ACA: Helping or Hurting Solo Practice?

It won’t surprise many to learn that the age of the solo practitioner has, for the most part, come to an end. Over the past several years, small and solo practices have closed, been sold to hospitals, or merged with larger groups. The reasons are fairly obvious. Declining payments, rising malpractice costs, increasing regulatory burdens, costly new health information technology requirements, and crushing medical school debt have made it difficult for physicians to operate the small practices that once were commonplace around the country.

Now add the Affordable Care Act (ACA) to the mix. At a July 19 hearing of the House Small Business Subcommittee on Investigations, Oversight and Regulations, lawmakers questioned whether the health reform law would help or hurt physicians looking to keep their practices small and independent. The answers from the expert panel were mixed.

Gone are the days of Marcus Welby. Courtesy Wikimedia Commons/Public Domain License

The emergence of accountable care organizations (ACOs) will drive more hospitals to buy up small physician practices, Mark Smith, president of the physician recruiting firm Merritt Hawkins, predicted. The health reform law heavily promotes the formation of ACOs, which call for physicians and hospitals to work more closely and to share in bundled payments for episodes of care. Mr. Smith said small practices aren’t well-positioned to enter the ACO world if they aren’t integrated with a hospital because the ACO model calls on practices to assume financial risk.

But Joseph M. Yasso, Jr., DO, a family physician in Independence, Mo., who sold his practice to a hospital group 20 years ago, said the ACA’s promotion of patient-centered medical homes could be a lifeline for small practices. Physicians are adapting to the new environment by becoming medical homes and participating in government pilots where they can share in the savings they generate by providing more efficient care, he said.

One thing everyone on the panel did agree on was the need to fix the Sustainable Growth Rate (SGR) formula used in setting physician payments under Medicare. No surprises there either.

— Mary Ellen Schneider

Criticism of the AMA’s RUC Grows

Tom Scully, the outspoken former head of Medicare, recently said that one of the biggest mistakes policymakers made when redesigning the physician payment system in the early 1990s was giving the American Medical Association control over the Relative Value Scale Update Committee or the RUC.

The RUC, which is as controversial as it is unknown, is a 29-member panel that makes recommendations on how to value of thousands of physician services under Medicare. While Medicare officials are under no obligation to accept the panel’s decisions, most of the time that’s exactly what they do.

Courtesy Wikimedia Commons/ Public Domain.

Mr. Scully told members of the Senate Finance Committee that the current RUC structure, as run by the AMA, isn’t objective enough. There’s a lot on the line since the RUC’s decisions impact about $80 billion in Medicare spending each year, he said. As lawmakers consider how to reform the physician payment system, he urged them to also think about ways to make the RUC less political and more independent.

The comments in the Senate hearing room were just a sampling of the criticism that the AMA and the RUC have received recently. Over the past year or so, the RUC has been under near constant attack from a small group of primary care physicians who are suing the Centers for Medicare and Medicaid Services with the goal of getting the agency to dump the RUC. Their contention is that the RUC is biased toward subspecialists and that the panel’s recommendations have contributed to a significant gap between primary care and specialty pay.

The AMA has continued to support the RUC process, arguing that a group of physicians is best positioned to determine the value of medical services and that the panel has often championed payment increases for primary care services.

— Mary Ellen Schneider

A Hospitalist’s Call to Action

Dr. Patrick Conway is the Chief Medical Officer at the Centers for Medicare and Medicaid Services, but he also happens to be a practicing pediatric hospitalist. So when he showed up at the Society of Hospital Medicine’s annual meeting earlier this week to deliver one of the keynote addresses, he got a warm welcome from fellow hospitalists happy to see one of their own in a real position to make decisions about Medicare’s policies.

Dr. Conway gave the standard speech about what CMS officials are doing to transform the health care system. Then he turned to his hospitalist colleagues and gave them some things to do, too. Hospitalists need to partner with the hospital administration and their quality improvement teams. They need to understand their hospital’s performance data. And they need to take charge, he said, by leading multidisciplinary teams.

“We’re at a unique time in health care where we can drive change,” Dr. Conway said. “My challenge to you would be, please don’t sit on the sidelines.”

