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Wednesday, March 31, 2010

Time's up! You're making 21 percent less

The last grains have trickled out of the Senate's hour glass, and the Medicare patients you see starting tomorrow will bring you 21 percent less. Or they would, if you were being paid for them. Fortunately (?), CMS is directing its regional carriers to hold claims for 10 days, so (with luck and less sand in the gears of the Senate) you may eventually get paid for tomorrow's work at the same rate you earned yesterday.

Donald Berwick, MD, faces his biggest challenge yet

President Obama’s impending nomination of Donald Berwick, MD, MPP, to head the Centers for Medicare & Medicaid Services (CMS) is welcome news. Berwick, a pediatrician and professor at Harvard Medical School and Harvard School of Public Health, is president and CEO of the Institute for Health Care Improvement (IHI), a think tank whose impressive and ambitious work we at FPM have been following since it launched the Idealized Design of Clinical Office Practices (IDCOP) initiative in 1998 (read more about IDCOP in FPM). Our only beef with Berwick is that, following IDCOP, IHI hasn’t devoted more focused attention to office-based practice.

Washington Post blogger Ezra Klein calls Berwick "the most important health-care reformer you’ve (probably) never heard of” and Maggie Mahar’s two-part profile of Berwick introduces him (don’t miss the video clip that, near the end, features Berwick’s thoughts on primary care payment). Having heard several of Berwick’s rousing keynote addresses at IHI’s Annual National Forums, it’s hard to imagine him not making the most of the new tools and authority of the CMS position to improve health care for patients and providers. If only we will let him. Let’s hope his confirmation isn’t a casualty of the resentment bred by the passage of health care reform legislation. May it be quick and painless. This man has work to do.

EHR incentives: Reader poll results

We recently asked our readers, "Do you intend to pursue the EHR incentives offered by the federal government under the HITECH Act?"

The results? A nearly even split. Out of 462 responders, 51 percent said "No," they don't intend to pursue the EHR incentives; 49 percent said "Yes."

For more on this topic in FPM, see:

Monday, March 29, 2010

Medicare payments: Time is about to run out ... again

With about 60 hours left, it looks as though we'll get to see our countdown clock hit zero, unleashing (sort of) the much-discussed 21 percent cut in Medicare payments. At least, that's the word from the AAFP Washington office: "The Senate did not pass a bill that would have extended the SGR [sustainable growth rate] payment rate for physicians until April 30 prior to leaving for a 2-week recess.  ... The bill was ready for passage under standard unanimous consent procedures, but Senator Tom Coburn (R-OK) objected because the bill was not completely paid for.  As a result, the 21-percent reduction in physician payments will go into effect April 1."

Again, however,  CMS has told carriers to hold claims for 10 business days:

Information Regarding the Holding of April Claims for Services
Paid Under the 2010 Medicare Physician Fee Schedule (3-26-2010)

The Centers for Medicare & Medicaid Services (CMS) is working with Congress, health care providers, and the beneficiary community to avoid disruption in the delivery of health care services and payment of claims for physicians, non-physician practitioners, and other providers of services paid under the Medicare Physician Fee Schedule (MPFS). As you are aware, the Temporary Extension Act of 2010, enacted on March 2, 2010, extended the zero percent (0%) update to the 2010 MPFS through March 31, 2010.  

CMS believes Congress is working to avert the negative update that will take effect April 1. Consequently, CMS has instructed its contractors to hold claims containing services paid under the MPFS (including anesthesia services) for the first 10 business days of April. This hold will only affect claims with dates of service April 1, 2010, and forward. In addition, the hold should have minimum impact on provider cash flow because, under the current law, clean electronic claims are not paid any sooner than 14 calendar days (29 for paper claims) after the date of receipt. 

Be on the alert for more information about the 2010 Medicare Physician Fee Schedule Update.

The AAFP Washington update goes on to say that negotiations between the two sides will continue during the recess and it is likely that the bill will proceed quickly through the Senate when they return April 12.

Making more but enjoying it less?

If you see some improvement in your income from year to year but you don't find it any easier to make ends meet, you may just not be making enough allowance for inflation. Although a 2009 AAFP survey indicates that the median income from practice for AAFP members increased 14.5 percent from 2004 to 2008 – from $131,000 to $150,000 – even the apparently modest inflation of the past few years has eaten away the entire gain. According to the AAFP data, $150,000 in 2008 dollars has the same buying power as $128,190 in 2004.

