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

What if the Supreme Court Tosses Out the ACA?

Opponents of the Affordable Care Act are hoping that the Supreme Court will soon invalidate the law and put a permanent end to the federal government’s expanded role in health care. But one Capitol Hill watcher says the defeat of the ACA by the high court could lead to something conservatives would like even less – single-payer health care. Well, not anytime soon. But tossing out the law could help nudge things in that direction over time.

Norman J. Ornstein, Ph.D., an author and resident scholar at the American Enterprise Institute, said he could imagine a scenario where if the ACA were defeated, over time, Democrats would move to expand Medicare beyond the 65 and older crowd. Mr. Ornstein, who has a new book coming soon on the growing dysfunction in Washington, offered his two cents while speaking to a group of physicians at the Society of Hospital Medicine’s annual meeting in San Diego this week.

Protesters outside the Supreme Court in March. Photo by FRANCES CORREA/ IMNG Medical Media.

Another way that single-payer health care could become a reality is at the state level. Individual states might experiment with single payer-type programs along the lines of the Green Mountain Care program in Vermont, Mr. Ornstein said. Lawmakers in that state have enacted legislation allowing them to phase in a single-payer health care system over the next several years. But they have yet to hammer out details on how to pay for the program and it’s unclear how long it will take to move from the current framework of public and private insurance to a single-payer system.

— Mary Ellen Schneider

House: System Reforms Second to SGR Repeal

Delivery system reforms come second to repealing the Sustainable Growth Rate formula. That’s according to congressional testimony by private sector payers at a recent hearing of the House Ways and Means Committee.  While each of the panelists presented compelling ideas for delivery system reform, all agreed that the first step to progress is a new payment model.

“The extent to which Medicare can more more swiftly to payment reforms, I think we’d see progress there,” said panelist Dr. Jack Lewin, the chief executive officer of the American College of Cardiology.

Rep. Mike Thompson (D-Calif.) said SGR repeal, not delivery reform, is the number one concern of both doctors and Medicare beneficiaries.

Alicia Ault/Elsevier Global Medical News

“[Doctors] want to make sure that they’re going to get paid for the medical services they provide and Medicare patients want to make sure they’re going to have a doctor to go to; and it stops right about there,” he said. His concerns were echoed by Ranking Member Pete Stark (D-Calif.).

“We keep avoiding the topic of Sustainable Growth Rate formula, in favor of the easier conversations about delivery system reforms, around which we have much stronger agreement,” Rep. Stark said.

Dr. John Bender, president and CEO of Miramont Family Medicine of Fort Collins, Colo., testified that if SGR is not repealed, doctors could have a harder time keeping their practices afloat. He added that he was forced to take out $70,000 loan to cover payroll 4 years ago when SGR was not repealed and Medicare payments were delayed. Today, with stricter policies on loans, that might not be an option, Dr. Bender said, and his practice could go bankrupt.

Len Nichols, director for health policy research and ethics at George Mason University, testified that the Affordable Care Act has brought an end to “business as usual.” He said that Medicare and private payers must work together to find savings, or else face steep cuts.

“We could cut our way to fiscal balance, and in so doing, reduce access to care for millions of Americans. I fear this pathway would likely fail,” Nichols said. “Alternatively, we could align incentives so thoroughly that we actually link the self-interest of clinicians with our common interest in cost reduction and quality improvement, which covering all Americans.”

Rep. Thompson called on his fellow lawmakers to put partisan differences aside to solve the problem that Congress created.

“We have dropped the ball on this one … We need to come together as members of Congress, party stripe not withstanding, and figure out how we come up with the dollars to fix this,” he said.

—Frances Correa (@FMCReporting on Twitter)

The Trauma of Politics in Medicine

It’s been a quick reversal for the Susan G. Komen for the Cure Foundation, reinstating funding some 72 hours after cutting off Planned Parenthood because of new criteria barring grants to organizations under investigation, prompted in this case, by a Republican congressman.

“We will amend the criteria to make clear that disqualifying investigations must be criminal and conclusive in nature and not political,” Komen CEO and founder Nancy Brinker said in a statement issued Friday.

The uproar brought more than $3 million in donations to Planned Parenthood in just three days, but also highlights the volatile mixture of politics and medicine.

Dr. Richard Carmona recently observed that one of the most popular presentations he made during his tenure as the 17^th Surgeon General of the United States did not address emerging infections, physical trauma, or national diasters, but rather the plague of politics in medicine.

