AMA RUC to Increase its Transparency

The American Medical Association panel that recommends values for physician services to CMS for Medicare Part B payment purposes, which has been widely criticized for its closed-door process, has initiated some changes in an effort to make them more transparent. The AMA Specialty Society Relative Value Scale Update Committee, commonly known as the RUC, will now publish meeting minutes and how the panel as a whole voted for individual current procedural terminology codes; how individual members voted will not be released. The information will be posted on the AMA website after CMS releases its annual Medicare physician fee schedule. The new Medicare fee schedule typically is released around Nov. 1, but this year, because of the government shutdown, CMS announced it may not be released until Nov. 27.

Increased transparency in how physician services are valued in Medicare could have significant implications for physician payment in Medicaid and the private sector. Most commercial insurance plans set physician payment as a percentage of the Medicare physician fee schedule. Employers should take note of the increased transparency at the federal level, and advocate for similar transparency within commercial insurance plans. This increased transparency, combined with the real possibility of SGR reform in the near future, could have significant downstream impacts on the entire health care delivery system.

Physician Payment: Forget Carrots And Sticks, It’s Motivation

Today the Health Care Incentives Improvement Institute, Inc. issued a report, developed with support from the Robert Wood Johnson Foundation (RWJF), questioning conventional wisdom about how to improve the quality and affordability of U.S. health care.

The report, entitled “Improving Incentives to Free Motivation,” rejects the premise of current payment reform discussions, which assumes that health care costs will drop and quality will improve if policymakers and payers simply find the right mix of rewards (“carrots”) and punishments (“sticks”).

The Issue Brief also analyzed cost and quality variability data for over 20 health conditions, identifying those (such as diabetes and coronary heart disease) most ripe for incentive experimentation and reform.

Additional details can be found in today's news release. Blog posts on the topic were also published today in  the Health Affairs Blog and The Health Care Blog.

Study: Doctors Look To Others To Play Biggest Role In Curbing Health Costs

When it comes to controlling the country’s health care costs, doctors point their fingers at lawyers, insurance companies, drug makers and hospitals. But well over half acknowledge they have at least some responsibility as stewards of health care resources.

In a study, published in the Journal of the American Medical Association, Mayo Clinic researchers surveyed more than 2,500 doctors to assess their views of different approaches to rein in the nation’s health care costs. The doctors were randomly selected from an American Medical Association database.

Based on the findings, 59 percent of doctors believe they have some responsibility in holding down health care costs. Only 36 percent think they have a major role. More than half of doctors, however, said each of five other groups carry “major responsibility:” trial lawyers, health insurance companies, pharmaceutical companies, hospitals and patients.

When asked about options to reduce health care costs, most doctors viewed efforts to improve the quality and efficiency of care most favorably. For example, 98 percent are enthusiastic about efforts to promote care coordination for people with chronic diseases. Doctors were also mostly in favor of improving conditions for evidence-based decisions, including efforts to prevent corporate influence of physicians’ decisions and promoting head-to-head trials of competing treatments. They were less enthusiastic about changing current payment models. Only 7 percent, for example, were very enthusiastic about eliminating the traditional fee-for-service payment system, while another 23 percent were somewhat enthusiastic. About a third of the physicians expressed enthusiasm for bundled payment systems.

Should Physician Pay be Tied to Peformance?

We need to rethink how we pay doctors. That's one thing almost everyone can agree on.

 

The question is, how?

 

In today's Wall Street Journal, Francois de Brantes, executive director of the Health Care Incentives Improvement Institute, weighs in on incentives. "Should Physician Pay Be Tied to Performance?"

NCQA Launches Specialty Practice Recognition Program

The National Committee for Quality Assurance—architect of America’s most popular patient-centered medical home model—has extended medical home concepts to specialists and released its latest program: NCQA Patient-Centered Specialty Practice (PCSP) Recognition.

Now specialty practices committed to access, communication and care coordination can earn accolades as the “neighbors” that surround and inform the medical homes and colleagues in primary care.

Practices that become recognized will demonstrate patient-centered care and clinical quality through: streamlined referral processes and care coordination with referring clinicians, timely patient and caregiver-focused care management and continuous clinical quality improvement.

Earning NCQA Patient-Centered Specialty Practice Recognition shows consumers, private payers and government agencies that a specialty practice has undergone a rigorous review of its capabilities and is committed to sharing information and coordinating care. Recognition also signals to primary care practices that a specialty practice is ready to be an effective partner in caring for your shared patients.

