Tuesday, the Senate Finance Committee hosted the first of three roundtable discussions on health care reform. This session honed in on reimbursement and delivery reform; future roundtables will focus on expanding health coverage to all Americans (May 5) and financing health care reform. (May 14). (Many thanks to reader Brad F. for calling my attention to a report on the roundtable.)
“Medicare is the big driver here,” declared Finance Chair Max Baucus (D-MT), and “How to scale it up” will be one of the key questions, he said, but “Medicare will be a big part of that solution.”
As I have suggested in the past, Medicare is likely to become the place where policymakers can experiment with wringing some of the waste out of our health care system, so that we can provide affordable, sustainable, highly effective care for everyone. In fact, Medicare already has embarked on pilot projects that provide incentives for health care providers to collaborate and become more efficient. The projects that work are likely to be expanded and become part of national health care; those that don’t work can be quickly discarded. During the roundtable discussion, many suggested that Medicare needs more freedom to innovate, additional funds, and a mandate to launch more pilot projects. Ultimately, a new, improved Medicare could become a model for a public insurance option. National health care reform does not have to wait on Medicare reform; I suspect that policy-makers will be working on both, simultaneously, over the course of President Obama’s first term.
Medicare to Reward Those Who Use Comparative Effectiveness Information
Reporting on the discussion, InsideHealthPolicy.com noted that “Many on the panel suggested that Medicare will be the fulcrum that enables health reform to move forward. They said this will have to come, however, with expanded authority and more money for CMS. [Centers for Medicare and Medicaid Services.]
“One theme throughout the testimony was that policymakers need to find out what works through comparative effectiveness research, then either require or reward doctors and patients who follow the evidence-based medicine to improve quality, lower costs and improve outcomes.”
As I’ve discussed in the past here and here the Congressional Budget Office made it clear in its January report that comparative effectiveness research could lead to significant savings —if it is given financial teeth. A program rewarding doctors and patients who choose the most effectiveness treatments would more than pay for itself since often (but not always) the most effective treatments will not be the most expensive. Costly new drugs, devices and procedures become popular, not because they are better than the older products and services they are replacing (we rarely run head-to-head comparisons of alternative treatments), but because they have been hyped, by the manufacturer, the sponsor, or the media. Unfortunately, it is all too easy persuade patients—and even some physicians and hospitals—that what is newest and most expensive must be “best” for all patients.
During the roundtable discussion, Glenn Steele, president of the Geisinger Health System in Danville, PA agreed that “the leverage is in Medicare.” According to InsideHealthPolicy.com, “he explained that delivery and reimbursements reforms should be slowly phased in and take the form of numerous ‘patient-focused goals’ in the ‘highest utilization areas’ — which include chronic obstructive pulmonary disease, diabetes and heart disease. A deadline for achieving the goals should be set in law and resources should go to crafting metrics that can track quality and value improvements in high-cost illnesses.”
‘And if you don't get there in three to five years, maybe there should be a Plan B, that is something that is a lot more onerous,’ Steele said. ‘That Plan B should be pretty motivating.’
“Pressed by Baucus about details about Plan B, Steele said ‘I'm not willing to say,’ adding that ‘we can talk about Plan B later.’
‘Sometimes,’ Baucus said, ‘a very sobering Plan B will encourage Plan A’. InsideHealthPolicy.com notes that “Much nervous laughter followed from provider, hospital and other stakeholders who realize how difficult improving patient health is.”
But in his opening address, Baucus made it clear that simply covering everyone is not enough; U.S. healthcare requires structural reforms: “The U.S. health system scores 65 out of 100 on indicators of health outcomes, quality, access, equity, and efficiency. And we know from previous research that adults receive recommended care only about half of the time. [And these are adults who have access to care.] We have the opportunity to modernize our outdated payment systems. Those payment systems encourage the delivery of more care, rather than better care.”
Geisinger’s Example: Bundling Payments, Hospital Eats its Mistakes
Steele knows it can be done. In his written testimony, he described how Geisinger, an integrated health care organization located in central and northeastern Pennsylvania, has cut costs while raising the quality of care. It’s worth noting that Geisinger is a provider that also offers a health care insurance product (Geisinger Health Plan) and that it serves a population that is poorer, older and sicker than the national average. Many of its patients suffer from multiple chronic diseases, such as diabetes, high blood pressure and lung disease. Nevertheless, Geisinger has made real strides in improving outcomes.