“This traumatic plague of politics is more insidious and virulent than emerging infections; has potentially more morbidity and mortality than hemorrhagic shock or blunt or penetrating trauma; has virtually no diagnostic criteria; and is resistant to all therapy, especially voices of reason, substantive discussion or positions of compromise,” he said during a memorial lecture at the recent meeting of the Eastern Association for the Surgery of Trauma.

Dr. Richard Carmona Patrice Wendling/Elsevier Global Medical News

Dr. Carmona didn’t have far to look for examples to flesh out his diagnosis.

More than a century ago, public health officials’ efforts to control the bubonic plague outbreak of 1900 in San Francisco were nearly derailed by politicians who claimed that quarantine procedures, including closing the city’s harbor to incoming ships, were an over-reaction that would impede commerce and tourism, and result in the collapse of San Francisco, and possibly California. The Surgeon General who intervened based on the scientific evidence was labeled a heretic and asked to resign.

In the 1980s, similar calls were made after former Surgeon General Dr. C. Everett Koop refused to back down from statements that HIV could be prevented. At the time, Dr. Carmona reminded the audience, senior elected officials were telling the American public that HIV was God’s way of punishing homosexuals.

In the 1990s, the tenure of Surgeon General Dr. Joycelyn Elders  was cut short after controversy erupted over a 1994 speech at the United Nations World AIDS Day that included remarks that masturbation was a normal part of sexuality and that abstinence-only education was “child abuse.”

During his own term under President George W. Bush, Dr. Carmona said, abstinence-only became the mantra of the administration, “based solely on ideological and theological concepts, and not science.

“Science had really demonstrated that abstinence alone was a failed proposition,” Dr. Carmona said. “Ironic, that an administration that was repeatedly caught up in the issue of abortion did not see the connection that comprehensive sex education was the best method to prevent STDs, unwanted pregnancies, and therefore abortions. As Surgeon General, this is a science-based position I have always held.”

Dr. Carmona, the only Surgeon General to be unanimously confirmed to the position in over 200 years, said the trauma of politics and its preventable deleterious outcomes are owned equally by politicians on both sides of the aisle.

He pointed out that over-the-counter sales of Plan B stalled under the Bush administration before gaining limited approval in December 2006, but fared no better seven years later under the more liberal Obama administration. In December 2011, HSS Secretary and Democrat Kathleen Sebelius overruled the FDA’s decision to make the emergency contraceptive available, without prescription, to girls of all childbearing ages. While Sebelius cited a lack of conclusive data, Dr. Carmona said it was the administration’s desire to avoid a political battle in the face of an upcoming election.

“The immunization for preventing the continued viralness of political trauma is transparency, full disclosure, accountability for elected officials, a citizenry that is informed and participatory, coupled with civil discourse of complex issues,” he said.

–Patrice Wendling

Examining the IPAB: The Policy & Practice Podcast

The Independent Payment Advisory Board, the new panel that will be charged with reducing the growth in Medicare spending, was the focus of intense debate on Capitol Hill last week. In the July 18 edition of the Policy & Practice podcast, we have all the details on the two House hearings held on the panel and why physicians are worried about its impact.

The Independent Payment Advisory Board (IPAB) was created under the Affordable Care Act to help keep Medicare spending under control. But most physician groups are calling on Congress to scrap the board or substantially change how it operates. Opponents, who include the American Medical Association, say that if the IPAB goes forward, physicians would be subject to two levels of cuts: one from the IPAB and one from Medicare’s Sustainable Growth Rate (SGR) formula. Physicians are already facing a nearly 30% Medicare fee cut next year from the SGR unless Congress steps in.

HHS Secretary Kathleen Sebelius tours Frager’s Hardware Store in Washington, D.C., before an event to announce new rules on health insurance exchanges. HHS photo by Chris Smith.

This week’s Policy & Practice podcast also has news on the new federal regulations for how states can set up health insurance exchanges. Those exchanges, which aim to make it easier for Americans to buy insurance, are slated to be up and running by 2014. And check out the podcast for the latest on the debt ceiling negotiations and how Medicare could be affected.

Take a listen and share your thoughts:

Check back with us next week for more on the debt ceiling legislation and the Institute of Medicine’s recommendations on what preventive services health plans should cover for women.

— Mary Ellen Schneider (on Twitter @MaryEllenNY)

A Chance at an SGR Fix?: The Policy & Practice Podcast

There’s a lot at stake in the negotiations over raising the nation’s debt limit, from the impact on the global economy to the potential elimination of Medicare’s Sustainable Growth Rate (SGR) formula. That’s right, the much-despised SGR, which is used in determining physician payments under Medicare, has even made its way into the talks about increasing the debt ceiling.