Report of the National Commission on Physician Payment Reform

The National Commission of Physician Payment Reform said in a recent report that systems that reward quality of care, such as bundled payment systems and accountable care organizations, should replace physician fee-for-service (FFS). While acknowledging that the move to bundled payments will be gradual, the Commission suggested starting with patients with multiple chronic conditions makes sense particularly beginning with bundling payments for conditions that involve in-hospital and post-acute care, such as heart attacks and joint replacements. The Commission made these twelve recommendations:

• Over time, payers should largely eliminate stand-alone fee-for-service payment to medical practices because of its inherent inefficiencies and problematic financial incentives. 
• The transition to an approach based on quality and value should start with the testing of new models of care over a 5-year time period, incorporating them into increasing numbers of practices, with the goal of broad adoption by the end of the decade. 
• Because fee-for-service will remain an important mode of payment into the future, even as the nation shifts toward fixed-payment models, it will be necessary to continue recalibrating fee-for-service payments to encourage behavior that improves quality and cost-effectiveness and penalize behavior that misuses or overuses care. 
• For both Medicare and private insurers, annual updates should be increased for evaluation and management codes, which are currently undervalued. Updates for procedural diagnosis codes should be frozen for a period of three years, except for those that are demonstrated to be currently undervalued. 
• Higher payment for facility-based services that can be performed in a lower-cost setting should be eliminated. 
• Fee-for-service contracts should always incorporate quality metrics into the negotiated reimbursement rates. 
• Fee-for-service reimbursement should encourage small practices (those having fewer than five providers) to form virtual relationships and thereby share resources to achieve higher quality care. 
• Fixed payments should initially focus on areas where significant potential exists for cost savings and higher quality, such as care for people with multiple chronic conditions and in-hospital procedures and their follow-up. 
• Measures to safeguard access to high quality care, assess the adequacy of risk-adjustment indicators, and promote strong physician commitment to patients should be put into place for fixed payment models. 
• The Sustainable Growth Rate (SGR) should be eliminated. 
• Repeal of the SGR should be paid for with cost-savings from the Medicare program as a whole, including both cuts to physician payments and reductions in inappropriate utilization of Medicare services. 
• The Relative Value Scale Update Committee (RUC) should make decision-making more transparent and diversify its membership so that it is more representative of the medical profession as a whole. At the same time, CMS should develop alternative open, evidence-based, and expert processes to validate the data and methods it uses to establish and update relative values.

Research on Provider Cost Transparency Published

In a new article published in the Journal of the American College of Radiology, researchers sought to determine whether presenting providers with cost information at the point of order entry significantly influenced imaging utilization. Using data from fiscal year 2007, the 10 most frequently ordered imaging tests were identified. Five of these were randomly assigned to the active cost display group and 5 to the control group. During a 6-month baseline period from November 10, 2008, to May 9, 2009, no costs were displayed. During a seasonally matched intervention period from November 10, 2009, to May 9, 2010, costs were displayed only for tests in the active group. At the conclusion of the study, the radiology information system was queried to determine the number of orders executed for all tests during both periods. The main outcome measure was the mean relative utilization change between the control and intervention periods for the active group vs the control group.

Researchers found that there was no significant difference between the active cost display group and the control group, indicating that provider cost transparency alone does not significantly influence inpatient imaging utilization. While this research was conducted entirely within one specialty, there may be significant implications for value-based insurance design, and shared decision-making. If providers acting on their own are not influenced by cost data when making decisions, the role of patients and their families may become even more important.

Hospital Value-Based Purchasing Conundrum

Investors Business Daily reports on an interesting juxtaposition that is resulting from two separate provisions of the ACA. The Hospital Value-Based Purchasing (HVBP) program in the ACA has identified hospitals that provide patients with the most value. The program rewards hospitals that meet certain quality standards with a small percentage increase in their Medicare payments. Those that fall short face small Medicare payment percentage cuts. Nine of the top 10 hospitals in the first round of HVBP were physician-owned. In fact, doctor-owned hospitals accounted for 48 of the 100 top spots, according to data from the Centers for Medicare and Medicaid Services. More than 3,400 hospitals were included in the program. However, a separate provision in the ACA places limits on existing physician-owned hospitals, and establishes significant barriers to the establishment of new physician-owned hospitals. 

According to the physician-owned hospitals, the ACA has impeded the expansion of the hospitals that may provide patients with the most value, hindering beneficiaries' access to high-quality care. Critics say that the HVBP program measures are dominated by heart care and orthopedic care, which is where physician-owned hospitals are likely to excel; most physician-owned hospitals tend to specialize in one field, such as cardiac or orthopedic surgery. Additionally, hospitals that are newer and smaller do better on patient satisfaction measures, and those differences make it more challenging for general, acute-care hospitals to score as well as their physician-owned counterparts.

While CMS will certainly be monitoring this in future years of the HVBP program, one lesson that emerges is that value-based purchasing programs must be carefully designed to balance the competing interests of all of those involved.

