’t think this is a minority view. Many health policy big wigs think having Congress function as the “Board” for Medicare is a bad thing that needs fixed.]

Q: CBO score for Senate Bills?
A: We don’t know when we’ll get them.

Q: Other countries physicians’ have less financial pressure coming out of training.
A: We agree and are working on it.

Q: What should physicians be doing now?
A: AMA is happy to help and reach out. Like this call. Hard to say what to do; gives example of tea baggersand cautions that physicians need to be rational and let people know we want to take care of patients without government interference and make sure uninsured get in system and don’t saddle kids with crushing debt. Don’t fall for labels and rhetoric.

Q: What happens to HSAs?
A: Mr. Deem: HSAs stay in so far. And we will push for that.

Q: Geographic variation?
A: AMA pushing for money for IOM study. Gypsy payment floor (?)

Closing, Dr. Neilsen: This is moving target. What’s the difference between an echanges and a co-ops? Exchanges are like a mall to shop; co-op like a single store where owners are also customers.
[CMHMD: I’d call this mutual insurance, and it could be a good thing if well regulated.]

CMHMD final comments: I fouund this very encouraging. There was the expected conservative push back, but that’s OK, Dr. Nielsen did a great job of keeping things focused on what are truly high goals for physicians: universal access and fairness in the system. She also stuck to the markers she must or get pummelled by the membeship on tort reform and “choice,” but, hey, pretty good from where I’m sitting!

Doctors Oppose Giving Commission Power Over Medicare Payments – WSJ.com

Doctors Oppose Giving Commission Power Over Medicare Payments – WSJ.com:

But doctors are objecting to proposals that would allow a federal commission to set the size of Medicare payments to doctors, hospitals and other health-care providers. Under a proposal from White House budget director Peter Orszag, if the president accepted the commission’s recommendations, they would automatically take effect unless Congress acted to block them.
Doctors’ objections to the commission idea highlight the difficulty of maintaining the support of different health-care constituencies when the focus turns to controlling costs.
Surgeons would ‘vigorously oppose’ legislation that gave an unelected executive agency power to set Medicare rates, said the American College of Surgeons, which claims more than 74,000 members, in a letter to House Speaker Nancy Pelosi last week. Several surgical-specialty societies also signed the letter.
The AMA, which claims 250,000 members, said a commission shouldn’t be authorized to set Medicare payment rates for physicians. ‘If the solution is we’re just going to have a big board that will make draconian slashes, that’s not getting at the root cause of what the problem is,’ said AMA President J. James Rohack.

This is interesting. First, reimbursements are virtually set now by an unelected board, the RUC, made up largely of the highly paid, procedure based specialists.

Second, I just heard Chuck Grassley on NPR this morning saying the House and Kennedy Bills did nothing to bend the curve. This is what is required to bend the curve. Put up or shut up. Bending the curve isn’t some magical thing where everyone gets to keep making as much money, on the same trajectory as they do now.

And it’s worth pushing back on the AMA in particular. They’ve been talking a good game about what needs to be done to improve health care, reluctantly (because of fear of retribution, I suspect) pointing out whose oxen to gore, but they’ve been very silent about what physicians will be required to give up in all of this.

I frankly don’t expect to have to give up much, (I’m 49) and what I do give up will occur over ten to twenty years and so accommodation will be made by the “youngsters,” those going into and coming out of medical school and residencies now). They are the the physicians who will actually be affected by this. The old guys pissing and moaning are ready to retire soon, so shouldn’t be holding the country hostage to their reactionary, out dated ideas of what medicine should be about.

UPDATE: I was researching Medcare for a talk on the 44th anniversary of the program, and it is worth mentioning that one of the things LBJ had to do to pass Medicare was to cave to the American Medical Association and American Hospital Association, essentially giving them whatever was required to stop opposing the legislation. This had good and bad effects: lots of hospital construction, advances in medicine, and huge revenue boosts for hospitals and doctors.

