Sunday, August 22, 2010

FMA Off Base Fighting Reform

The recently published OpEd succinctly characterizes the Florida Medical Association's policy vis-a-vis healthcare reform.
The authors concluded that
"The FMA's challenge to the AMA was the old guard denouncing the new. But the new way is what mainstream patients, doctors and the people who pay the bills for care desperately need. It is coming, and the FMA should get on board or out of the way."
In a NEJM (N Engl J Med 2009;360: 2495-2497) article Fisher et al clearly defines the positions we as physicians can take.
“ In the face of this uncertainty, physicians have a choice: to wait and see what happens or to lead the change our country needs. We'd prefer the latter....Physicians can become our most credible and effective leaders of progress toward a new world of coordinated, sensible, outcome-oriented care in which they and their communities will be far better off. Defending the status quo is a bankrupt plan, and physicians have an opportunity to help us all see beyond it."
I wholeheartedly agree with this conclusion.

Guest column: Florida Medical Association is off base fighting reform

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At an Orlando meeting last week, Florida Medical Association members fumed that their parent, the American Medical Association, isn't adequately representing Florida's private practice doctors.

After talk of secession, they settled for writing a stern letter urging the AMA to straighten up.

The FMA dustup began with a resolution written by Douglas Stevens, a Fort Myers cosmetic surgeon - you can't make this stuff up - complaining that the AMA's support for recent reforms was "a severe intrusion in the patient-physician relationship and allows government control over essentially all aspects of medical care."

He wrote that it will "relegate physicians to the role of government employees ... and essentially end the profession of medicine as we know it."

A St. Petersburg neurological surgeon, David McKalip, added that without AMA support, reform would have died.

Well, no. Stevens might have had two reform provisions in mind.

One uses subsidies to encourage doctors to obtain electronic health record technologies, so patient information can be easily exchanged and unnecessary or redundant services can be reduced.

Some data would be submitted to a federal repository, so doctors can better understand how effectively they practice compared to their peers and how to improve if needed.

Of course, physicians opposed to these rules could opt to avoid patients whose care is paid for with public dollars. But we think most doctors will welcome the opportunity to modernize their care.

The second bone of contention was a well-intentioned but flawed 1997 Medicare formula, the Sustainable Growth Rate, which tied physician payments to the growth of the U.S. economy. If Medicare physician spending exceeded the target in one year, then payment the following year would be reduced.

But every year, Congress has delayed the payment reductions. Now, in 2010, the accumulated cuts would be 21.2 percent.

Congress is reluctant to spend the additional $200 billion to forgive the cuts. American specialists, who make triple the salaries of their primary care colleagues, are bound to see smaller Medicare checks.

In the past, we've had many differences with the AMA, which was often more focused on physicians and their economic prosperity than on patients and theirs, especially as health insurance costs relentlessly grew four times faster than the economy.

Through a specialist-dominated reimbursement advisory committee, the AMA urged Congress to pay specialists more at the expense of primary care physicians. So it is not far-fetched to lay much of the current health care cost crisis at the AMA's feet.

But recently, the AMA became more progressive. It mounted a three-year campaign for universal coverage. It supported government's efforts to reward the meaningful use of modern computerized tools and the best medical science in clinical practice.

They are incredibly important to us, but over the last half century, American physicians have been handsomely, even often excessively, rewarded.

But now, the system that has been hugely wasteful must find ways to reduce costs while improving quality, and make sure that care is accessible to everyone. These imperatives are emerging just as data and information tools are becoming more available. Health care will become more like a market than before.

Medical practice is changing profoundly, mostly for the better. Doctors will still be highly valued, but many may earn less.

The FMA's challenge to the AMA was the old guard denouncing the new. But the new way is what mainstream patients, doctors and the people who pay the bills for care desperately need.

It is coming, and the FMA should get on board or out of the way.

Brian Klepper of Atlantic Beach and David Kibbe, a physician from Chapel Hill, N.C., write on health care policy, market dynamics and technology.

Monday, August 16, 2010

Medicare Conundrum

I highly recommend reading an article published in AMA NEWS entitled, "Medicare trustees' upbeat outlook relies on big pay cuts for doctors, Aug. 16, 2010."
In the 2010 Medicare trustees report the trustees said Medicare savings that are included in the overhaul will extend the insolvency date of Medicare's hospital trust fund to 2029, 12 years beyond the point that last year's report said Part A would run out of money.Medicare Part B does not face insolvency because it is funded by a combination of general tax revenues and beneficiary premiums. Expenditures on outpatient care grew at an average annual rate of 8.3% during the past five years, exceeding gross domestic product growth by 4.2 percentage points annually, on average. Projected annual spending growth for Part B is estimated to average only 5.3% during the next five years, about the same as the GDP growth rate, the report said. But this assumes deep physician pay cuts will take effect. Unless Congress steps in, physician rates are scheduled to decline 23% on Dec. 1, an additional 6.5% in January 2011 and 2.9% in 2012.
Medicare Part B spending now approximates 1.5% of the GDP, the report said. Last year's report projected that figure would increase to 4.5% by the end of the trustees' 75-year projection. With the new law, it is now projected to reach only 2.5% of GDP by the end of the long-term window.Preventing rate cuts to doctors would increase that estimate, as would a failure to realize long-term savings envisioned under reform.
What does this mean for physicians?

* We need to focus on the implementation of new care models, such as patient-centered medical homes, accountable care organizations.
* We should expect and prepare for payment bundling and pay-for-performance.
* We should deploy and apply systems that help us to measure, optimize and improve productivity.

Unfortunately, many of us will prefer to resist and protest the inevitable change. In my opinion responsible physician leaders should prepare their membership for and guide them towards meeting the new challenges of a more complex healthcare delivery system by using finite (financial) resources.


Sunday, August 15, 2010

Impaired Physicians

In a recently published article " Physicians reluctant to report impaired colleagues, study says,"( the author summarizes the findings of a national survey of 2,000 physicians. The survey results were published in the July 14th edition of JAMA " Physicians' Perceptions, Preparedness for Reporting, and Experiences Related to Impaired and Incompetent Colleagues."
Unfortunately, the key findings are troubling:

* Just 64% of physicians completely agreed that they had an obligation to report all impaired or incompetent doctors. The rest of the physicians either "somewhat agreed" that they were obliged to report problem colleagues or disagreed that they had such a responsibility.
* The most common reason for not reporting incompetent or impaired colleagues was physicians "thought someone else was taking care of the problem," the study said. Some physicians said reporting would be fruitless, while 12% feared retribution.

Only 17% of respondents had direct knowledge of an impaired or incompetent physician. The question remains if this is due to ignorance or choice.
What can we do? Doctors need to be better educated on how to report problem colleagues and their ethical responsibility to do so. Those who do report should be kept in the loop on how a colleague's case is progressing, and that the reporting process should be confidential.
Looking forward to your comments.

Barriers to Reporting:

Two-thirds of physicians with direct knowledge of an impaired or incompetent physician colleague reported them to a medical board, hospital, clinic, professional society or other body. Of doctors who didn't report:

19% thought someone else was taking care of the problem.

15% believed nothing would happen as a result of the report.

12% feared retribution.

10% believed it was not their responsibility.

9% believed the person would be excessively punished.

8% did not know how to report.

8% believed it easily could happen to them.

Note: respondents could answer "yes" to more than one reason.

Source: "Physicians' Perceptions, Preparedness for Reporting, and Experiences Related to Impaired and Incompetent Colleagues," Journal of the American Medical Association, July 14 (