For example, “Our cardiology service line reviewed the American Heart Association and the American College of Cardiology guidelines for cardiac surgery and translated these into 40 verifiable best practice
steps that we could implement with each patient undergoing this surgery,” says Steele. “We hardwired these into our electronic health record so that we would be prompted to meet each identified step – or document the specific reason for any exception. ” This serves as an excellent example of how “best practice” guidelines can live leave room for variation when treating individual patients.
“We then established a package price that included costs of the first physician visit when surgery was deemed necessary, all hospital costs for the surgery, and related care for 90-days after surgery, including cardiac rehabilitation,” Steele explained. “We named this program “ProvenCare,” since it is based on evidence or consensus of best practices by our heart experts. Pre-operative, postoperative and rehabilitation are part of the single charge. And we take the financial responsibility for any associated complications and their treatment.”
In other words, if a patient has to stay longer in the hospital because he acquired an infection, if he has to be re-admitted for any reason, or needs more rehabilitation than the average patient, there is no extra charge.
“While our cardiac surgery outcome was already well above the national average (and near the top of Pennsylvania’s PHC4 data set) upon initiation of this program only 59% of patients received all 40 best practice steps.” (This is one example of how, in the current system, U.S. patients receive the recommended care only about half the time, even at a good hospital.) “Three months into the study, 86% were receiving best care. We raised that to 100% and, with few exceptions, have kept it at that high rate”
Steele reports that Geisinger expanded on “its experience with heart surgery to ‘warranty’ programs that include: hip replacement, cataract surgery, obesity surgery, prenatal care for babies and mothers (supported by the March of Dimes) – from an infant’s conception to birth . . . As a result of implementing this “warranty” program, our patient care was better – using comparative, standardized data from the Society of Thoracic Surgery. We had a reduction in all complications of 21%, sternal infections were down 25%, and re-admissions fell by 44%. Costs for treatment fell, too. Our average length of hospital stay decreased by half a day.
Many hospitals would argue that they cannot afford to offer warranties—mistakes happen, they argue, and with Medicare reimbursements so low, how could they afford to “eat” their errors? In fact, as the Medicare Payment Advisory Commission pointed out in its March 2008 report, some hospitals do make a profit on Medicare reimbursements: “hospital costs [what it costs a hospital to treat a patient] and Medicare profitability vary widely. Some hospitals are efficient enough to have low costs, positive Medicare margins, and high quality scores.”
And this isn’t an accident; researchers at Dartmouth have shown, again and again, a hospital that spends less while treating a patient usually offe
rs better care. The more efficient hospital gets the diagnosis right in the first place, and hospital errors are fewer. In short, lower cost and higher quality go hand in hand.
But the MedPac report notes, inefficient hospitals are able to stay in business because private insurers pay more (and pass the higher reimbursements on to their customers in the form of higher premiums. Thus sloppier hospitals “often face little financial pressure to control their costs. Medicare should encourage hospitals to be efficient,” the report adds, “rather than accommodating high cost-growth resulting from lack of financial pressure.”
Of course, some hospitals truly are under financial pressure. These tend to be institutions that care for a large number of uninsured and Medicaid patients. And there is no question that, unlike Medicare, Medicaid underpays all providers. But many hospitals that grouse about Medicare reimbursements are not treating large numbers of poor patients; instead they are paying the hospital CEO $9 million while embarking on lavish construction projects.
As MedPac points out in that 2008 report: “Spending on hospital construction has risen substantially in recent years—with increases averaging almost 20 percent in the past two years. For the second year in a row, the median values of many financial indicators (e.g., days cash on hand and measures of debt service coverage) were among the best ever recorded. This ready access to capital indicates that revenue is sufficient to give the capital markets confidence in the creditworthiness of the industry”.
The whole notion that hospital reimbursement should be based on what a hospital reports that it “costs” that hospital to care for a patient is fundamentally flawed. It means that inefficient hospitals are rewarded for being not trying to reduce waste. For example, we know that when a patient is treated at UCLA , Medicare winds up spending 50% more than when a very similar patient is treated at the Mayo Clinic. And outcomes are better at Mayo. No doubt, UCLA is among the many hospitals that complain that Medicare reimbursements are too low—probably UCLA does not make a profit on most Medicare patients. But would it make any sense to hike Medicare payments simply because UCLA, in contrast to the Mayo Clinic and Geisinger, has not figured out how to deliver better value for our health care dollars?