On principle, we should not cave to get reform, but on a pragmatic level, fear works and the erosion in support for reform is evidence of that. But let’s call BS, at least, on Grassley and the other reborn deficit hawks: If you want to bend the curve, then you have to make some tough choices.

Health Care Renewal: A Letter from the RUC, and My Reply

This is a terrific, comprehensive review of the committee that places value on the things physicians bill for.

It is clear why procedure based specialists do so very, very well, and primary care docs constantly get the short end of the stick.

AMNews: June 29, 2009. AMA meeting: Don’t shortchange specialists to fund care model … American Medical News

AMNews: June 29, 2009. AMA meeting: Don’t shortchange specialists to fund care model … American Medical News:

“Chicago — In the discussion of how to pay for coordinated care under the patient-centered medical home model, the AMA House of Delegates agreed that primary care physicians should not be rewarded at the expense of specialists.

“At its June Annual Meeting, the house voted to advocate that additional pay to physicians for operating a medical home should not come from a reduction to the pay of specialists. Delegates approved language that medical home payments not be subject to requirements for budget neutrality in Medicare, where an extra dollar spent somewhere means a dollar has to be cut elsewhere.

“The house also approved recommendations that private plans and the Centers for Medicare & Medicaid Services develop one standard for a medical home, and that specialty practices as well as primary care practices should be able to serve as that home.

‘Primary care needs more help. It just shouldn’t come at the expense of specialists,’ said Kim Williams, MD, a cardiologist from Chicago and a delegate for the American College of Cardiology.”

I am aware that, in the House of Medicine, it is impolite to disagree with this notion that primary care physicians should get more money but there should be no adjustment of specialist reimbursement. It is not just impolite, it is also likely to start fights. I expect that the notion of knocking down the uber-specialists reimbursement lurks in the darkest places of the hearts of many a PCP and psychiatrist, the class-warfare-that-must-not-be-named.

But, consider the incomes of internists starting at $150K or so and neurosurgeons, radiologists (nuclear medicine), thoracic surgeons, invasive cardiologists and orthopedic surgeons starting at between $400K and $600K, it is hard not to wonder whether the economic disincentive of going into primary care can ever be overcome by raising PCP income by 20 or 30 or 40 per cent or more. Value is relative and simply increasing PCP income a bit and still having one’s peers making vastly more explicitly marks the value we place on primary care.

Societies generally reward physicians with good incomes, but except for the incomes of specialists in the Netherlands, nowhere near as highly as we do. But, on the other hand, no country saddles their young doctors with the massive debt that we do. Heavily subsidized tuition is the norm, not the exception, and so young doctors around the world do not feel the economic imperative to enter the best paid fields as we do here. Nor do other countries have the massive overhead of physicians beyond debt: malpractice insurance, billing staff to fight with insurers and so on.

I expect that if we graduated medical school with debt similar to those of our non M.D. peers, incomes more comparable to our international peers would be more acceptable.

AMNews: June 29, 2009. AMA meeting: AMA reaffirms stance in health system reform debate … American Medical News

AMNews: June 29, 2009. AMA meeting: AMA reaffirms stance in health system reform debate … American Medical News:

“Chicago — Addressing what has become the hottest flashpoint in this year’s health system reform debate, the American Medical Association House of Delegates at its Annual Meeting in June renewed its existing reform policies rather than declare a position on whether lawmakers should establish a new national federal health insurance plan that would compete with private insurers.

“Delegates agreed that the AMA should ‘support health system reform alternatives that are consistent with AMA principles of pluralism, freedom of choice, freedom of practice and universal access for patients.’

“Both supporters and opponents of the public plan concept wanted the Association to take a definitive stand on the issue. But after AMA Immediate Past President Nancy H. Nielsen, MD, PhD, warned that such a move could handicap the organization as it tries to influence the health reform debate, delegates backed away from those resolutions.