Dr. Patrick Conway

He urged the audience – hospitalists gathered in San Diego for continuing education and networking – to make an effort to lead some type of system improvement in their hospital. “I don’t actually care what it is, but work on some broader system changes in your local setting,” Dr. Conway said.

If hospitalists are looking for a reason to get out in front when it comes to system change, there are plenty of financial carrots and sticks coming very soon from the Medicare program. Dr. Conway outlined many of them, from Accountable Care Organizations to the readmission reduction program to the hospital value-based purchasing program. But the best reason to be active in changing the way the health system works is for the benefit of patients, he said. That’s the reason that Dr. Conway still works as a hospitalist nearly every weekend for free. “It’s about those families that you take care of,” he said.

— Mary Ellen Schneider

A Younger Kennedy’s Mental Health Crusade

Patrick J. Kennedy is no longer in Congress, but he’s still campaigning passionately on behalf of mental health. In a plenary talk at the annual meeting of the American Association for Geriatric Psychiatry (AAGP), the former democratic congressman from Rhode Island described his recent mission: An organization he founded called One Mind for Research, which “brings together the science, technology, financial resources, and knowledge required to create an unprecedented understanding of brain disease.” Its goal is to increase the investment in research by $1.5 billion each year for the next 10 years and to achieve a minimum 10% reduction in the cost of brain disease per year.

Courtesy of AAGP

The initiative was launched last May 25th on the anniversary of his uncle John F. Kennedy’s “Moonshot” speech, at the suggestion of his cousin Caroline. He said he told her at the time, “Great, instead of going to outer space, we’ll go to inner space!”

On a more serious note, Mr. Kennedy drew a parallel between President Kennedy’s focus on civil rights as a moral issue and the cause of the mentally ill, telling the audience of psychiatrists “What you all do in the field of mental health is to help lessen the marginalization of too many Americans…I think we have a historic opportunity now, with the implementation of the Mental Health Parity Bill and the [Affordable Care Act] to break down the segregation of mental health from overall health.”

Referencing his own struggles with substance abuse, depression and bipolar disorder and his role in Congress as chief sponsor of the parity bill, Mr. Kennedy decried the current insurance reimbursement system as being “wholly inadequate” for treating chronic mental conditions. “If we treated diabetics the way we treat alcoholics and addicts, we’d be waiting till we were cutting off their toes and they’d lost their eyesight before we paid for treatment,” he said, to applause.

He was equally emphatic regarding the politics involved in securing funding for One Mind’s 10-year plan. “If you consider how much money we put into neuroscience today compared to the burden of [mental] illness, any CEO in the country would be kicked out of their job for not doing enough research…it just doesn’t compute,” he said, again to applause.

He acknowledged there would be challenges. “I can’t tell you we’re going to be successful, but at least I’m going to do my part to see that we try something different.”

The AAGP plenary session was supported in part by an educational grant from Lilly USA, LLC.

-Miriam E. Tucker (@MiriamETucker on Twitter)

Innovation Center Seeks to Renovate Medicare

Government officials have stood before doctors many times and talked about the need to change the perverse incentives that pay them more for caring for sick patients than for keeping people healthy to start. Dr. Richard Gilfillan, who runs the new Center for Medicare and Medicaid Innovation, had a similar pitch when he talked to more than 1,000 people who recently convened at a Washington, D.C. hotel for a day-long summit on health care innovation. The difference is, Dr. Gilfillan has some leverage.

Under the Affordable Care Act, his new center is charged with rapidly testing alternative payment and health care delivery models. If those pilot projects are proven to both improve the quality of care and bring down health care costs, the Secretary of Health and Human Services can roll out the program nationally. There’s a little more paperwork involved, but that’s the general idea.

Dr. Richard Gilfillan (R), with HHS Secretary Kathleen Sebelius and former head of the Centers for Medicare and Medicaid Services, Dr. Don Berwick, in November. HHS Photo by Chris Smith.

What that means is that in a relatively short amount of time, Medicare could fundamentally change the way it pays doctors. That is, if the pilot projects sponsored by the Innovation Center are successful.

Dr. Gilfillan offered an example: Let’s say the Innovation Center launches a project where it pays primary care physicians an extra $10 per patient per month to coordinate care. If officials at the Innovation Center can prove that the project improves outcomes and reduces costs, HHS can publish regulations to roll it out to primary care physicians around the country. “As you can see, this is a powerful tool for changing the way we deliver care,” Dr. Gilfillan said at the summit.