Incomplete Information on Online Doctor Rating Sites

NPR reports on a study of online reviews of urologists, finding that there still aren't enough reviews on sites that rank doctors to make them reliable. Urologists averaged just 2.4 reviews on the big online doctor rating sites like Healthgrades.com, Vitals.com and RateMDs.com. The paltry number of participants means that one cranky patient's complaint — or a rave from one doctor's relative —can skew a rating. The 500 urologists surveyed averaged 2.4 reviews on 10 physician-ranking websites, with total reviews per doctor ranging from 64 to zero. The reviews were overwhelmingly positive, at 86 percent. But the negative reviews focused more on things like office decor than whether the doctor delivered good health care.

People may have figured this out for themselves, according to a survey coming out later this month from the Pew Internet Project. Researchers there found that while 80 percent of Internet users say they research products or services online, just 20 percent say they have used online reviews and rankings for providers of health care. Medicare has started collecting data on physician performance, but so far the government's Physician Compare website is useful only for finding doctors who accept Medicare for payment. That should change in the near future, as performance data mandated by the Affordable Care Act comes online.  In addition, community-based public reporting efforts, such as the Medicare Data Sharing program and the RWJF's Aligning Forces for Quality program, aim to provide more objective physician performance information to the public.

California Attorney General Probes Provider Consolidation

The L.A. Times reports that a wave of consolidation among hospitals and physician groups has drawn scrutiny from the California attorney general's office amid concerns that these alliances could boost medical prices. Some hospital chains and insurance companies in the state said they have received civil subpoenas from the attorney general's office seeking information about market concentration among medical providers and the effect on healthcare pricing.

The Affordable Care Act creates strong incentives for medical providers to collaborate more on patient care in hopes that that will reduce costs in a fragmented industry. That has driven much of the acquisition activity across California and nationwide as hospitals and large medical groups merge. Some health care experts, however, worry that this consolidation will raise costs as competition lessens in certain markets. It could also cause setbacks in the small amount of progress gained thus far in achieving greater price/cost transparency.

Many Americans See Specialists For Primary Care

Two in five adults in the U.S. are getting general health care from specialist doctors, according to a new study showing that figure held steady for nearly a decade.  Researchers found that in 1999 and 2007, approximately 59% of visits in the U.S. for primary care were to family physicians. The other 41% were to specialists, such as internists and obstetricians-gynecologists.

There is evidence that in health care systems where primary care doctors are the first point of contact, patients see better outcomes, according to the study's lead author.  A study from 2011, for example, found that seniors living in areas with more primary care doctors were less likely to be hospitalized with a preventable disease and had lower death rates.

On top of quality concerns, another issue is cost. A 2010 study found that primary care doctors earn about $60 per hour, which is much less than the $92 per hour and $85 per hour rates for surgeons and ob-gyns, respectively.

The researchers write in the Archives of Internal Medicine that there can be a few reasons people turn to specialists over family doctors for primary care. One may be a belief that specialists are better at treating specific conditions. Another reason may be that a shortage of family doctors in the U.S. drives people to specialists.

The 2010 health care reform legislation, the Affordable Care Act, contains provisions directed at alleviating that shortage, including incentives for doctors to choose to specialize in primary care.

New study finds doctor rating websites concern physicians

According to a July 2 article written by Kaiser Health News in The Washington Post, the growth of physician rating websites is of increasing concern among doctors.

Many physicians have criticized doctor rating sites that allow patients to provide feedback anonymously. They argue that such sites do not offer accountability or a way for physicians to defend themselves.

Consumer Reports recently ventured into physician rating territory in Massachusetts. The ratings, published as an insert in the July issue for the magazine’s Massachusetts subscribers and available online as well, put 487 primary-care and pediatric practices through their paces, assigning scores.

The article notes, "Rating sites of any sort help consumers take a more active role in managing their health and making health care choices, say experts. And that’s important, whether the information comes from a scientifically valid survey or an anonymous online review."

Doctors take issue with new language of medicine

In a recent commentary in The New York Times, Dr. Danielle Ofri, an associate professor of medicine at New York University School of Medicine, looks at how physicians view increasingly ubiquitous terms such as health care provider, hospitalist and health care consumer.

She notes the recent essay on this topic by Dr. Pamela Hartzband and Dr. Jerome Groopman in The New England Journal of Medicine.

According to Dr. Ofri... "maybe it’s splitting hairs to want to be called a doctor, rather than a provider. Yes, maybe there is a hint of paternalism in preferring “patient” over “consumer” or “customer.” And yes, there are probably grander problems in medicine that require urgent attention. But words do influence us. In a world that is increasingly depersonalized, it is ever more critical to maintain protected spheres of human interaction."

What do you think?