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Monday, August 31, 2009

Medicare's pay-for-performance experiments

The Centers for Medicare & Medicaid (CMS) recently announced the results of three of its latest  pay-for-performance demonstration projects – one for large physician practices, one for solo and small physician practices and one for hospitals. In all three settings, offering financial incentives for meeting or exceeding performance standards improved quality of care and saved Medicare money, according to CMS.

In the first three years of the Physician Group Practice (PGP) demonstration, the 10 large practices involved in the project increased their quality scores an average of 10 percentage points on diabetes measures, 11 points on congestive heart failure measures, six points on coronary artery disease measures, 10 points on cancer screening measures and one point on hypertension measures. All of the practices reached benchmark performance on at least 28 of the 32 measures.

In the first year of the three-year Medicare Care Management Performance (MCMP) demonstration, more than 560 of the 610 small and solo physician practices in the demonstration will be rewarded for their performance on 26 quality measures. The average incentive payment per practice is $14,000 (out of a possible bonus of $50,000 per practice), although some practices will receive as much as $62,500 if they qualify for an additional 25 percent bonus for using an electronic health record (EHR) certified by the Certification Commission for Health Information Technology.

The Hospital Quality Incentive Demonstration (HQID) began in 2003 with hospitals in 38 states. Participating hospitals raised their overall quality scores by an average of 17 percentage points over four years. This number is based on 30 nationally standardized measures for heart attack, coronary by pass graft, heart failure, pneumonia, and hip and knee replacements. For year four of this demonstration, CMS is awarding a total of $12 million to 225 hospitals for their achievements and has shelled out more than $36.6 million during the course of this demonstration alone.

Words of caution

Mathematica Policy Research, Inc., has been contracted to independently evaluate the MCMP project for CMS. In their first report, issued March 4, 2009, the researchers noted that although demonstration practices reported greater awareness of care or documentation gaps, "At the same time, the data submission effort was labor-intensive, according to many visited practices; five had calculated that the cost of their effort was greater than the incentive payment they received for reporting the quality measures. Several were unsure if they would submit data in the coming year, because they were uncertain whether the potential reward was worth the effort. Half of these tentative practices consisted of solo practitioners. Many practices with EHRs felt frustration as their EHRs did not facilitate submission very well, due to system limitations, variations in use within the practice, or both." Mathematica's final report is due in 2011.

Tuesday, August 11, 2009

The more things change, the more they stay the same

Does this sound like your practice today? “[Family physicians] are depressed, discouraged and overwhelmed. They work two to three times as many hours as physicians in other specialties but get paid only half as much (family physicians always rank near the bottom of lists that compare average incomes of various medical specialties). They receive frequent nighttime calls that are devastating to their family and personal life. They practice in an uncertain atmosphere of liability and lack of trust that has led to defensive medicine, over-ordering and anxiety. ... This hellish type of life needs appropriate reimbursement if we expect to attract quality physicians and maintain quality care."

In fact, these words were written nearly 16 years ago, during the last push for health care reform, in an open letter from John Pfenninger, MD, to Hillary Clinton published in FPM. Of course we all know the outcome of the Clinton reform effort. In many respects, President Obama’s strategy for getting health care reform passed seems to be the opposite of the Clinton administration's. Still, as Ezra Klein argued in a recent Washington Post article, “The Ghosts of Clintoncare” are haunting the current debate. It’s hard to predict whether President Obama’s push for health care reform will meet a different fate. The bipartisan negotiations that preceded the August Congressional recess seem to have been replaced with ideological rancor. An article in Sunday’s New York Times breaks down the arguments on both sides.

A decade and a half after its writing, Dr. Pfenninger's letter reminds us that the stakes are high for family physicians and their patients – and have been for a very long time. Let’s hope that the next time we dust off his letter, the problems he describes won’t sound quite so familiar.

Tuesday, August 4, 2009

Good news, bad news

How about starting with the good news? Family medicine is among the 10 best paid occupations in the country, at least according to Forbes. Note: That's not the 10 best paid medical specialties; it's the 10 best paid occupations of any sort. Even better, at $161,490 per year, the average family physician makes $1,050 more than the average CEO. Congratulations! (No way to tell whether the CEO salary figures count golden parachutes, though ... )

You already know the bad news, I'm sure: While family physicians make the top-10 list, they're number nine, behind general surgeons, anesthesiologists, orthodontists, obstetricians and gynecologists, oral and maxillofacial surgeons, general internists, prosthodontists, and a group called "other physicians and surgeons" – those outside the "main specialties."

Don't despair. That doesn't mean that family physicians are the worst-paid physicians in the country. Other major specialties didn't even make it into the top 10. General pediatricians made 13th place, for instance, behind general dentists and psychiatrists. And lawyers show up in 16th place. See? Even the bad news isn't that bad.

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