The Innovation Center has been around for about a year and officials there have been busy putting together a set of pilot projects that look at new ways to deliver primary care and home-based care. They are also testing other concepts like bundled payments and accountable care organizations. Check out the Innovation Center’s report on its first year for descriptions of all the projects.

One thing they are trying to do in each of the projects, Dr. Gilfillan said, is to work closely with private payers. The goal, he said, is to make life a little simpler for doctors by ensuring that when they find new payment mechanisms that work, all the payers, both public and private, will adopt it in the same way.

— Mary Ellen Schneider (on Twitter @MaryEllenNY)

New Questions on Lung Cancer Screening

Would you allow patients to self-refer for a CT lung cancer screening? Would you screen a never-smoker? What size nodule would trigger a follow-up exam? What is your lower age limit and lower pack-year limit for screening?

These are just a few of the questions tackled during an interactive lung cancer screening session at the recent Radiological Society of North America meeting, and that highlight the uncharted waters physicians face in the wake of the pivotal National Lung Screening Trial.

The NLST demonstrated a 20% reduction in lung cancer mortality when low-dose CT screening was used, compared to chest X-ray, among 53,000 asymptomatic current or former heavy smokers. However, CT produced more than three times the number of positive results and a higher false-positive rate than radiography.

Without a clear plan to manage abnormal findings or a firm handle on cost, policymakers and payors are hesitant to back reimbursement for widespread lung cancer screening. Results of the ongoing NLST cost-effectiveness analysis are expected early next year. Based on already published data, however, a crude back-of-the-envelope estimate puts the incremental cost-effectiveness ratio at $38,000 per life-year gained, NLST investigator Dr. William Black told attendees.

“That actually is a pretty good deal compared to a lot of things we do in medicine, and in fact most people would put the threshold for acceptability somewhere between $50,000 to $100,000 per life-year gained,” he said. “So it certainly is feasible”

Dr. Black pointed out that low-dose CT saved one lung cancer death per 346 persons screened in NLST, which again is very favorable compared to the rate of 1 per 2,000 patients for mammography.

Although the session provided just a small snapshot in time, audience responses suggest there is much work ahead. A full 77% of attendees were not using low-dose CT to screen for lung cancer and 72% reported not being familiar with the recently published National Comprehensive Cancer Network guidelines for lung cancer screening.

One-quarter of the audience had no lower age limit for screening, and 34% said they did not provide either decision support or obtain informed consent.

Dr. Caroline Chiles. Image by Patrice Wendling/Elsevier Global Medical News

Radiologist and NLST collaborator Dr. Caroline Chiles said informed consent in NLST helped prepare patients for the potential risks of a screen, the likelihood of a positive result and that a positive result didn’t mean they had lung cancer.

“It made a huge difference once they got that letter saying they had a positive screen, because at that point you don’t want everyone rushing out to a surgeon to get that nodule resected,” she added.

What attendees and panelists could agree on is the need for smoking cessation to be included in any future lung cancer CT screening program, with 60% of attendees saying they already do so.

Dr. Chiles pointed out that 16.6% of participants in the NELSON lung screening trial quit smoking compared with 3%-7% in the general public, but that participants were less likely to stay non-smokers. She also cited a recent MMWR that found 70% of adult smokers want to quit smoking, but only about half had been advised by a health professional to quit.

“We really have to think of lung cancer screening as being a teachable moment,” she said.

She suggested physicians visit www.smokefree.gov for help in guiding their patients. Dr. Black also noted that the NLST team is working on a lung cancer screening fact sheet for physicians and patients that will be ready in a few weeks and made available on the Internet.

—Patrice Wendling

Spurring Health IT Adoption

The Obama administration really, really wants doctors to start using electronic health records (EHRs). For the past few years, they have been out urging physicians to invest in the systems and offering a pretty big carrot for adoption. Under the 2009 HITECH (Health Information Technology for Economic and Clinical Health) Act, physicians who meet certain quality metrics through the use of certified health IT systems can qualify for incentive payments from Medicare and Medicaid. Under the Medicare program, the maximum incentive is $44,000 over 5 years. Under Medicaid, it’s nearly 64,000 over 6.

