Tuesday, May 6, 2014

Fwd: qotd: Embracing Fee-For-Non-Service - Again!

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-------- Original Message --------
Subject: qotd: Embracing Fee-For-Non-Service - Again!
Date: Tue, 6 May 2014 07:08:55 -0700
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>

Society of General Internal Medicine
March 2013
Report of The National Commission on Physician Payment Reform

Recognizing that the level of spending on health care in the United
States is unsustainable, the return on investment is generally poor, and
the way that physicians are paid contributes substantially to the high
cost of health care, The Society of General Internal Medicine (SGIM)
convened The National Commission on Physician Payment Reform in March
2012 to recommend new ways to pay physicians that will ultimately
improve patient outcomes but also rein in health care costs.

The commission's recommendations focus on the near-term, calling for
drastic changes to the current fee-for-service payment system and a
five-year transition to a physician- payment system that rewards quality
and value-based care. The recommendations pertain to the way physicians
are paid throughout the health care system — both public and private payers.



Journal of General Internal Medicine
May 2014
Do We Get What We Pay For? Transitioning Physician Payments Towards
Value and Efficiency
By Malathi Srinivasan and Mark D. Schwartz

In March 2013… the National Commission on Physician Payment Reform
(NCPPR), released a report with twelve recommendations to reform how
physicians are paid, linking incentives to quality in patient care to
curtail rising health care costs.

In this issue, SGIM ad hoc Committee members offer three Comments
addressing the Commission's recommendations. First, Selker and
colleagues review the first three recommendations, which argue for
phasing out the current volume-based, fee-for service (FFS)
reimbursement model over 5 years, to be replaced by a system emphasizing
value and efficiency, with incentives that promote high quality,
coordinated, and cost-effective, patient-centered care. Then Siddiqui et
al., addressing Commission recommendations four through nine, contend
that while transitioning away from FFS, the US must strengthen the
primary care foundation of high performing healthcare systems, notably
evaluation, management and preventive services. Finally, Patel and Nadel
examine the Commission's last three recommendations, arguing that
Medicare's Sustainable Growth Rate (SGR) formula be repealed and
replaced with policy that rewards value rather than volume, and that is
based on a valuation of physician work that rectifies the current
relative value unit (RVU) bias in favor of procedural compared with
cognitive-based services.



Journal of General Internal Medicine
May 2014
Editorial and Comment
Global Amnesia: Embracing Fee-For-Non-Service — Again
By David U. Himmelstein, MD and Steffie Woolhandler, MD, MPH

Now SGIM's Commission has joined the growing policy bandwagon to
reanimate the HMO strategy. There are semantic changes — ACO has
replaced HMO, and when insurers drop expensive doctors (e.g. the
1,000-member Yale Medical Group5), it's called "network optimization"
not "delisting". In a new twist on gag clauses, today's ACO patients
(e.g. seniors in Medicare's Pioneer ACOs) aren't told they're enrolled.
But the diagnosis and prescription are unchanged.

As in 1971, fee-for-service is the culprit. A shift to "bundled payment,
capitation, and increased financial risk sharing" is the solution, with
"risk adjustment... to avoid physicians and other providers
cherry-picking the healthiest patients"; and "quality measures... to
assure that evidence- based care is not denied as a cost-saving mechanism."

Twentieth century risk adjustment and quality monitoring were
overmatched by HMOs' gaming and deception. Despite additional decades of
work to devise bullet-proof risk adjustment, gaming remains so powerful
and pervasive that cost and quality rankings are often distorted, or
even inverted. No solution is on the horizon.


Like the SGIM Commission, we rue the toxic incentives of the current
fee-for-service system. But in the profit-maximizing milieu of American
medicine, capitation risks making things even worse. "Risk-sharing" too
often means that physicians earn bonuses for denying care — a danger
perceived by patients, who take a dim view of capitation. Risk-sharing
is not simply the inverse of fee-for-service, but of fee splitting, the
illegal practice of kickbacks for referrals.

There are many bad ways to pay doctors, and no particularly good ones.
Other nations have achieved better outcomes, lower costs and fairer
compensation of physicians using a variety of methods: fee-for-service,
capitation, and salary; none is clearly best. The common theme isn't
mode of payment, but a universal system with regulations that restrain
costs and minimize the opportunities for profit and the risk of loss.

Payment reform should focus not on manipulating greed, but on dampening
it. Then the real motivations for good doctoring — altruism, social
duty, and the glow we feel when we help our patients — can flourish.

Use the following link to read the entire article or to download the PDF:


Comment by Don McCanne

Regarding controlling health care spending, the meme of this decade
seems to be that we must start paying based on value and not volume, as
if the greatest value would be realized by reducing the volume of health
care to as close to zero as possible.

There are plenty of articles on how this might be accomplished, many of
them centering on concepts such as accountable care organizations and
bundling of payments. What seems to be missing are comprehensive
discussions of how unrealistic and misdirected these proposals are.

That is why it is important that you download the article by Himmelstein
and Woolhandler. It should be used in your advocacy work to move us away
from the empty managed-care promise of supposedly replacing volume with
value, so that we can move forward with reform that actually will
improve value - a single payer national health program.

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