“Dr. Nielsen said the resolution that ultimately passed would allow her and AMA President J. James Rohack, MD, to keep the AMA engaged in the debate without restriction but with a clear directive to advocate for choice for both physicians and patients.”

An encouraging sign for progressives at the AMA House of Delegates. I am pleased to be wrong in expecting the conservatives to win the day and the resolution that passed gives wiggle room to the AMA leadership.

It is worth pointing out that there will be much struggle throughout this process. AMA policy language stands largely against any reforms leading to any expanded role for government in health care and specifically declares that an “Unfair concentration of market power of payers is detrimental to patients and physicians,” and labels single payer as such and calls for continued opposition by the AMA.

Interestingly enough, however, the AMA has endorsed the principles of Medical Professionalism of the ABIM, ACP-ASIM and European Federation of Medicine. This Charter unequivocally advocates the physicians role in promoting social justice, fair distribution of finite resources and promoting fair access to care.

I am sure my conservative colleagues would argue that this can all be achieved by a more libertarian/Randian approach to health care, but I think, finally, that the number who believe that is growing smaller by the week.

Certainly polls indicate that most physicians now recognize that our system is broken and that the cure is not rearranging the deck chairs on this sinking ship and clinging to a heyday that hasn’t offered us or our patients much “hey.”

Health Beat: The AMA Would Make Health Care Unaffordable for Many Americans

Health Beat: The AMA Would Make Health Care Unaffordable for Many Americans:

“The American Medical Association has announced its opposition to a public-sector health plan that would compete with private insurers. Why? Because the AMA fears that Medicare E (for everyone) might not pay some specialists as handsomely as private insurers do now.

“Why do private insurers pay more? Because they can pass the cost along to you and I in the form of higher premiums. Medicare E has no one to pass costs on to—except taxpayers. And taxpayers will already be helping to subsidize those who cannot afford insurance.

“Everyone agrees that primary care physicians are underpaid. Democrats in both the House and the Senate propose raising their fees, as does the Medicare Payment Advisory Commission (MedPac)—the group that might take over setting fees for Medicare. Moreover, the House, the Senate, President Obama and MedPac have made it clear that they do not favor the across-the-board-cuts called for under the sustainable growth rate (SGR) formula. Congress has consistently refused to make those cuts and President Obama did not include them in the 2010 budget that he originally sent to Congress. On that score, the AMA has nothing to worry about.

“Protecting Excessive Fees for Some Specialists’ Services

“So what does the AMA fear? That either MedPac or Medicare will trim fees for certain specialists’ services. Keep in mind that Medicare’s fee schedule has traditionally been set –and adjusted on a regular basis, by the RUC– a committee dominated by specialists.( Private insurers then follow that fee schedule, usually paying somewhat more for each service.) I have described this group in the past: They meet behind closed doors. No minutes are kept of their meetings. They rarely suggest lowering fees—even though as technology advances, some services become easier to perform. MedPac has pointed out that a less biased group should be involved in determining fees—perhaps physicians who work on salary, and are not affected by Medicare’s fee schedule.

“There is good reason to suspect that the RUC has over-rated the value of some services.. MedPac has suggested taking a look at particularly lucrative tests or treatments that are being done in large volume. Often, this may mean that patients who don’t need the service are receiving it; if the procedure isn’t necessary, then, by definition, they are being exposed to risks without benefits. And in fact, experience shows that when high fees are trimmed, volume falls, suggesting that rich fees were, in fact, driving overtreatment.”

There is more here about using medicare to “bend the curve,” or reduce over-utilization, improve use of preventive services, as well as a discussion of how a Public Plan might besubsidezed, etc. well worth reading, particularly about subsidization.

I would only add that the title falls a bit short: The AMA, or rather, conservative physicians, are hardly the only group fighting significant change. The Health Insurance industry, despite conciliatroy noise, will be the big guns or long knives as this goes forward. And behind them will be Pharma, other device and equipment manufacturers, probably home health servicers, ambulatory care centers, and, for purely ideological reasons, all conservatives.