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Neurologists Focus on Potential E&M Bonus As Health Reform Proposals Move through Congress


doi: 10.1097/01.NT.0000365766.33558.63
Departments: Policy Watch

As health reform debate moves into its final laps, neurologists are focusing on one issue in particular: ensuring that neurology is among the specialties eligible to receive a primary care bonus.

Policy-watchers are cautiously optimistic about the 10 percent bonus, said AAN Professional Association (AANPA) Chief Health Policy Officer Rod Larson, even as they worry about the financial implications of several pay-related issues in the health reform legislative proposals.

Elaine C. Jones, MD, co-chair of the Academy's Legislative Affairs Committee, laments that none of the proposals under debate would create a payment system that reflects the cost of running a medical practice.

“I'm fairly pessimistic because the way we are reimbursed is a random process that is not based on a real business model,” she said. “I don't see that any (proposed) changes that are based on the reality of practice or the cost of treating patients.”

While the scope of increased health care coverage will not be known until a law is passed, a combination of measures may reduce America's uninsured rate significantly — perhaps by up to half, according to some estimates.

That means many more patients with a payment source, but it does not necessarily benefit physicians as much as might be expected. Dr. Jones practices in Rhode Island, where a state-funded insurance program has reduced the number of uninsured patients but, because the insurance coverage is skimpy, it has not helped physicians very much.

“It affects revenues negatively,” Dr. Jones said. “If you agree to accept that insurance, you are agreeing to give the same care you give to everyone but you are accepting lower rates.”

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Jack Meyer, PhD, a principal in the Washington, DC, office of Health Management Associates, a health policy think-tank, understands physicians' frustration with reimbursement rates, and he does not expect this year's reform legislation to give them any significant relief. That will take an overhaul of the Medicare system, which apparently must wait for another year.



That said, Dr. Meyer believes that reform legislation may advance an important concept that will allow physicians to control their own financial destiny. He contends that the bills that emerge from both the House of Representatives and the Senate — and thus may see final passage — are likely to authorize Medicare demonstrations of the accountable care organization (ACO) model. That model provides financial incentives to physicians and hospitals who work together to improve care coordination and score well on quality and cost measures.

The ACO model supports one of the strongest trends in health care: physician pay that is tied to clinical performance. Private payers are already experimenting with the ACO model; Dr. Meyer thinks health reform legislation will advance it within the Medicare and Medicaid programs — and possibly within state-based health insurance exchanges.

Those payers all believe that patients will be healthier — and overall costs will be lower — if physicians comply with best-practice standards of care.

“Where we're moving in this country — with or without health reform, but it will be spurred if legislation is passed — is toward a much greater emphasis on physicians adhering to their own specialty society-developed clinical standards,” he said.

He encourages neurologists to look for opportunities to participate in actual or virtual integrated health care delivery systems that can prove to private and public payers alike that they follow best practices and, thus, provide better value than their competitors.

“If they can do so, they might be in a position to receive favorable treatment under Medicare, and if they get a stamp of approval of best practices from Medicare, that's likely to spill over into reimbursement policy in the private sector,” Dr. Meyer said.



The big picture, in his view, is that physicians should worry less about the government's pay rates and more about how to qualify for bonuses based on delivering the kind of care that government payers want.

“Even though a lot of the pushing and shoving is on what to do about Medicare payments and whether Medicaid payments will be raised, the emphasis on physicians following best practices and organizing into a delivery model that supports integrated care should not be overlooked,” he said.

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The AAN board of directors has approved a set of principles for health care reform that encourages the federal government to use quality programs to encourage the use of evidence-based practice. (See “The AAN Principles for Health Reform.”)

At present, the Academy's top priority is to have neurology included in a reform-bill provision that would increase evaluation-and-management code payments by 10 percent for physicians who provide primary care services.

Both houses of Congress seem to support bonuses for physicians who primarily provide cognitive services, including those who specialize in family medicine, general internal medicine, geriatric medicine, and obstetrics and gynecology, as opposed to procedures.

Neurologists, on average, bill 61 percent of their services via E&M codes, but are not currently on the list of cognitive service-providers.

“It is very clear that neurologists share a lot of the same issues that primary care and internal medicine physicians are facing, including a lack of payment for spending time with patients,” Larson said. “Neurologists spend a lot of face time with their patients on very complex issues.”

Dr. Jones said it appears that neurology was left off the list inadvertently, as the Congressional staffers who wrote the legislation mistakenly thought neurology was a subspecialty of internal medicine.

Larson said several large patient-advocacy groups, including the Alzheimer's Foundation, ALS Association, Parkinson's Action Network, Epilepsy Foundation, and National Multiple Sclerosis Society, signed a letter to Congress members seeking an amendment that would make neurologists eligible for the 10 percent bonus payments.

Both Larson and Dr. Jones believe that Congress is likely to agree that neurology should be included in the bonus program. The challenge is getting an amendment just when Congress is trying to limit the cost of the health care bill.

“I think it is a very good argument and everyone seems to agree that we should be included,” Dr. Jones said. “But it may come down to the bottom line.”



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The AAN board of directors supports the following principles for health reform:

  • Portable and continuous health care coverage for all Americans regardless of pre-existing conditions
  • Enhanced reimbursement for face-to-face, patient-centered care while removing the perverse incentives that favor procedures over spending time with patients
  • Replacement of the Sustainable Growth Rate formula with a system that reflects the real cost of treating Medicare beneficiaries
  • Medical liability reforms to reduce the cost of premiums and defensive medicine
  • Preservation of the physician-patient relationship including independent medical decision-making and patient access to needed treatments
  • Quality programs that are evidenced-based, relatively easy to implement and not administratively burdensome or complicated while contributing to improved patient care
  • Incentives to assist large, small, and solo neurology practices in the implementation of e-technology
  • Well-designed comparative effectiveness research that promotes high quality evidence-based care
©2009 American Academy of Neurology