HHS officials want to make paper medical records a thing of the past. Courtesy Wikimedia Commons/U.S. Navy Photo by Rod Duren/ Public Domain.

Now officials at the Health and Human Services department are trying to drive up adoption by removing a potential barrier to early participation in the program. HHS recently announced that physicians can begin participating in the incentive program this year and not have to meet quality standards until 2014. Previously, if a provider reported to HHS that he or she was using health IT as part of the incentive program in 2011, they would have to meet the quality standards starting in 2013. But those that started sometime in 2012 wouldn’t have to meet the standards until 2014 and would still qualify for the maximum incentive payments. It can get a little complicated, but essentially HHS is trying to take away reasons for people to hold off on adopting EHRs.

It’s hard to tell if this latest policy change will make a big difference to physicians considering an EHR. But the incentive program as a whole does seem to have physicians interested. A new survey from the Centers for Disease Control and Prevention found that 52% of office-based physicians report that they plan to take advantage of the new incentive payments. As for doctors who have already adopted some type of “basic” EHR, that number has climbed from 17% in 2008 to 34% this year.

Tell us what’s driving your decision to adopt an EHR in your practice? Take our poll:

— Mary Ellen Schneider

Bundled Dialysis Payments May Leave Some Shortchanged

It’s difficult not to equate the Centers for Medicare and Medicaid Services’ bundled payment system for outpatient hemodialysis with, say, handing a 12-year-old boy a $10 bill to buy lunch and telling him to keep the change.

That the 12 year old might decide to forego the healthful $9.95 veggie wrap with a side of fruit in favor of the $1 Snickers bar so he can pocket the $9 profit is well within the realm of possibility. In the same vein, should we really be surprised to learn that hemodialysis facilities might not be optimizing patient care when they are being paid a flat fee vs. separate payments for each service —  if not to make a buck, to avoid losing one? A study reported during Kidney Week 2011, the annual meeting of the American Society of Nephrology, hints at just such a scenario.

Image courtesy of Image Courtesy Wikimedia Commons/Elembis/Creative Commons

Using data from the nationally representative Dialysis Outcomes and Practice Patterns Study (DOPPS) practice monitor, investigators with the Ann Arbor Research Collaborative for Health in Michigan determined that uncontrolled secondary hyperparathyroidism has been on the rise among black hemodialysis patients since the implementation in January 2011 of the CMS’s prospective payment system for dialysis services. The system bundles payments for dialysis treatments, supplies, drugs, and lab tests. It rewards facilities for meeting or exceeding quality measures in the Medicare fee-for-service system.

Although the revised payment system is intended to “improve patient outcomes and promote efficient delivery of health care services,” in the words of CMS administrator Donald Berwick, the Ann Arbor investigators hypothesized that the increased financial constraints may lead to less use of intravenous vitamin D analogs, and thus poorer control of secondary hyperparathyroidism (SHPT). Black patients would be left especially vulnerable because they require higher vitamin D doses on average than other patients, according to lead investigator Dr. Francesca Tentori.

To test the hypothesis, the investigators examined trends in parathyroid hormone (PTH) values and SHPT in dialysis patients from July 2010-February 2011 and observed a notable increase in PTH levels overall and in severe, uncontrolled SHPT (defined as a PTH level greater than 600 pg/ml) among black patients.

Specifically, the median PTH value rose among blacks from 296 to 379 pg/ml and from 244 to 283 among non-blacks, and the prevalence of SHPT rose significantly from 16-25% among blacks and slightly, from 9-11% among nonblacks,  Dr. Tentori reported.

Based on preliminary analysis, “these changes don’t appear to be related to decreased overall use of [SHPT] treatments, as the percentage of prescribed intravenous vitamin D rose slightly in both groups, or to changes in serum calcium or phosphorous,” Dr. Tentori said. The findings warrant further evaluation to tease out the cause of the trend, particularly because untreated SHPT has been linked to increased mortality risk in dialysis patients, she stressed.

Dr. Tentori disclosed financial relationships with Amgen, Genzyme, KHK, Abbott, and Baxter.

