Report of The National Commission on Physician Payment Reform
Society of General Internal Medicine, March 2013
Recognizing that the level of spending on health care in the United States is unsustainable, the return on investment is generally poor, and the way that physicians are paid contributes substantially to the high cost of health care, The Society of General Internal Medicine (SGIM) convened The National Commission on Physician Payment Reform in March 2012 to recommend new ways to pay physicians that will ultimately improve patient outcomes but also rein in health care costs.
The commission’s recommendations focus on the near-term, calling for drastic changes to the current fee-for-service payment system and a five-year transition to a physician- payment system that rewards quality and value-based care. The recommendations pertain to the way physicians are paid throughout the health care system — both public and private payers.
http://physicianpaymentcommission.org/wp-content/uploads/2013/03/physician_payment_report.pdf
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Do We Get What We Pay For? Transitioning Physician Payments Towards Value and Efficiency
By Malathi Srinivasan and Mark D. Schwartz
Editorial, Journal of General Internal Medicine, May 2014
In March 2013… the National Commission on Physician Payment Reform (NCPPR), released a report with twelve recommendations to reform how physicians are paid, linking incentives to quality in patient care to curtail rising health care costs.
In this issue, SGIM ad hoc Committee members offer three Comments addressing the Commission’s recommendations. First, Selker and colleagues review the first three recommendations, which argue for phasing out the current volume-based, fee-for service (FFS) reimbursement model over 5 years, to be replaced by a system emphasizing value and efficiency, with incentives that promote high quality, coordinated, and cost-effective, patient-centered care. Then Siddiqui et al., addressing Commission recommendations four through nine, contend that while transitioning away from FFS, the US must strengthen the primary care foundation of high performing healthcare systems, notably evaluation, management and preventive services. Finally, Patel and Nadel examine the Commission’s last three recommendations, arguing that Medicare’s Sustainable Growth Rate (SGR) formula be repealed and replaced with policy that rewards value rather than volume, and that is based on a valuation of physician work that rectifies the current relative value unit (RVU) bias in favor of procedural compared with cognitive-based services.
http://link.springer.com/article/10.1007/s11606-014-2818-9/fulltext.html
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Global Amnesia: Embracing Fee-For-Non-Service — Again
By David U. Himmelstein, MD and Steffie Woolhandler, MD, MPH
Editorial and Comment, Journal of General Internal Medicine, May 2014
Now SGIM’s Commission has joined the growing policy bandwagon to reanimate the HMO strategy. There are semantic changes — ACO has replaced HMO, and when insurers drop expensive doctors (e.g. the 1,000-member Yale Medical Group5), it’s called “network optimization” not “delisting”. In a new twist on gag clauses, today’s ACO patients (e.g. seniors in Medicare’s Pioneer ACOs) aren’t told they’re enrolled. But the diagnosis and prescription are unchanged.
As in 1971, fee-for-service is the culprit. A shift to “bundled payment, capitation, and increased financial risk sharing” is the solution, with “risk adjustment… to avoid physicians and other providers cherry-picking the healthiest patients”; and “quality measures… to assure that evidence- based care is not denied as a cost-saving mechanism.”
Twentieth century risk adjustment and quality monitoring were overmatched by HMOs’ gaming and deception. Despite additional decades of work to devise bullet-proof risk adjustment, gaming remains so powerful and pervasive that cost and quality rankings are often distorted, or even inverted. No solution is on the horizon.
Conclusion
Like the SGIM Commission, we rue the toxic incentives of the current fee-for-service system. But in the profit-maximizing milieu of American medicine, capitation risks making things even worse. “Risk-sharing” too often means that physicians earn bonuses for denying care — a danger perceived by patients, who take a dim view of capitation. Risk-sharing is not simply the inverse of fee-for-service, but of fee splitting, the illegal practice of kickbacks for referrals.
There are many bad ways to pay doctors, and no particularly good ones. Other nations have achieved better outcomes, lower costs and fairer compensation of physicians using a variety of methods: fee-for-service, capitation, and salary; none is clearly best. The common theme isn’t mode of payment, but a universal system with regulations that restrain costs and minimize the opportunities for profit and the risk of loss.
Payment reform should focus not on manipulating greed, but on dampening it. Then the real motivations for good doctoring — altruism, social duty, and the glow we feel when we help our patients — can flourish.
Use the following link to read the entire article or to download the PDF: http://link.springer.com/article/10.1007/s11606-013-2745-1
Comment:
By Don McCanne, MD
Regarding controlling health care spending, the meme of this decade seems to be that we must start paying based on value and not volume, as if the greatest value would be realized by reducing the volume of health care to as close to zero as possible.
There are plenty of articles on how this might be accomplished, many of them centering on concepts such as accountable care organizations and bundling of payments. What seems to be missing are comprehensive discussions of how unrealistic and misdirected these proposals are.
That is why it is important that you download the article by Himmelstein and Woolhandler. It should be used in your advocacy work to move us away from the empty managed-care promise of supposedly replacing volume with value, so that we can move forward with reform that actually will improve value – a single payer national health program.