By offering warranties that it will not charge more even if there are complications, Geisinger put itself under pressure—and proved that it could trim how much it to care for a patient, while simultaneously reducing complications and infections.
Geisinger also took a close look at “other high volume, hospital-based treatments” Steele reports. “For instance, in orthopedic surgery, why should one doctor use one set of surgical instruments and prosthetic devices and another insist on a different instrument set-up for the same procedure? That type of variation often has no medical justification, results in unnecessary costs that are passed off to third party payers (such as Medicare) and, we believe, compromises patient outcome.” Moreover, when each surgeon picks the prosthetic device he prefers, this opens the door for device-makers to pay “kickbacks” to physicians who choose their device.
Medicare Will Raise Payments to Some Doctors
Recently some pundits have argued that if we have a public sector insurance plan that models itself on Medicare, it will be cheaper than private insurance because it will pay doctors so much less. As a result, many doctors will refuse to participate in “Medicare E” (Medicare for Everyone) and the public sector alternative will become a second-tier program for the middle-class, offering a very limited choice of doctors.
The truth is that while Medicare underpays some doctors, it overpays other doctors—and Medicare plans to hike reimbursements to underpaid doctors very soon. President Obama’s budget does not include the across-the board cuts in Medicare payments to physicians that are scheduled for this January The administration knows that Congress will not slash fees–nor does it want legislators to use such a crude tool to contain spending.
As White House budget director Peter Orszag has said: "We want to work with the Congress to get a better system of providing incentives for doctors to provide high-quality care rather than just more care." He suggested that better rewarding primary care doctors and more closely examining specialist spending could be in order. Sen. Baucus agrees, saying that “revising Medicare's physician pay formula” is “a top priority” this year.
At yesterday’s Finance Committee Roundtable, Medpac Commission Chair Glenn Hackbarth reiterated the theme, recommending that Congress should both increase the level of reimbursement for primary care physicians and the method by which they are paid for their services. “The commission has recommended bonus payments for primary care-focused physicians, but also lump sum payments per-patient for the medical home model,” Hackbarth observed. “We have abundant research that shows strong primary care is essential for a well-functioning, high-performing health care system. As you know all too well, primary care in the United States is weak and, unfortunately, getting weaker. That is a key priority.” Hackbarth also supported Medicares efforts to increase payments for Evaluation and Management services and to “better value” all services. This means that family practitioners, pediatricians and others who provide preventive care and chronic disease management over time are likely to be in line for increases, while others will see fees reduced for less valuable services—services that provide less benefit to patients.
If Congress shows some spine (and when it comes to Medicare, I remain hopeful), it will let Medicare follow MedPac’s advice and adjust the physician pay schedule in a “budget neutral” way. This means that while some doctors toward the bottom of the income ladder will see reimbursements rise, others will see fees for certain services cut. MedPac has suggested that Medicare take a close look at services where volume is high—often this means that the service is particularly lucrative, which can lead to overtreatment. Experience show that if fees for such services are lowered, volume will drop, saving Medicare money, and sparing patients who would have undergone unnecessary tests and procedures.
Granted, sub-specialists will be up in arms—in fact, the protest already has begun. But while they will rail against fee cuts, is unlikely that a large number will refuse to take Medicare patients. Even in Manhattan, while many primary doctors have stopped taking new Medicare patients, it is quite easy to find specialists who take Medicare. And even if fees for certain services are trimmed, a specialist now earning $600,000 still will be making a comfortable living if he finds that his income falls to $575,000. . Meanwhile, if that $25,000 turns into a pay increase and a bonus for a family practitioner now making $125,000, the extra $25,000 will represent a meaningful jump in her inc
ome—enough, perhaps, to make her think twice about switching specialties. (Today, a fair share of physicians who start out in primary care wind up becoming dermatologists, radiologists . . . you name it.)
