Earmarks and P4P

"Medicare now pays the same amount regardless of quality .... even rewards poor quality,paying doctors to treat complications caused by their own mistakes."
Senators Charles E. Grassley, Republican of Iowa, the outgoing chairman of the Senate Finance Committee

“I am very skeptical of pay-for-performance. I’m not sure we can measure quality and performance that well."
Representative Henry A. Waxman, Democrat from California


Dear Friends and Colleagues:
Attached two recent articles from the New York Times highlighting two important issues: 1) last minute insertion of earmarks or special provisions into bills that favor pet projects for certain constituencies , 2) Pay-For-Quality measures in Medicare bill.


1) Earmarks or special provisions are increasing in an exponential fashion.Whereas Congress spent $10 billion on 1,439 such projects in 1995, it ran ran up $27.3 billion for a record 13,997 such projects last year, according to the nonpartisan Citizens Against Government Waste.
That means that our tax money is being used to satisfy the insatiable appetite of congress to funnel money away from budgeted projects to please local constituents. Medicares budget serves just as one example how precious resources are being squandered by politicians.Unfortunately, payment to doctors are being cut year by ear, if one takes inflation and increased practice expenditures into consideration. What can we do? Ally with our patients to point out those abuse by politicians and their financial backers and target them in the media. Lets not forget that doctors are also have their lobby in Washington, but we need to align our interests with the public to promote public health and not only our financial well being.


2) After averting a major pay cut, doctors have to prepare themselves for the next challenge: Pay-for-Quality. Now, doctors can qualify for a 1.5 percent bonus in the second half of 2007 if they report data on the quality of their care, using measures specified by the government. For example, doctors could be asked to report how often they prescribe a particular drug after a heart attack or how well they control blood pressure in patients with diabetes.Beyond broader questions about whether the government can accurately measure the quality of care, many are concerned about the feasibility of developing standards for hundreds of thousands of doctors within six months. The quality reporting system begins on July 1.
In a recent speech to the American Medical Association, Dr. Scott Gottlieb, deputy commissioner of the Food and Drug Administration, said he worried about intrusions into the practice of medicine by federal agencies, including his own.
We have several choices left: boycott Medicare and opt-out of the system or insist that we ONLY participate in such quality assessment program if they criteria are being developed with our significant input.
In my opinion, we cannot objectively measure quality in the ambulatory setting, unless we have tools i.e. medical information technology available and successfully implemented in the clinical practice. Then we should start with pilot projects to validate the feasibility of those assessments including outcome measures.
At this moment I think our elected politicians FROM BOTH PARTIES are shoveling those P4P measures down our throat.
My tip: don't swallow.
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December 15, 2006
Last-Minute Inserts Offer Benefits in Medicare Bill
By ROBERT PEAR

WASHINGTON, Dec. 14 — By slipping four sentences into a big bill passed last week, Speaker J. Dennis Hastert secured a major change in Medicare policy avidly sought by a few health insurers, in particular a multinational company with headquarters in his home state, Illinois.

In the final hours of the 109th Congress, the Senate Democratic leader, Harry Reid of Nevada, also got special treatment for a hospice in his state. The bill did not name the hospice, but specified the Medicare provider number for the intended beneficiary, the Nathan Adelson Hospice in rural Pahrump, Nev.

Representative Bill Thomas, Republican of California, inserted a provision earmarking $40 million for a valley fever vaccine sought by his constituents, while the Senate Republican leader, Bill Frist of Tennessee, obtained tens of millions of dollars for hospitals in his state.

These examples illustrate how power is exercised in the final, chaotic hours before Congress adjourns. Obscure provisions of interest to just a few lawmakers were quietly stuffed into a grab bag of legislation, with no indication of their parentage or purpose.

The White House has indicated that President Bush will sign the bill, which deals not only with health care but also with a variety of tax and trade issues. The bill, for example, creates a special tax depreciation allowance for property used to produce ethanol from corn stalks, regulates the use of wine names like Champagne and Chablis, and suspends the tariff on imported rayon fibers used in making certain tampons.

Mr. Hastert’s provision showed up mysteriously after House and Senate negotiators had finished writing the bill. The provision was added by the House Rules Committee, just a few hours before the bill went to the House floor last week.

Congressional aides, Medicare officials and insurance lobbyists said the main proponent of the measure was the Aon Corporation and its subsidiary, Sterling Life Insurance Company. Aon, a Fortune 500 company, is based in Chicago and does business in more than 120 countries.

Under current law, Medicare beneficiaries can sign up for a prescription drug plan or a private Medicare Advantage plan from Nov. 15 to Dec. 31 each year. They have a limited ability to make changes through March 31 and are generally locked in for the remainder of the year.