Is there any hope, or are family physicians doomed to tread water forever? At this point, health care reform does seem to offer some glimmers of hope in the temporary 10 percent Medicare bonus for most primary care physicians, the increased payment for Medicaid services for 2013 and 2014, and perhaps the payment reform experiments the bill mandates. For now, just keep your head above water; help may be on the way.


(Click the graph for a larger image.)

Friday, March 26, 2010

And it's done

Last night, with a vote of 220 to 207, the House of Representatives approved the budget reconciliation bill containing a package of fixes to the recently passed health care reform bill. The reconciliation bill now awaits President Obama's signature, making health care reform legislation complete.

Thursday, March 25, 2010

Study reveals flaws in physician cost-profiling programs

A study published last week in the New England Journal of Medicine verified what many already believed: Health insurance programs that rate physicians based on cost of care have major flaws. According to the study of claims data, conducted by the RAND Corporation, 22 percent of physicians would be misclassified in a two-tier system due to unreliable cost-profile scores.

Health insurance companies use cost profiles to decide which doctors will be included in their networks, and may use incentives to steer patients to the lower-cost doctors.

John L. Adams, a senior statistician at RAND, had this to say, "Our findings raise questions about the utility of cost profiling tools for high-stakes activities such as tiered health plans and the likelihood that wide use of these strategies will reduce health care spending. Consumers, physicians and those who pay for health care are all at risk of being misled by the results from these tools."

The study found that only 40 percent of physicians had cost-profile scores that were at least 70 percent reliable, and only 10 percent had profiles that were at least 90 percent accurate.

Monday, March 22, 2010

The health care reform bill: What's in it for doctors?

Last night, the House of Representatives voted 219 to 212 to approve the health care reform legislation passed by the Senate in late December. Thirty-four Democrats joined Republicans, who were unanimous in voting against the bill. The President is expected to sign the bill into law tomorrow. The House also adopted a package of “fixes” to the bill, which will now go to the Senate.

To obtain the last few votes needed to pass the bill, the White House promised anti-abortion Democratics that it would issue an executive order ensuring that federal funds will not be used for abortions.

The bill is expected to provide coverage to 32 million uninsured Americans, leaving 23 million uninsured in 2019. One-third of those remaining uninsured would be illegal immigrants.

The bill is estimated to cost $940 billion over 10 years but would reduce the deficit by $143 billion during that same time frame, according to the Congressional Budget Office. The savings are projected to come from Medicare reforms and from new taxes and fees, including a tax on high-cost (or “Cadillac”) health plans and increased taxes on individuals making more than $200,000 per year or couples making more than $250,000.

Although “Washington may live and die by the pronouncements of the Congressional Budget Office,” wrote pollsters Doug Schoen and Scott Rasmussen in The Wall Street Journal, “81 percent of voters say it’s likely the plan will end up costing more than projected.” The Cato Institute estimates that the bill will cost nearly $3 trillion.

How will the bill affect doctors?

The bill establishes a 10-percent Medicare bonus for many primary care physicians (those whose Medicare charges for office, nursing facility and home visits comprise at least 60 percent of their total Medicare charges) for the next five years; increases Medicaid payments for primary care physicians to 100 percent of Medicare payment levels for 2013 and 2014; and increases funding for primary care scholarships, loan repayment programs, residency programs, the National Health Service Corps and community health centers. Whether these measures will succeed in reversing the shortage of primary care physicians, which will become increasingly critical as newly insured patients seek care, remains to be seen.

The bill also establishes multiple pilot projects to test payment reform in federal health programs such as moving from payment based on quantity of services to payment based on quality of services, financially rewarding physicians who make their offices “medical homes” for high-need beneficiaries, and establishing “accountable care organizations” that allow providers who voluntarily meet quality standards to share in the cost savings they achieve for the Medicare program.

The bill does not repeal the Medicare sustainable growth rate (SGR) formula or provide comprehensive tort reform.

How will the bill affect patients?

The bill would almost immediately provide the following:

  • Patients who become ill cannot be dropped by their health insurer.
  • Insurers must provide free preventive care.
  • Lifetime benefits cannot be capped.
  • For children under age 18, insurance companies cannot deny coverage for pre-existing conditions.
  • Young adults can remain covered on their parents’ insurance until age 26.
  • Small businesses can claim tax credits to help purchase health insurance for their employees.

