Sunday, January 31, 2010

Doctors versus Medicare

Attached a very interesting article from Saturday's Miami Herald emphasizing the issue of cost-control in healthcare and the resistance by physician groups to accept the inevitable truth: we must bend the cost curve, otherwise someone will bend it for us!We definitely need to shift our paradigm of thinking: from quantity to quality, from volume to value, from physicians- centered to patient-centered care. Now is the time to discuss and resolve the issue. Politicians from both parties must understand that concessions may only provide short-term gains but represent long-term loss. Lets not miss this opportunity.

Cardiologists battle Medicare over payment cuts

In a striking example of the conflict between controlling healthcare costs and providing quality service, a group of South Miami cardiologists has written a letter to patients complaining that huge cuts in Medicare rates may force many heart specialists out of business or mean reduced services for their patients.

The doctors of South Miami Cardiology said that on Jan. 1 Medicare reduced ``reimbursement for cardiac services on average by 40 percent. This is unrelated to the current healthcare reform, which is planning an additional 21 percent reduction, effective March 1.''

In fact, none of the cuts are related to the healthcare reforms before Congress. They're Medicare actions required by existing laws in an attempt to moderate doctor pay while not going broke -- a painful issue that reveals how difficult any kind of reform can be when strongly entrenched interests disagree on what should be done.

In this case, the nation's outraged cardiologists filed a federal lawsuit in Miami and have persuaded 50 members of Congress to co-sponsor a bill to rescind the cuts.

Some healthcare experts like the cuts.

``I'm not at all sympathetic with the cardiologists,'' said Robert Berenson, a doctor who was once in charge of Medicare payment policy and now is a fellow with the Urban Institute. ``Studies show they make well over $400,000 a year'' -- more than twice what a family practice physician earns.

In fact, Medicare is reducing pay to cardiologists as part of a rebalancing plan in which primary care doctors will get a 7 percent increase. ``This system is much more fair,'' said Lori Heim, president of the American Academy of Family Physicians. ``It's not the savior for primary care, but it's a start.''

Heim finds it ``disingenuous'' that the cardiologists' letter blames reform proposals for their rate cuts.

Most of the cuts involve expensive imaging diagnostics, like $800 nuclear stress tests. Studies show that when physicians have expensive imaging machines in their office, they tend to prescribe far more tests.

That's particularly true in Florida, where a study by the Government Accountability Office, the investigative arm of Congress, found that in-office imaging per senior cost $472 in 2006 -- eight times more than in Vermont.

Still, cardiologists say the changes have been devastating. Manuel Abella, a cardiologist in a large group practice in West Kendall, said he and his colleagues have been forced to lay off 15 people, cut salaries 10 percent and eliminate health insurance.


``When a patient comes in and says he has chest pains, you have to have state-of-the-art technology,'' said Romeo Majano, one of the three South Miami cardiologists who sent the letter. ``These are basic tools of our trade, and it's imperative patients have access to them.''

``This technology has greatly improved care,'' said Jack Lowen, president of the American College of Cardiology. ``We've seen a 30 percent reduction in morbidity and mortality in heart disease over the past 10 years.''

``The most affected, of course, will be the patients,'' the South Miami cardiologists warned in their letter, ``as cardiologists will be either forced out of business or forced to drastically increase the number of patients seen, most likely with physician assistants or nurse practitioners to help manage the increased volume.''

The cardiologists say that if Medicare won't pay for, say, a nuclear stress test in a cardiologist's office, the patient will have the test performed at a hospital where it might cost three to five times as much.

Medicare spokeswoman Ellen Griffith said, ``It is difficult to compare payments head-to-head because services may not always be directly comparable.'' Hospitals often get paid more for a service because they must be open around-the-clock and by law must provide coverage for the uninsured in their emergency rooms.

Berenson at the Urban Institute looks at it this way: ``If the hospitals are getting paid too much, the answer is to reduce their payments.'' He doubted the cardiologists' threat of giving up Medicare patients, noting that oncologists made a similar threat several years ago when they saw certain payments taken away and it didn't bear out.

For years, Republicans were leaders in the movement to curtail soaring Medicare costs. Tommy Thompson, secretary of health and human services under President George W. Bush, has frequently given speeches that Medicare costs must be brought under control or aging baby boomers would bankrupt the plan.

But in recent months, as the reform debate intensified, Republican leaders warned that the proposed bills would cut seniors' benefits. A poll this month by the Kaiser Family Foundation found that 48 percent of those over 65 are opposed to the reform bills while 37 percent support them.

In fact, for the past 12 years, under the Clinton, Bush II and Obama administrations, Medicare has been ordered to find ways of curtail costs without reducing quality of care. The Balanced Budget Act of 1997 required physician payments by Medicare to be adjusted annually so that the program didn't go broke.

Every year since 2003, Congress has listened to doctors' complaints and halted pay cuts. Each postponed cut gets added to the next year's calculation and this year all doctors are facing a 21 percent reduction. Congress postponed the cuts until March 1, when they take effect unless lawmakers take action.