Mr. Hastert’s amendment permits certain Medicare Advantage plans, like Aon’s, to enroll people throughout the year. Ron Bonjean, a spokesman for Mr. Hastert, said the purpose was “to get more people enrolled in Medicare Advantage plans.” Al Orendorff, a spokesman for Aon, said, “We are not going to comment.”

The provision could benefit several other insurers, but Larry Oday, a lawyer and lobbyist for Aon, said the company was “actively involved in consideration of this piece of legislation” and had led opposition to the lock-in requirement.

The addition of the provision infuriated Senate negotiators from both parties.

Senator Charles E. Grassley, the Iowa Republican who is chairman of the Senate Finance Committee, said the provision did not go through the regular legislative process.

“It disturbs me that this major policy change — one that treats some plans unfairly — was included at the last minute by the House Rules Committee,” Mr. Grassley said.

The senior Democrat on the Finance Committee, Senator Max Baucus of Montana, said: “I soundly rejected this proposal during negotiations with our House colleagues. They were clearly informed of my position. Our final agreement did not include this provision.”

Mr. Reid’s amendment provided $3.8 million in relief to the Nathan Adelson Hospice. Medicare officials said they had overpaid the hospice and were trying to recover that amount.

Mr. Reid said the legislation would overturn “a flawed administrative ruling” by the federal Centers for Medicare and Medicaid Services. The legislation retroactively designates the Adelson hospice in Pahrump as a branch of one in Las Vegas, making more money available.

Hospice trustees used their influence with the state’s Congressional delegation, and the hospice retained a Washington law firm, Hogan & Hartson. But Carole A. Fisher, president of the hospice, said Mr. Reid and Nevada’s Republican senator, John Ensign, “were the real champions of our cause, who ensured that we got relief from our Medicare debt.”

In Tennessee, hospitals estimate that they will get at least $131 million because of the provision added by Mr. Frist, who is retiring from the Senate next month. The money will go to about 90 hospitals serving disproportionate numbers of low-income Medicaid patients and people without insurance.

Craig A. Becker, president of the Tennessee Hospital Association, said his organization had received help from an influential Washington lobbyist: Thomas A. Scully, former administrator of the Centers for Medicare and Medicaid Services, who is now a lawyer at Alston & Bird.

The same section of the bill provides $10 million for hospitals in Hawaii. That state’s senators, Daniel K. Akaka and Daniel K. Inouye, both Democrats, have been trying to get such an allotment for years.

Hawaii, like Tennessee, is exempted from many requirements of the federal Medicaid law because of a waiver granted by federal officials. The waivers give the states a great deal of freedom in setting eligibility and benefits, but do not provide the extra money available to other states for hospitals serving large numbers of poor people.

In seeking money for a vaccine against valley fever, Mr. Thomas said he was addressing a serious health problem caused by inhalation of a soil-borne fungus in southwestern states.

“The disease is especially prevalent in Kern County, Calif., which I represent,” Mr. Thomas said. “Unfortunately, there is no vaccine for valley fever, and there is no private industry interest in making the investment, estimated at $40 million, needed for development of the vaccine.”

Among those seeking the legislation was Sandra P. Larson, executive director of the Valley Fever Americas Foundation in Bakersfield, Calif. “Thomas is the guy who got this done for us,” Ms. Larson said. “We are so appreciative.”

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December 12, 2006
Medicare Links Doctors’ Pay to Practices
By ROBERT PEAR

WASHINGTON, Dec. 11 — After years of trying to rein in the runaway cost of the Medicare program, Congress has decided to use a carrot instead of a stick to change doctors’ behavior.

Doctors had been fearing a pay cut under Medicare, the health care program for 43 million elderly and disabled, but Congress instead has offered doctors a small bonus with big strings attached. To get the money, doctors will have to report how often they provide quality care, as defined by the government.

Lawmakers approved the change as one of their final acts before adjourning early Saturday morning, and proponents said it would improve the quality of medical care.

But the plan immediately raised concerns among some doctors and lawmakers who specialize in health issues. They said they worried that it could be a step toward cookbook medicine and could erode the professional autonomy of doctors.

Doctors had been facing a 5 percent cut in Medicare payments in 2007. Congress deferred the cut, freezing doctors’ payment rates instead.

Now, doctors can qualify for a 1.5 percent bonus in the second half of 2007 if they report data on the quality of their care, using measures specified by the government. For example, doctors could be asked to report how often they prescribe a particular drug after a heart attack or how well they control blood pressure in patients with diabetes.

With these statistics, Medicare officials say, they will , in the near future, be able to reward doctors who follow clinical guidelines and perhaps penalize those who flout such standards without justification.