These are, of course, only hypothetical numbers, but the point is that some redistribution of Medicare dollars is warranted, and the loss for a high-income physician should feel smaller than the gain for a physician at the bottom of the pay scale. Moreover, while some doctors train longer than others, and some specialties require unique stamina and skills, it makes no sense for some physicians to earn four and five times as much as others, year after year, for thirty years. (At what point do you stop paying for the extra three years of training?) Such wide disparities in physician pay are unheard of in other countries. (As I’ve explained here specialists’ fees are so much higher in the U.S. because Medicare’s fee schedule is adjusted, behind closed doors, by a committee composed largely of specialists. )
All in all, the Senate Finance Committee’s discussion produced some excellent ideas. Powerful voices were saying sensible things at the right time and in the right place. There is just one catch: will conservatives balk at funding Medicare reform? According to InsideHealthPolicy.com, the question of money began to divide the room: “There was a clear tension felt by many Republicans on the panel about the level of spending involved in real, sea change-like, innovations.”
Yet a sea-change is what we need if we are to improve health and make U.S. health care affordable. To refuse to pay for needed changes in Medicare delivery and reimbursement is to ensure that fee-for-service Medicare continues to squander health care dollars–while providing the treatment patients need only about half of the time. But if you are a conservative who would like to see Medicare “privatized” (i.e. turned over to the for-profit insurance industry) then the idea of traditional Medicare going broke while the quality of care heads south has a certain appeal.
Stay tuned for the May 14 Senate Finance Committee Roundtable on financing reform.
We need not search far for a model reform plan with a REAL public option – built around expansion of a state employee insurance pool.
In Connecticut, where we have more than 325,000 uninsured, HB6600, or “SustiNet,” just got another favorable report from a second state legislative committee and is gaining momentum.
SustiNet ensures that the state wisely uses the dollars it is already spending on state employees, HUSKY (for low-income children) and SAGA by uniting them into a large self-insured health plan.
SustiNet (which is Latin for “sustains” and is taken from our state motto) uses this critical mass of insured residents to improve the health care delivery system (with cost savings) and to phase in the enrollment of more residents of Connecticut, including: the uninsured; people with unaffordable or inadequate insurance; sole proprietors and other self-employed people; small businesses, municipalities, and non-profit employers; and, finally, businesses of any size.
By a “real” public option, I mean that EVERYONE in the state will have quality, affordable health care. If they are employed and their employer isn’t offering insurance that gets them that care, then they ALWAYS have an effective public alternative.
SustiNet was developed with extensive input from all health care stakeholders and with the expertise of Stan Dorn of the Urban Institute. It has the support of, among others: the Connecticut Realtor’s Association; the Connecticut State Medical Society; the Connecticut Public Health Association; and Small Businesses for Health Care Reform.
For more information about the bill, you can go to: http://www.healthcare4every1.org/sustinet
Baucus has found religion.
This is very exciting. I can’t believe how closely these proposals fit with what I think we need to do to make US health care work. If we actually follow these approaches, and also incorporate Obama’s ideas for universal access, we could end up with a health care system that actually provides Americans with world class care without breaking the bank.
Maggie,
What’s your sense of the magnitude of compensation increases primary care docs might actually see? In your example, which I know is entirely hypothetical, the $600k specialist drops to $575k while the PCP shoots up from $125k to $150k. Fundamentally, we have to make primary care a viable option for third year medical students, which won’t happen with trivial pay increases. Students will have to see that primary care can be rewarding to practice, rather than grueling and full of hassles, and they will have to make perhaps 75% of the specialist’s pay instead of 25%. I wonder if the administration and CMS are willing to pay primary care docs the $250,000 or $300,000 yearly it would take to actually close the gap and make primary care a viable career choice for M.D.s?
Maggie-
A pet peeve.
The term “reimbursement” is an absurd euphemism adopted by health care providers to avoid saying “payment” because, God forbid, that might imply that they are affected my monetary considerations like everyone else when, of course, they are much better than that.
The term originated way back when patients paid providers directly and then were reimbursed for their expenditures by their insurance. When it became common practice for insurers to pay providers directly, providers continued to refer to the insurance payments as “reimbursements” even though there was no prior payment by anyone that could be reimbursed.