House Speaker John Boehner (left) and Senate Majority Leader Harry Reid (right) met with the President on July 10 to discuss the debt limit. Official White House Photo by Samantha Appleton.

As the president and congressional leaders go into overdrive, holding daily meetings on ways to trim the deficit, the medical establishment is pushing hard for lawmakers to stop the cycle of threatened physician pay cuts followed by last-minute legislative Band-Aids. The American Medical Association, along with more than 100 state and medical specialty societies, recently sent a letter to lawmakers warning that the cost of an SGR fix will only go up. Right now, they estimate the 10-year cost of replacing the SGR is nearly $300 billion, but that figure could rise to more than $500 billion in just a few years, they wrote. The debt ceiling legislation provides “the best—and perhaps only—opportunity to ensure stability in Medicare payments, ensure continued beneficiary access to care, and address the SGR deficit in a fiscally responsible manner,” the organizations wrote in their letter.

Get the full scoop on the SGR in this week’s Policy and Practice Podcast.

Take a listen and share your thoughts:

And stayed tuned next week for all the details on new regulations on state-based health insurance exchanges.

— Mary Ellen Schneider (on Twitter @MaryEllenNY)

Rolling Out Health Reform: The Policy & Practice Podcast

Many of the hallmarks of the Affordable Care Act, such as state-based health exchanges to purchase insurance, won’t go into effect until 2014. But, in the meantime, officials at the Department of Health and Human Services are plenty busy rolling out other provisions of the law, making adjustments to some of the law’s programs, and just promoting what they’ve done so far.

Recently, HHS officials announced that they would stop granting exemptions that allow limited-benefit health plans to keep in place low annual coverage limits that are at odds with the Affordable Care Act. HHS has been granting waivers to these so-called “mini-med” plans in an effort to keep the products affordable for consumers. But no more. Starting on Sept. 23, HHS will no longer accept waiver applications or extension requests from these plans. And, in 2014, all health plans will be barred from placing annual limits on coverage under the health reform law.

HHS has also been busy promoting the availability of free preventive services for Medicare beneficiaries. Starting at the beginning of this year, Medicare beneficiaries were eligible to receive recommended preventives services ranging from mammograms to smoking cessation counseling with no copays or deductibles under Medicare Part B.

Photo courtesy National Cancer Institute.

But seniors haven’t flocked to take advantage of the services. Only about one in six Medicare beneficiaries has accessed the free services, according to a government report. So HHS is launching a public outreach campaign that includes radio and TV ads. The government is also reaching out to physicians, asking them to discuss the preventive services with patients.

For more on the implementation of the Affordable Care Act, plus a recap of the American Medical Association’s House of Delegates meeting, check out this week’s edition of the Policy & Practice podcast.

Take a listen and share your thoughts:

The Policy & Practice podcast is taking a break next week, but check back on July 11for all the latest developments in health reform.

— Mary Ellen Schneider (on Twitter @MaryEllenNY)

FDA Misses Lessons of Device Recalls

A new report from the U.S. Government Accountability Office (GAO), the auditing arm of Congress, found that the Food and Drug Administration isn’t doing everything it can to learn from medical device recalls. That’s despite the fact that on average more than 700 medical devices are recalled each year. The report was requested by Sen. Chuck Grassley (R-Iowa), the chairman of the Finance Committee and Sen. Herb Kohl (D-Wisc.), the chairman of the Committee on Aging.

The GAO investigators didn’t take issue with what the FDA does in initiating and classifying the mostly voluntary recalls of medical devices. Instead, they wrote that the agency took a haphazard approach to assessing the effectiveness of recalls and analyzing information after a recall. Those gaps represent a missed opportunity to learn went wrong and keep it from happening again, the GAO warned.

An open and charged AED. Image via Wikimedia Commons user Owain.davies.

Specifically, because of the FDA’s lack of analysis on medical device recalls, they couldn’t give definitive answers to questions from the GAO about the common causes of recalls, the trends in the number of recalls over time, the variation in recalls by risk level, the types of devices and medical specialties that account for the most recalls, and the length of time it takes for companies and the FDA to complete recall activities.

But the FDA told the GAO investigators that it does use recall information help target their inspections. And the GAO gave FDA a gold star from use of recall information to detect and address safety issues with automated external defibrillators. Late last year, the FDA held a conference on AEDs where in presented historical recall data to make the case for safety improvements in the device, the GAO wrote.

For its part, the FDA says it’s getting better. In statement in response to the GAO report, FDA officials said that last year launched the Recall Process Improvement Project, which is aimed at better educating the industry about the recall process. And about a year ago, the FDA began using recall data to aid in the review of devices. The agency has also developed initiatives that use recall data to help improve the safety of infusion pumps, external defibrillators, and radiation from medical procedures.