For several years, Medicare officials have advocated a pay-for-performance system, noting wide regional variations in the practices of hospitals and medical specialists. The idea was supported by the Bush administration and by Senators Charles E. Grassley, Republican of Iowa, the chairman of the Finance Committee, and Max Baucus, the Montana Democrat who will be chairman next year.

“Medicare now pays the same amount regardless of quality,” Mr. Grassley said. Indeed, he said, Medicare “rewards poor quality,” paying doctors to treat complications caused by their own mistakes.

But some influential Democrats, and even some administration officials and Republicans who support the general idea of pay-for-performance, expressed concern with federal agencies setting benchmarks for care.

“This is a very significant step,” Catherine G. Cohen, vice president of the American Academy of Ophthalmology, said Monday. “It’s the first time Medicare has ever paid individual doctors a differential for reporting quality measures. It could impose a significant new burden on doctors’ offices.”

The legislation has created strange bedfellows.

Some doctors, health policy experts and politicians, including liberals like Representative Henry A. Waxman and conservatives like Robert E. Moffit, director of health policy studies at the Heritage Foundation, are apprehensive. Beyond broader questions about whether the government can accurately measure the quality of care, they are concerned about the feasibility of developing standards for hundreds of thousands of doctors within six months. The quality reporting system begins on July 1.

In an interview, Mr. Waxman, a California Democrat who has been working on health policy for more than three decades, said: “I am very skeptical of pay-for-performance. I’m not sure we can measure quality and performance that well.”

Representative Pete Stark of California, who will become chairman of the Ways and Means Subcommittee on Health in January, said, “The entire concept of pay-for-performance is offensive.” Doctors, Mr. Stark said, are supposed to provide “quality care” and should not be paid extra for doing so.

Moreover, he said, federal officials “do not have the capability, the understanding, the knowledge or the training” to set standards for the quality of care.

Representative Charlie Norwood, Republican of Georgia, led efforts to enact a “patients’ bill of rights,” saying insurance companies should not tell doctors how to practice medicine. He objects just as much to government efforts to define quality.

“When government bureaucrats determine what good medicine is, instead of patients and doctors, I get very suspicious,” said Mr. Norwood, a dentist.

The administration says Medicare should not simply pay for more services, but should reward doctors for efficiency and high-quality care.

Representative Nancy L. Johnson, Republican of Connecticut, also championed the idea of pay-for-performance. But in an interview, Mrs. Johnson said she was disappointed that Congress had not gone further to ensure that doctors would develop the criteria for measuring quality. “Bureaucrats must never be allowed to dictate medical practice,” she said.

This concern is shared by some administration officials. In a recent speech to the American Medical Association, Dr. Scott Gottlieb, deputy commissioner of the Food and Drug Administration, said he worried about intrusions into the practice of medicine by federal agencies, including his own.

The original Medicare law, passed in 1965, said, “Nothing in this title shall be construed to authorize any federal officer or employee to exercise any supervision or control over the practice of medicine.”

Mr. Moffit of the Heritage Foundation said the new initiative was “a backdoor attempt to repeal” this guarantee.

“It’s pay for compliance, not pay for performance,” Mr. Moffit said. “Doctors will be financially pressured to comply with government guidelines and standards. The integrity and independence of the medical profession could be compromised.”

Dr. Stephen C. Albrecht, a family doctor in Olympia, Wash., said Monday: “Medicare has a good idea here, but has not put much money behind it. The 1.5 percent bonus does not justify the extra effort required to do the quality reporting that the government wants.”

Some doctors, like anesthesiologists and thoracic surgeons, have been eager to develop their own quality measures.

Over the last 17 years, the Society of Thoracic Surgeons has collected demographic and clinical data on three million patients. Doctors say they have used the data to improve the quality of care.

Dr. Frederick L. Grover, president of the Society of Thoracic Surgeons, said, “We have provided feedback to doctors, comparing their performance with state and national benchmarks, and in this way we have significantly reduced mortality and complications.”

When possible, Medicare officials are supposed to use “quality measures” that have been endorsed by the private sector.

Despite the move toward pay-for-performance, Medicare payments to doctors are unlikely to keep pace with inflation. Congress postponed for one year a cut in fees but did not change the Medicare law’s formula for computing payments to doctors. They face an even bigger cut next year, in the range of 5 percent to 10 percent, ensuring that Congress will have to revisit the issue.

Representative Stark said, “Doctors and others who like pay-for-performance have to remember that it’s a zero-sum game.” As a result, he said, most doctors will have to accept lower fees if Medicare is to pay bonuses to the best performers.

Dr. Frank G. Opelka, a surgeon at the Louisiana State University School of Medicine in New Orleans, said: “We fully support the goal of enhancing the quality of care, but this is a new program. It will take some time to get broad acceptance by physicia