On medical salaries: Maggie is perhaps exaggerating to make a point, but the average specialist does not make four times the salary of the average primary care doc–not even close. The salary discrepancy is closer to $100k to $150k per year–still a lot of meal tickets in the hospital cafeteria. Of course it is larger with radiology, orthopedics, etc. That said, if the feds are fixin’ to raise my salary I’m all for it.
Mark Nugent: Your question about necessary salary increases is excellent, but the answer is not known. That particular experiment has not been done. Dr. Mark Ebell did a couple of studies published in JAMA correlating doctor salaries with residency fill rates — you might be interested. The R-squareds were most impressive.
An unintended ? consequence of this sort of approach will be that it will be suicide to care for the truly poor and sick, whose “outcome” is likely to stay poor, unrelated to medical care, good, bad or in-between.
Doctor income has already been falling for the last ten years, and hours lengthening. How can a cost that is falling be the cause of the overall rise in healthcare costs?
Maggie,
One of the major issues that divides Republicans and Democrats is “financing medicare reform.” Can you comment more on this? Are we talking about financing increased access or financing the drive towards better quality? Can the gains from cost savings finance the improvement in care on its own?
It is the procedure oriented specialists who make $600 K and over. How did we ever get to this spot that is so skewed? In private practice it is laughed at if some gets a execise treadmill instead of nuclear study or cardiac CT. MRI Backs and knees are overused like crazy and patients demand it and that is why we need time to sit down and gain their trust why it is not needed and reassess them clinically. Honestly, unless patients pay a 5-10% for their tests, it is impossible to rein these costs and it may turn out to be a win -win if they start paying a small fee for each test over $100 which will surely start a discussion of value of tests. Wonder if this can be feasible in real world.
Last month, I submitted to the Committee on Comparative Effectiveness Research Priorities, who is conducting a study to recommend national priorities for comparative effectiveness research conducted or supported with funds from the American Recovery and Reinvestment Act of 2009, a specific priority via their survey tool.
I asked that they compare the effectiveness of various genetic and cell culture assay technologies for targeted as well as conventional cancer treatments. The purpose of the study is to show what technologies work.
The primary condition to be studied would be oncology and hematology. The types of interventions to be compared would be testing, monitoring and evaluation (e.g. lab, functional assessments), pharmacological treatments, and treatment pathways (e.g. chemotherapy selection).
The types of research that would be most effective in providing the needed evidence would be synthesis of existing evidence (e.g. qualitative review, meta-analysis), primary research using existing health care databases, primary research using prospective data collection without randomization (e.g. observational study, registry), and primary research through a prospective randomized trial.
Real-world studies are not being performed under real-world conditions. No one is publishing real-world studies, except private laboratories performing cell-based analysis, which can only do real-world studies, because their studies require fresh, viable specimen, which must be accessioned and tested in real-time under real-world conditions.
Most of the evidence what doctors believe to be “evidence-based medicine” is more infomercial than dispassionate science. Many journal articles are biased in favor of their sponsors’ products. The type of sponsorship that is available for randomized controlled trials is strongly linked to the results and conclusions of those studies, even when other factors are taken into account.
And sometimes trials produce unfavorable results that are not published, or that unfavorable outcomes are suppressed. Patient outcomes need to be reported in real-time, so patients and physicians can learn immediately if and how patients are benefiting from new diagnostics and therapies.
I received a positive reply. Hope to see a positive study.
I’ll say this again: there’s 2 ways to control heatlhcare costs:
1) Flat salaries for doctors
2) Govt bureaucrat who rejects treatments.
Pay primary care docs a flat 150k salary and specialist docs a flat 250k salary and healthcare costs would PLUMMET overnight. No more ridiculous MRI scans for every shoulder pain. No more ridiculous CABGs for 95 year olds. No more ridiculous chemo regimens at $500k just to extend life a measly 3 months.
Get rid of the incentive for docs in overutilizing services and it does 2 things: stops the drastic escalation in healthcare costs, and docs would be happier instead of trying to increase volume everything Medicare cuts their per-procedure reimbursement by 5 or 10%
Congratulations to Geisinger for its innovation. its willingness to assume some risk and for showing that bundled payments for expensive surgical procedures can work to improve outcomes and reduce costs at the same time. In the meantime, CMS began a bundled payment pilot project on July 1, 2008 that is scheduled to last THREE YEARS. After that, it will take additional time to evaluate the results and to decide to what extent, if any, to expand the program.
