The new health reform legislation is better for neurologic patients than it is for neurologists.
That's the way AAN health policy analysts characterized the Patient Protection and Affordable Care Act (HR 3590) passed by the US House of Representatives in March by a vote of 219–212.
The landmark legislation will expand health insurance to some 30 million currently uninsured Americans and significantly improve coverage for those who are insured by barring coverage exclusions based on pre-existing conditions; preventing insurers from dropping enrollees who become ill; banning lifetime coverage limits and sharply restricting annual coverage limits; and establishing health insurance exchanges to improve access. The legislation also subsidizes insurance costs for low-income families and permits dependents to be covered on parents' insurance to age 26.
Those provisions are all bound to help neurologic patients, and have been longstanding elements in the Academy's own reform principles, said AAN Professional Association Legislative Counsel Michael Amery and Senior Manager for Advocacy Amy Kaloides.
A MIXED BAG FOR PHYSICIANS
For doctors, though, it's a mixed bag with a couple of major flaws. An extension of the “floor” for Medicare's geographic payment adjustment will help neurologists working in rural areas, and some modest measures around administrative simplification will be good news for all physicians. Quality reporting measures in the bill are largely in line with guidelines AAN has developed for its members and neurologists who participate should anticipate benefitting from incentive payments.
But the bill's measures around medical malpractice fall very far short of physician expectations.
And the greatest disappointment is the failure of the bill to fix the Medicare payment formula, especially the Sustainable Growth Rate component, which mandates that increases in volume be compensated for by decreases in physician payment.
“In a general sense, the legislation is better for the neurologic patient than it is for the physician,” Kaloides told Neurology Today. “The main problem for physicians is that the bill doesn't change the payment system. The work neurologists do is mainly through evaluation and management visits, and we have known for a long time that procedural specialties have an unfair advantage.”
For neurologists, especially, a flaw in the legislation is the failure to include the specialty among those eligible for a 10 percent primary care payment incentive beginning in 2011. Eligible specialties are defined in the law as family medicine, internal medicine (including its subspecialties), geriatrics, and pediatrics, as long as an individual physician's Medicare charges for office-based evaluation and management comprise at least 60 percent of their total Medicare charges.
Exclusion of neurology from the payment provision was an especially harsh blow because neurology is the only specialty that meets the 60 percent threshold that it not eligible for the incentive, Kaloides said.
During the health care debate, congressional leaders mandated that an amendment to the legislation required a “score” by the Congressional Budget Office (CBO) to determine its effect on spending—and the CBO was never forthcoming with an estimate. “We commissioned our own score and found the cost [of including neurology in the primary care incentive] would have been between $45 and $200 million, so it was not a huge amount of money relatively speaking,” Kaloides said. “But you can't move anything forward without a cost analysis by CBO.”
Amery said he believes there will yet be opportunity to include neurology in the incentive. “We are confident there will be a technical corrections bill and we have already begun efforts to influence that,” he said.
Following is a list of other provisions in the bill and their possible effect on physicians and neurologists:
GEOGRPAHIC PRACTICE COST ADJUSTMENT
Beginning this year, the bill calls for an extension of funding for Geographic Practice Cost Index practice expense and work floor extensions. This provision extends the current adjustments used to account for geographic differences in practice expenses, and will be helpful to neurologists and other physicians working in “low cost” areas.
Physicians who successfully reported in 2010 for the Medicare Physician Quality Reporting Initiative program will receive a one percent bonus; successful reporting in 2011, 2012, and 2013 will qualify for a 0.5 percent bonus in the year subsequent to the reporting. An additional 0.5 percent incentive payment would also be available in years 2011–2014 for professionals who also meet the requirements of a Maintenance of Certification Program. In 2012, providers organized as accountable care organizations that voluntarily meet quality thresholds will share in the cost savings they achieve for the Medicare program. And in 2015 a PQRI penalty of 1.5 percent for non-participation goes into effect, with the penalty rising to 2 percent in 2016.
“We certainly want to see quality reporting be a reward rather than a stick,” Amery said. “The AAN has extremely good quality measurements so I don't think members will be penalized by this provision. The Academy has been way out in front in terms of pushing quality initiatives.”
For physician groups, the bill falls far short in this area. Beginning in 2011, it calls for five-year funding of state demonstrations to test alternative liability reform models beginning in 2011. “Pretty meager,” is how Amery described the provision. “Go to states like Texas where they have instituted serious medical malpractice reform with caps on awards — rates dropped almost immediately. There is plenty of evidence that real reform works and Congress needs to step up and institute those reform nationwide.”
Kaloides and Amery agreed that the reform bill is a step forward, with much work yet to be done. “The main positives are for patients with the elimination of the barriers they face when they can't get coverage, or when chronic neurologic illness keeps them out of work,” Kaloides said. “These changes will benefit our patients immediately.”
“For members it's important for them to know how active the Academy has been in this debate,” she said. “We didn't get everything we want, but we did have some successes.”
Going forward, she said advocacy in Congress will require better education about the role of neurologists in the American health care system. “One of the problems is that generally members of Congress don't understand what a neurologist is,” she said. “We have to make our advocacy much more educational, explaining that our members treat high cost patients and that it is vital to have qualified specialists to treat them. So much of internal medicine isn't trained in neurology and if we start funneling all these patients into primary care, we will have a shortage of qualified physicians to treat many chronically ill neurologic patients.” •
FOR MORE INFORMATION
©2010 American Academy of Neurology
- All of the Academy's information related to health system reform can be found online at www.aan.com/go/advocacy/reform
- Additionally, the Academy has developed these two documents that are available online: The Critical Role of Neurology in our Health Care System: www.aan.com/advocacy/issues/tools/109.pdf; The AAN's Commitment to Quality: www.aan.com/globals/axon/assets/5304.pdf.
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