—Diana Mahoney

Moving Beyond the Hospital

Recently, officials at Hoag Memorial Hospital Presbyterian, a regional health care system in Orange County, Calif., decided to rebrand their 60-year-old institution. The not-for-profit health care system is now known simply as Hoag. They weren’t just going for brevity. They specifically wanted to drop the word “hospital.”

Dr. Richard Afable, Hoag’s president and CEO, recently spoke to a small meeting of hospitalists in Las Vegas and explained that the name change reflects a shift toward providing more services outside of the hospital. Hoag’s hospitals do a great job treating the acutely ill, he said, but the leadership wanted to reach out to people in the community before they got sick enough to make it to the hospital.

Dr. Richard Afable. Photo by Mary Ellen Schneider/ Elsevier Global Medical News.

So officials at Hoag have been working to offer more services related to conditions that either slightly touch the hospital or don’t touch it at all, Dr. Afable said. For example, the system has beefed up its offerings around diabetes care and now provides counseling on how to manage the disease and prevent complications. In the old days, they would have waited for someone to have a heart attack or lose a limb before taking care of them, Dr. Afable said. They also are developing community-based programs for breast cancer, a condition that today is treated primarily outside of the hospital.

And Dr. Afable advised hospitalists to consider following Hoag’s lead and look how they can be involved in care outside of the hospital. He noted the example of CareMore, a medical group and health plan based in California, which is being acquired by the health insurer Wellpoint, Inc. Under CareMore’s model, hospitalists not only care for patients while they are in the hospital, but also after they leave. Once a patient is stable, they are sent back to receive the rest of their care from their primary care physician. Since CareMore uses a capitation payment model, there aren’t concerns about which physician gets the payment for the post-discharge care. The model is food for thought for hospitalists as care becomes increasingly less hospital centric, Dr. Afable said.

— Mary Ellen Schneider

Help Is on the Way for Primary Care Doctors (Wink, Wink)

Help is on the way “very soon” for family physicians, internists, and pediatricians in the form of a final rule for accountable care organizations (ACOs).

Based on extensive feedback on the proposed ACO rule, changes are coming that primary care physicians are going to like, Dr. Nancy Nielsen said.

The preliminary  rule  “was met with – how shall I say? – an underwhelming response by the medical community,” said Dr. Nielsen, Senior Advisor of the Center for Medicare & Medicaid Innovation established as part of Centers for Medicare and Medicaid Services (CMS) by the Affordable Care Act.

“We have a few code words we have to work out here so I don’t get into trouble, but you get what I am trying to say,” Dr. Nielsen said at the American Academy of Family Physicians Congress of Delegates. For example, if I tell you ‘it has been suggested to us,’ that is REALLY important and it may be coming out, but I can’t announce anything yet,” said Dr. Nielsen, an internist and former president of the American Medical Association.

Regarding ACOs, Dr. Nielsen said, “Very soon the final rule will come out. Very soon. CMS has listened to the feedback:”

“It has been suggested to us that 65 quality measures are way too many.”

“It has been suggested to us that the mechanism for the shared savings ought to be done differently.”

“And it clearly has been suggested to us that hospitals have the ability to come up with the capital to start an ACO, but it’s really tough for doctors. So it has been suggested to us that we give advanced payment. I am here to say that very soon you will see that, and very soon you will like what you see.”

Although doctors have always been accountable for the care of patients, now they also will be accountable for resource expenditures, and the Center for Medicare & Medicaid Innovation plans to help, Dr. Nielsen said. There will be new expectations and new tools given to primary care physicians. “I will tell you that never once in my 23 years of practice did I see data showing me what it cost when I ordered an x-ray. Do you know what it costs when you write a prescription for an antibiotic? Do you get that data? No, you have never seen that.”

“But you must help us achieve this … when the [internal] warfare within the house of medicine begins,” Dr. Nielsen said. “I have a pet peeve. It really makes me crazy when people talk about people who do primary care as ‘primary care physicians’ and all the other docs as ‘specialists.’” She said that family physicians, internists, and pediatricians should stand together and say ‘We are specialists, just like you are specialists. We have a critical role to play and we need to have the tools to help us play that role.”

“Stay tuned. A lot of things you are going to, like, have been suggested to us.”

Dr. Nielsen’s comments were streamed live on the Internet during the congress and are available as archived video.

–Damian McNamara

@MedReporter on Twitter