— Mary Ellen Schneider (on Twitter @MaryEllenNY)

A Sales Pitch for ACOs

There’s been a lot of criticism of the accountable care organization (ACO) concept lately, or more precisely, the federal government’s proposal to share Medicare savings with qualifying ACOs starting next year.

That proposed regulation, which was released at the end of March, outlined how qualifying ACOs could earn additional payments if they could save the Medicare program money. But there were plenty of caveats. The Centers for Medicare and Medicaid Services proposed that ACOs meet a certain threshold of savings before they could get any money back. And the rule also set rigorous standards for quality of care, requiring ACOs to meet 65 quality measures.

Since the rule came out, many physicians’ groups have criticized the proposal, saying that it made it too difficult for physicians to get involved. The steep up-front investment in technology, workflow redesign, and staffing, coupled with the uncertainty of achieving savings, would be too much for many practices, they argued. And even officials at the Cleveland Clinic, a health system that many viewed as a prime candidate for being a successful ACO, have said they see major problems with the Medicare plan for ACOs as it stands today.

Dr. Don Berwick. Photo by Laurie Swope.

Earlier this week, Dr. Don Berwick, the CMS administrator, defended the direction his agency is headed with ACOs. In a speech to participants at an ACO learning session sponsored by CMS in Minneapolis, Dr. Berwick said ACOs are one big step toward building a different, better health care system that promises to improve care for individuals and the population as a whole, all while lowing cost. But he admitted that it was a “very, very difficult step.”

There will be growing pains for everyone in the health care industry as they move forward with ACOs, he said. For instance, physicians, nurses, and other health care providers will have to learn to work together in teams to care for patients with chronic illnesses. Physicians working in the operating room and in the intensive care unit will need to truly embrace checklists. And everyone will have to grow used to their electronic health records and disease registries. Prevention, he said, must become an “obsession.”

And beyond those cultural changes, there are many other obstacles. There’s stranded capital, Dr. Berwick said, and a workforce that is underinvested in primary care and not well suited to supporting continuity of care. There are immature metrics to measure what goes on in an ACO and limited capacity to use the metrics that do exist, he said. Plus, there’s the problem that most of the money paid out by Medicare and private insurance is for the volume of care delivered, not the quality of care received.

But those aren’t reasons to shy away from ACOs or other fundamental reforms of the health care system, Dr. Berwick said. To help overcome some of the obstacles to the success of ACOs, CMS’s Innovation Center is holding learning programs like the one in Minneapolis. They are also experimenting with the idea of advancing funds to promising ACOs that lack start-up money. And they are working to get better data out of the Medicare system. “We intend to help,” Dr. Berwick said.

How many ACOs are likely to emerge next year when the program begins? Dr. Berwick said he doesn’t know, but he’s hopeful that officials at CMS can craft a final rule that will attract many organizations. He urged physicians, hospitals, and others to consider taking a leap of faith, despite the risks. “I ask you to think again about what you risk if, while the world shifts around you, you choose to stand still.”

So does Dr. Berwick make a convincing case for ACOs and the government’s shared savings program? Let us know what you think.

— Mary Ellen Schneider (on Twitter @MaryEllenNY)

Fixing the SGR: The Policy & Practice Podcast

Doctors know that the Medicare physician payment system is broken. Lawmakers know it. Maybe even some patients know it, too.

The problem is how to fix it so that it doesn’t bust the federal budget. And if lawmakers choose to replace the Sustainable Growth Rate (SGR) formula, which is currently used to determine physician payments under Medicare, they will face another challenge: choosing a new formula that won’t create the same problems in a few years.

Medicare payments could fall off a cliff if Congress doesn't act this year. Image via Wikimedia from User Urban.

The Medicare Payment Advisory Commission, which advises Congress on all things Medicare, has come out with a new report that outlines several alternatives to the SGR. In its report, MedPAC tells lawmakers that by replacing the SGR with a structure that doesn’t have scheduled payment cuts to doctors, they would have the chance to adopt other payment changes that could save the system money.

For example, in exchange for across-the-board pay increases to physicians, Medicare officials could reduce payments for specific services that are overpriced, they wrote. Or they could shift payments away from procedures and toward services that promote care coordination and population health.

Get all the details on the SGR, Medicaid reform options, and the 2012 GOP presidential field in this week’s Policy & Practice podcast.

Take a listen:

And check back throughout the week for all the policy news out of the American Medical Association’s House of Delegates meeting.

— Mary Ellen Schneider (on Twitter @MaryEllenNY)