The challenges that surround bundled payments relate to estimating total episode costs with sufficient accuracy to ensure that it at least covers all costs for the total number of procedures performed even if some cost considerably more than the average estimate and striking an agreement with physicians and other providers who are not hospital employees regarding the equitable division of the bundled payment. I think the bundled payment is a sound concept that should be pursued, but it requires willingness among providers, especially hospitals, to take some risks. There is likely to be a definite learning curve associated with the whole process that could involve some short term pain for some participants.
Separately, the issue of accurately estimating costs is also critical to paying primary care physicians a capitated payment to provide patients who need it with a medical home and to oversee and coordinate their care.
Good no-nonsense comments Joe Blow
Dr.Rick Lippin
Southampton,Pa
Joe Blow, Dr. Rick, J.Rossi, Ray, Pat S., Marc Stone, West Hartford, Mark, Christian, Dustin, Gregory, Barry . . .
Thanks you all for weighing in.
Joe Blow & Dr. Rick— In the real world, one just can’t “mandate” that salaries of specialists now earning $300,000 to $1.4 million cannot exceed $250,000.
Beginning this year, I think that Medicare will begin paying more for cognitive services that involve talking to and listening to the patient—and less for certain procedures that are overdone. But clearly a redistribution of health care dollars to address the huge disparities (and overpayment in some cases ) will have to happen over a period of years.
It isn’t fair to individuals who have financial obligations (a very expensive home, four children headed ot college, etc.) based on the assumption that they are going to be earning $500,00 to suddenly try to cut their income in half. And it would be too disruptive to the system to try to make radical changes in pay all at once. (Too many doctors would retire, go into concierge medicine (taking very few very wealthy patients), or, at the very least, stop taking Medicare patients.)
J.Rossi–
You’re quite right, one cannot say that, in general, the average salary for specialists is 4 times the average for primary care specialists. Specialists salaries are all over the map–so the “average” is not as meaningful as it is for primary care (where the average, depending on where you live, might be $120,000 to $160,000 ).
Specialists incomes on the other hand, vary from $200,000 to $800,000 or more–not to mention celebrity specialists who make well make $1 million, $1.5 million . . . or more
But I wasn’t trying to exaggerate for effect. The truth is that in many cases, specialists make at least 3 if not 4 times as a much as a generalist. Here’s just one example of specialists making 3 1/2 times (If not four times ) as much as a generalist: “in 2008, geriatricians’ incomes averaged $165,000 annually vs. $504,000 for hematologists; the two specialties require a similar amount of training” Cambridge Associates reports. ( “http://www.cha.harvard.edu/news/press_releases_08/080707_medicare.shtml.
There are many cases like that–orthopedists, neurosurgeons, some cardiologist, radiologists, urologists, and eye surgeons often earn mid six figures–or more– while generalists (including general surgeons)make well under $200,000– often ranging from $110,000 to $160,000 . . .
This is where my back of the envelope estimate was coming from.
As for my hypotheticals as to how much of a raise it would take to make doctors choose primary care, working conditions and possible loan forgiveness are, I think, also important
Btw– Disparities between specialists and generalists are much narrower in other developed countries: “Physician compensation in the United States is 6.6 times per capita GDP for specialists and 4.2 times for primary care physicians. By contrast, in the average OECD country, specialists earn 4 percent of GDP per capita, while primary care doctors take home 3.2 percent.” Recent Robert Wood Johnson Foundation report. Not nearly as big a gap.
Ray– I’m all for higher co-pays for tests in cases where we know risks outweigh benefits–for instance, MRI breast scans for average-risk patients.
It’s harder in some grey areas where we just don’t have enough research on how useful the test is for particular patients, though I agree a co-pay of even $20 could start a discussion of “why is this more expensive” which would allow a doctor to explain that we don’t have solid evidence this does any good.
“Shared decision-making”- a protocol which I have written about in the past,is a very good way to get patients thinking about risks, benefits, and tradeoffs when contemplating something like a knee-replacement.
Under shared decision-making, the patient is given a pamphlet, and a video of other patients explaining how they decided to have–or not to have–the surgery.
