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Health Care Reform
Efforts Advance to Include Neurology in Primary-Care Incentives

When the US Senate and House of Representatives came out with their early draft bills for health care reform, Academy government relations experts reviewed the text — and found a glaring omission.

The two bills both sought to promote primary care by increasing Medicare payments to physicians for certain Evaluation and Management (E&M) codes by 5-to 10-percent. Physicians would qualify for the higher rates only if they met the bills' definition of “primary care provider,” and if their charges for E&M services are at least 60 percent (50 percent in the House version) of their total Medicare charges.

“The bills listed primary care practitioners, including family practice, internal medicine, geriatricians, pediatricians, and OB-GYNs were added later,” explained Mike Amery, AAN Professional Association (AANPA) legislative counsel. “Neurology met the second criterion — having E&M services, on average, of at least 60 percent of their total Medicare charges. But it was not included as an eligible specialty.”

Since then, the Academy, with the support of its members and allied patient groups such as the Parkinson's Action Network, the National Multiple Sclerosis Society, the Epilepsy Foundation, and many more, has sought to amend the health care reform legislation in order to include neurologists in the primary care incentive section. And as health care reform lurches erratically closer to a final vote in Congress, many are cautiously optimistic that this effort will succeed.

“We're not in any way trying to equate neurology to primary care or define neurology as a primary care specialty,” cautions Rod Larson, the AANPA chief health policy officer. “But neurologists, as a specialty, face many of the same issues as primary care and general internal medicine practitioners on assuring that there are well-trained, available providers to treat the growing demand for our care. And just as a primary care provider needs to spend a lot of face to face time with a patient with hypertension or diabetes, so do neurologists working with patients who have Parkinson disease, multiple sclerosis, or epilepsy over a long period of time. Like primary care providers, neurologists must spend a great deal of time with their patients doing evaluations and follow-up management of chronic disease.”

It's a point that few on Capitol Hill have disputed. The difficulty with getting neurology added to the primary care incentive section of health care reform legislation has been twofold: logistics and finances.

THE CHALLENGES: LOGISTICS AND FINANCES

Initially, Representative Betty McCollum (D-MN) attempted to add an amendment that would include neurologists in the incentive section, but the leadership of the House of Representatives did not allow main-line amendments to its bill, so that effort failed.

Attention then moved to the Senate, where Senator Amy Klobuchar (D-MN) introduced a similar amendment, hoping to have it added to the “manager's amendment” for the bill — a package of numerous individual amendments agreed to in advance.

At press time, the Klobuchar amendment was not included in the manager's amendment. However, Amery spoke to a likely conferee about getting this language added during the reconciliation process when members of the House and Senate will meet to work out their differences. A majority of the conferees on each panel must agree on a single version of the bill before it can be brought back to the full House and Senate for a vote on final passage.

The amendment was strengthened thanks to bipartisan support, with cosponsorship not only from Senator Sherrod Brown (D-OH), but also from Senator Susan Collins (R-ME). “Very few, if any, other aspects of the health care bill have gotten bipartisan support,” Amery pointed out.

Maine neurologist Bruce Sigsbee, MD, helped to secure Sen. Collins' backing of the bill at a meeting in Washington sponsored by BrainPAC, the Academy's political action committee, formed in 2008. “I have a very long relationship with Sen. Collins going back to when I stuffed envelopes for her first campaign,” Dr. Sigsbee explained. Last year, he helped the Senator craft legislation improving the management of traumatic brain injury among troops returning from Iraq and Afghanistan, the Dignified Treatment of Wounded Warriors Act.

“What I said to her about this amendment is that neurology is a unique specialty that does a great deal of evaluation and management face-to-face patient care,” Dr. Sigsbee said. “The primary care incentive section of the bill gives relief to physicians whose practices are dominated by that kind of care, and yet we were left out. We came in with documentation and evidence that supported our position, and a very clear argument supported by data that it's a fairness issue. The next day, she signed on as a cosponsor.”

But still standing in the way of the amendment was an initially sky-high assessment of its cost from the Congressional Budget Office. “We were told that it was over a billion dollars over 10 years on the House version, but we assume they didn't spend a lot of time on it or indicated that it would be ‘under a billion’ dollars and it got translated to one billion dollars,” said Larson.

ASSESSING THE COSTS

The Academy contracted with Avalere Health, a health care research and analysis firm, to provide a more precise cost estimate for including neurology in the primary care incentive section of the legislation. Their projection: “Under the Senate bill, if every neurologist qualifies for the payments, it would cost an additional $63 million; if half do, it will cost $31 million over 10 years,” Amery said. (Costs based on the House version of the bill were estimated to be higher, because the House primary care incentive section has a lower threshold for E&M services of 50 percent, and isn't restricted to a five-year period as the Senate version is.)

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DR. BRUCE SIGSBEE: “On the merits, were in very good shape. Ive heard that members of Congress are very supportive, and were cautiously optimistic. Whats unknown, of course, is the politics. ...But weve raised this issue of the inclusion of neurology in the bonus and the consequences to the specialty if it is not.”

“That's a relatively small amount of money,” said Dr. Sigsbee. “There hasn't been a lot of resistance to including neurology in the bonus provisions.”

Within the past few weeks, approximately 1,000 Academy members have made 2,000 contacts with their Senators about the Klobuchar amendment. “But even better has been the response of the patient advocacy groups whose members have made thousands and thousands of contacts with their Senators' offices,” said Amery.

“On the merits, we're in very good shape. I've heard that members of Congress are very supportive, and we're cautiously optimistic. What's unknown, of course, is the politics. We don't even know if this legislation is going to make it through,” admitted Dr. Sigsbee. “But we've raised this issue of the inclusion of neurology in the bonus and the consequences to the specialty if it is not.”