Other changes won’t go into effect for several years, such as the following:

  • Americans will be required to have health insurance or pay a fine.
  • Insurance companies will not be able to deny coverage for pre-existing conditions for adults.
  • Medicaid will be expanded to cover an estimated 16 million people.
  • Low- and middle-income Americans will be eligible for subsidies to purchase private health insurance – a cost of $938 billion over 10 years.
  • Employers with more than 50 employees will be required to offer health care coverage or pay a fine.
  • States would establish health insurance exchanges to help consumers without health care coverage and small businesses shop for insurance meeting federal standards.

For a timeline of key changes, see this Washington Post article.

Friday, March 19, 2010

2010 Match results: Family medicine gains 75 positions

Family medicine saw a 3.2 percent increase this year in the number of residency positions filled by medical students, according to preliminary information from the National Resident Matching Program. Out of 2,630 family medicine positions offered, 2,404 were filled – a 91.4 percent fill rate. While the number of positions filled in 2010 is not as high as it was a decade ago (2,603 positions filled in 2000), it reflects a modest but relatively steady increase over the last seven years.

The number of U.S. senior medical students matching with family medicine residencies increased by 101 seniors this year. At 1,184, this is the highest number of U.S. seniors matching with family medicine since 2004. (Applicants who were not U.S. seniors fell into one of several categories: Canadians, U.S. physicians, DOs, Fifth Pathway participants, U.S. residents trained internationally and non-U.S. residents trained internationally.)

The AAFP believes that health care reform discussions have helped to increase interest in primary care and raise awareness of its essential role in creating a more efficient health care system; however, student interest is not at the level it should be, mostly because of the need for payment reform. The Council on Graduate Medical Education recently stated that “Policies should be implemented that raise the percentage of primary care physicians among all physicians to at least 40 percent from the current level of 32 percent, which is actively eroding since the proportion of current primary care trainees is even less.” It also noted that “to attain a workforce of at least 40 percent primary care physicians, it is imperative that the incomes of primary care physicians be restored to at least 70 percent of median incomes of specialty physicians. Additional investments in primary care infrastructure, beyond reducing income disparity, will be needed to increase interest and improvement in primary care. Payment policies should be modified to support this goal.”

Of note, all 14 residencies participating in the Preparing the Personal Physician for Practice (P4) Residency Demonstration Initiative filled their open positions this year. These residencies are testing a variety of innovations – from just-in-time evidenced-based resources to online tools that gather patients’ symptoms before their office visits to new curriculums that emphasize chronic disease management and prevention – which may be attractive to students.

Here’s how other specialties fared:

  • Anesthesiology gained 48 positions for a total of 771;
  • Diagnostic radiology lost 9 positions for a total of 139;
  • Emergency medicine gained 81 positions for a total of 1,540;
  • Internal medicine-categorical gained 94 positions for a total of 4,947;
  • Internal medicine-pediatrics gained 16 positions for a total of 355;
  • Internal medicine-primary gained 7 positions for a total of 243;
  • Obstetrics-gynecology gained 3 positions for a total of 1,182;
  • Pediatrics-categorial gained 57 positions for a total of 2,383;
  • Pediatrics-primary lost 14 positions for a total of 65;
  • Surgery-categorical gained 15 positions for a total of 1,075.

Tuesday, March 16, 2010

Uninsured population grows dramatically in California

You had to wonder about the prospects for health care reform last summer when it became clear that Republicans and Democrats couldn’t agree on the number of uninsured Americans. A study released today underscores the fact that while politicians were arguing about the size of the problem, it may have been growing much bigger: In California, the uninsured population increased by 25 percent between 2007 and 2009, from 6.4 million to 8.2 million, according to the UCLA Center for Health Policy Research study, which provides some of the first solid evidence of the effect of the recession and high unemployment rates on people’s health insurance status. Nearly one-quarter of adults in California now lack health insurance.  

"The number of Californians who lost their insurance simply because they lost their job is the clearest indicator yet that our current system of health insurance is broken and that urgent change is needed," said Dr. Robert K. Ross, MD, president and CEO of the California Endowment, which, along with the California Wellness Foundation, funded the study.

