As America's health care reform debate heats up, almost everyone agrees on one thing: The way physicians and hospitals are currently paid is partly responsible for the cost and quality problems in the health care system, and payment reform is essential to any meaningful health care reform.
Agreement ends there. Many proposals for a new way to pay health care providers are being considered, and all of them have critics. Into this fray, the AAN Professional Association (AANPA) has proposed its own payment strategy that would provide bonus payments, based on quality reporting and care coordination - that might actually lower the cost of treating some neurologic patients while improving the care they receive.
The Academy's proposal, suggested as a temporary measure, is designed to relieve some of the disparities that currently exist in the health care payment system while the federal government tests other proposed models to determine a permanent replacement to the current fee-for-service model.
The Academy, as well as policymakers, recognizes that the current system has many serious flaws. What everybody is struggling with is to come up with a reasonable system that can replace it, said Bruce Sigsbee, MD, the Academy president-elect. I don't think anybody really has the right answer yet.
While President Obama has laid out a set of principles that reflect his priorities for a reformed health care system, he has asked Congress to propose a specific plan. Five Congressional committees have held hearings on reform ideas to date, with more on the way.
TOWARD PAY-FOR-VALUE
Many ideas are in play, but one concept shows up in almost all plans: The payment system should reward physicians for value - the highest quality care delivered at lowest cost - instead of the current system, which financially rewards high-tech care, procedures, and inpatient treatment over preventive care and cognitive services provided by physicians.
As host of a public discussion on health care reform in May, Stephen L. Hauser, MD, chair of the department of neurology at the University of California-San Francisco, cited stroke-prevention practices as a prime example of how the payment system incentivizes physicians to run up the nation's health care tab. Although prescribing a daily regimen of baby aspirin is appropriate for many patients at risk of stroke, the payment system rewards physicians who perform invasive carotid procedures.
The economic incentives are all aligned towards invasive therapies to the point that some estimate we are performing 100,000 more carotid procedures than are necessary based on the evidence, Dr. Hauser said. We need to restore appropriate incentives and that will also influence how our students select their areas of training.
BOLSTERING PRIMARY CARE PAY
Indeed, another theme of most payment reform plans is that primary care physicians should be much better paid, eliminating the current economic disincentive for medical students to choose primary care. Proponents say more and better primary care services can help patients better manage their chronic illnesses, avoiding the need for costly subspecialty care, procedures and inpatient stays.
The Medicare Payment Advisory Commission (MedPAC), which advises Congress on Medicare issues, has identified this as a top priority. In its 2009 payment policy report, MedPAC reiterated its recommendation from a year earlier: The Medicare program should increase payment for primary care services in a budget-neutral way, suggesting that subspecialists should see a pay cut.
That does not sit well with Amanda Becker, associate director of medical economics at the AANPA.
We recognize that the primary care problem must be addressed, but it cannot be at the expense of other specialties like neurology who really share a lot of the same problems as primary care, Becker said, referring to the undervalued evaluation and management services that both neurologists and primary care physicians provide.
Indeed, the Academy suggests that increasing pay for some physicians could actually lower total health care spending. Its proposal came in response to a suggestion, issued by the Senate Finance Committee, that a new Chronic Care Management Innovation Center (CMIC) be created to test payment models that encourage patient-centered care coordination for high-cost, chronically ill Medicare beneficiaries.
In a May 15 letter to Senators Max Baucus (D-MT) and Charles Grassley (R-IA), Academy President Robert C. Griggs, MD, said the AAN would like to work with the CMIC to develop a payment model that addresses the unique needs of neurologic patients.
In the meantime, the letter proposed that the Centers for Medicare & Medicaid Services (CMS) start issuing bonus payments over the current fee schedule for evaluation and management services provided to patients with certain chronic conditions, including dementia, stroke, Parkinson disease, and multiple sclerosis.
Adoption of this bonus payment will immediately begin to correct the misaligned incentives that reward procedure-based care at the cost of patient-centered care, the letter said. Further, this shift will realign incentives to deliver truly patient-centered care, enhance patient access, improve quality, and immediately lower costs.
According to the proposal, the additional payment would be tied to quality measurement and reporting and care coordination.
Joel M. Kaufman, MD, a neurologist in the Lifespan health system in Rhode Island, believes that physicians who can spend more time with their patients will refer them for fewer expensive diagnostic tests and, by better managing their chronic conditions, head off procedures and inpatient care. Thus, he believes increasing pay for evaluation and management services will reduce overall costs of care without cutting the rate at which any physicians are paid.
What you want to encourage is thoughtful care of patients -thoughtful diagnosis, thoughtful treatment plans, and thoughtful ongoing care, Dr. Kaufman said. You don't have to pay some physicians less in order to save money.
THE OBAMA HEALTH CARE REFORM PRINCIPLES
The Obama Administration has said it will support reform proposals in keeping with these principles:
* Reduce long-term growth of health care costs for businesses and government
* Protect families from bankruptcy or debt because of health care costs
* Guarantee choice of doctors and health plans
* Invest in prevention and wellness
* Improve patient safety and quality of care
* Assure affordable, quality health coverage for all Americans
* Maintain coverage when you change or lose your job
* End barriers to coverage for people with pre-existing medical conditions
Visit www.healthreform.gov for a complete record of how the Administration is promoting reform.
OTHER REFORM PROPOSALS
To stay apprised of fast-moving health reform proposals, keep an eye on these resources:
* AAN: At www.aan.com/go/advocacy, click on Health Reform and Medicare Reimbursement.
* Congressional Proposals: The Patient-Centered Primary Care Collaborative reports on Congressional hearings and reports related to health reform at www.pcpcc.net.
* Private sector: The Center for Payment Reform, an independent organization of top business, labor and health care providers, reports its activities at www.centerforpaymentreform.org.
© 2009 AAN Enterprises, Inc.