Meanwhile, Medicare made a second set of calculations -- about how to split up the budgetary pie among doctors. Both Republicans and Democrats have agreed for some time that primary care is a key to improved healthcare -- because these doctors can coordinate treatment and reduce unnecessary tests and repetitive care.

A 2009 study by Medpac, a federal group that studies Medicare costs, found that, even adjusted for severity of illness, cardiology patients going to a doctor with imaging equipment in his office were twice as likely to get a test as those seeing doctors with no equipment.

Going further, Medicare surveyed physicians about their costs. Based on those findings, Medicare decided to reduce overall payments to cardiologists by 13 percent over four years -- while payments for their imaging services were cut by 30 or 40 percent.


The ACC complained that the survey data for cardiologists was based on 55 interviews -- out of 20,000 in private practice. It called the resulting data ``patently erroneous and unreliable.'' When Medicare refused to budge, the ACC filed a lawsuit on Dec. 28.

The government argued that the courts did not have jurisdiction over a Medicare fee dispute. The judge agreed. The cardiologists have now gone to Congress, where lawmakers have a history of reversing Medicare pay cuts to pacify providers.

Griffith, the Medicare spokeswoman, said the agency is ``confident that the policies we have adopted are the most appropriate and will enhance overall access to physician services for beneficiaries. . . . If we find that there are unintended adverse consequences . . . we will have the opportunity to revisit them as part of the annual rule-making.''

Saturday, January 23, 2010

Should We Stop Healthcare Reform Now?

Should We Stop Healthcare Reform Now?

After the election in Massachusetts many predict the collapse of the health care reform efforts. President Obama seems to seek a scaled back version, which is acceptable for Republicans who are blocking ANY reform efforts. But why do we need health care reform NOW? Lets look at the facts: If nothing will happen healthcare spending will continue to outpace the growth in the rest of the domestic product by at least 2.5% annually. Despite the overall slowdown in national health spending growth in 2008, increases in this spending continue to outpace the growth in the resources needed to pay for it! At that rate health spending will absorb 40% of GDP by 2050! The suggested reform proposal will provide 30 Million uninsured Americans adequate coverage requiring about $800 Billion to $1 Trillion in federal subsidies over the next decade. This represents only 3% of the $35 Trillion projected by actuaries to be spent on U.S. health care in the coming decade in the ABSENCE of reform. The relatively small $ 1 Trillion investment in preventing the surge of neglected chronic disease will save Trillions of healthcare dollars normally spent for the emergency room care needed to serve the growing numbers of uninsured! We need to invest money in order to save money!!!
Furthermore, health care insurance companies know very well that the initial rise in health care stocks, on expectations that the Massachusetts’s vote might derail health care reform, may symbolize a pyrrhic victory only! Even though, the reform package included mandated coverage for everyone, regardless of health status, it also offered to heavily subsidize the health care for 30 million Americans who are currently uninsured. This potential financial windfall may not materialize. Insurance companies are very well aware that selling insurance package to employers has slowed because of rising premiums, which reflect rising health care expenditures. The insurance companies must have an interest to bend the cost curve and to expand insurance coverage to offer competitive products. Insurers may gamble with their financial future by supporting the Naysayer because without an overhaul of the insurance industry and the health care market they may face an even bleaker future, which will force draconian government intervention to cut costs.
Therefore, we must support rational reform efforts and President Obama should stop pandering to the opponents of any meaningful reform efforts. We have to act now to avoid a future financial crisis!

Bernd Wollschlaeger,MD,FAAFP,FASAM

Monday, January 18, 2010

What can we learn from Israel's efforts in Haiti?

Attached a video link to a CNN report contrasting Israels disaster response in Haiti with the US response.
In the words of Dr.DiGennaro, a Broward county physician, "it makes you almost embarrassed being an American."
Currently, the Israelis run the only fully functioning hospital in Haiti!
Its another example that we fail to understand that disaster and emergency preparedness is not measured by the amount of $$ we throw at the problem AFTER the fact but to continuously prepare and train teams of professionals in emergency and disaster response measures.This does not require a lot of money but dedicated leadership and commitment!
In 2006 I have witnessed the training of the Israeli team on a military base and participated in multiple training sessions myself. I can attest to the fact that they have mastered the art of perfection; each step is documented in a manual and everyone knows how to work in a team and per checklist.
Why we can't do it here? Because we are talking the talk instead of walking the walk. In October 2001 I was appointed by then Governor Bush to the Emergency and Disaster Preparedness Taskforce and urged on multiple occasions to follow the Israeli model. Nothing happened. Yes, we have special teams but too few and far apart. We need local teams that train on a quarterly basis and manage their own equipment and supplies. Do we need to learn another painful lesson from the next natural disaster or do we have to memorize the phone # of the Israeli team instead?
Kudos to their bravery and tireless efforts.