Friday, March 12, 2010

Nurse anesthetists' incomes higher than family physicians'

I interviewed a young woman earlier this week for a summer babysitting job who said she wants to pursue a career in the medical field after she finishes high school, possibly to become a nurse anesthetist. I found myself wanting to encourage her to go to medical school and study family medicine instead. I like the idea of a prospective family doctor taking care of my children, and she seems like she would be well suited for the profession. I decided to keep the career advice to myself until I get to know her better. Then an article published yesterday on CNNMoney.com made me realize just what a hard sell this might be.

Physician recruiting firm Merritt Hawkins & Associates reports that certified nurse anesthetists (CRNAs) were offered an average base salary of $189,000 in 2009, compared with $173,000 for primary care physicians. This is the fourth year in a row that CRNAs’ salaries have exceeded that of family physicians. Growth in the number of surgical procedures has fueled demand for anesthetists and anesthesiologists, according to the article. The firm projects that gap will close somewhat in 2010, but that CRNAs will continue to command higher wages than primary care doctors.

When the time is right, I’m still going to steer this impressive young woman toward family medicine, but I might need to rethink her babysitting salary. Clearly if she’s going to finance a medical degree and family medicine career, she needs to start earning more money -- now.

Monday, March 8, 2010

Free ICD-9 look-up tool

Gily Ionescu, MD, an internist practicing in rural Walla Walla, Wash., created an ICD-9 look-up tool that might just help you code a little easier. The web-based look-up tool is free, fast and iPhone compatible.

Dr. Ionescu decided to create the tool after a three-year struggle with oupatient internal medicine coding. He wanted a fast, user-friendly ICD-9 code search tool to make the task easier.

Give it a try. It may help you out, too!

Friday, March 5, 2010

Competition disappearing in health insurance industry

A recent AMA report shows that competition in the health insurance industry is fading, with more markets being dominated by one or two insurers.

In 24 of the 43 states studied, the two largest insurers had a combined market share of at least 70 percent. In the previous year's report, just 18 of 42 states had two insurers controlling such a large share of the market.

“The near total collapse of competitive and dynamic health insurance markets has not helped patients,” said AMA President J. James Rohack, MD. “As demonstrated by proposed rate hikes in California and other states, health insurers have not shown greater efficiency and lower health care costs. Instead, patient premiums, deductibles and co-payments have soared without an increase in benefits in these increasingly consolidated markets.”

Insurer dominance has also left physicians with virtually no bargaining power when it comes time to negotiate contracts and fee schedules.

The AMA study also found that:

  • 99 percent of metropolitan markets are “highly concentrated” according to federal merger guidelines (up from 94 percent the year before),
  • 54 percent of metropolitan markets have at least one insurer with a 50-percent or greater market share (up from 40 percent the year before),
  • 92 percent of the metropolitan markets have at least one insurer with a market share of 30 percent or greater (up from 89 percent the year before).

Free magazines for your waiting room

Many medical practices receive complimentary magazines for their waiting rooms, giving patients something to read when they come for their appointments and saving practices hundreds of dollars in subscription costs. The benefit for magazine publishers, of course, is the possibility of attracting new subscribers.

However, some publishers have been cutting the number of free magazines they distribute because of concerns about whether the magazines are really wanted and whether they actually get displayed.

To "opt in" to receive complimentary magazines for your waiting room, check out WaitingRoomPubs.com.

Wednesday, March 3, 2010

Senator Bunning stops strangling the Senate -- and your Medicare payments

You can breathe easy now – or at least a little easier. As today's update from the AAFP Washington office has it:

Last night, the Senate approved the House-passed bill that extends unemployment benefits, COBRA, the sustainable growth rate for Medicare payments (SGR) and other payment and benefit provisions. The bill funds Medicare payments to physicians at the current rate until March 31. The President immediately signed the bill.

Meanwhile, the Senate is working on another bill that would extend these same benefits for several more months. In the case of the SGR, payments would be extended to October 1 of this year. This bill will likely pass the Senate later this week or early next and would likely be approved quickly in the House. Most Senators who voted for the legislation cited the difficulties created for the unemployed, but they also heard from a large number of physicians and that made a significant difference in their sense of urgency.

So ... the execution has been stayed for at least a month. But the clock is still ticking.

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