After taking the video and pamphlet home, the patient talks to a decision-making coach who helps him sort out his priorities. About 20% of the time, patients decide not to go ahead with the surgery. They might decide to try physical therapy first, along with pain medication . . .
Pat S.– I agree; I found what Baucus and others were saying very encouraging.
Marc Stone–You are right-reimbursement goes back to the days when patients paid up front and were “reimbursed.”
Though today, the word is accurate insofar as doctors are “reimbursed” for the cost of providing the service (their overhead, value of their time, etc.)
West Hartford— I’ll look into Sustinet. A couple of question: are physicians and hospitals paid as well as Medicare pays, or are they paid Medicaid rates?
Is coverage as generous as Medicare? What percent of CT physicians take Sustinet?
Mark– I don’t see us paying primary care docs $250,000 to $300,000. The jump is just too big, and not affordable, even if we cut fees for other services.
In addition, if you look at where young doctors are going these days, they are not setting up in solo or small practices–they are going to work for a hospital or large medical center that will be covering their malpractice insurance and covering t their back office expenses.
So they no longer have the costs associated with running a small business–or the hassles.
As a result, I think that a salary of $150,000–and regular hours–could be very attractive. I also think we need loan forgiveness for physicians who agree to locate in areas (both geographic and specialties) where they are needed.
Christopher– From 2004 to 2007 overall physician income rose by 13% –rising more than inflation. Some specialties lost ground, others gained ground. But overall, physicians kept up with inflation by increasing volume: they performed more tests and treatments.
We know that outcomes for poorer patients are not as good. This is why we risk-adjust outcomes.This is not a perfect science, but has been done for many years by the Dartmouth researcherssand others. No one simply ignores differences in income.
Dustin–
Yes, squeezing the waste out of Medicare will allow us to improve quality without raising Medicare taxes or premiums and co-pays. Pilot projects will need seed money up front– but overtime, we will get that money back—and more.
Two decades of Dartmouth research suggests that1/3 of our Medicare dollars are squandered on unnecessary, unproven and over-priced drugs, devices and treatments.
Even if we excised just half of the waste, we are looking at huge savings.
The major goal is to make sure that Medicare spending isn’t rising any faster than GDP growth. If we do that, Medicare will be fine for decades to come.
(The aging of the Boomers is not the big problem: they will age gradually, over decades, just as they were born.
Over-use of advanced medical technologies over-treatment has been driving Medicare inflation so that Medicare spending is increasing 6% to 7% a year.
Rein in the waste, pay providers for quality of care, not quantity, and we can solve the problem.
Gregory–
Very glad to hear you received a positive response. Let me add that there is, in fact, unbiased research out there, including the Cochrane research.
Barry–
Yes I think the way Geisinger assumes risk is brilliant. The fact that it is both a provider and an insurer makes that easier.
Some have suggested that drug-maker and device-makers also should assume risk. IF the new cancer drug works for a particular patient, the company will be paid; if it doesn’t, they won’t. (This would discourage companies from bringing not-fully proven and hyped products to market.)
Estimating costs works if the group receiving bundled payments is large enough. You can’t estimate costs for one physicians practice or one hospital — but you can roughly estimate costs for one hospital and the hundreds of doctors treating patients before, during and after hospitalization. insofar as costs exceed estimates you can also reimburse the following year.. You can never get an accurate estimate for a small group of providers because medical needs are too unpredictable.
very nice article
America…wake up!!!! Start taking care of yourselves and then you won’t have to worry about relying on an overpaid doctor to fix you. Stop f-ing smoking!!! All those sinus infections and sore throats and chronic coughs you tobacco abusers and your kids get – IT IS FROM ALL THE SMOKE!!! Avoid the f-ing Mickey-D’s and Wendys drive-thrus and start exercising and you won’t have to worry about sleep apnea, hypertension, coronary artery disease, peripheral vascular disease, gallstones/gall bladder infections, osteoarthritis…the list goes on and on!!! If you don’t make enough money to raise a child, maybe you shouldn’t have 2,3…7 kids!!!!! It’s not that hard people!!! Then, our patients have the nerve to abuse their bodies and health and then sue us if we don’t run all the UNnecessary tests and jump through all the UNnecessary loops to try and reverse all the years of abuse!!! I’m about to graduate med school 200K in debt and experience this healthcare reform/crisis first hand and I would like to get compensated for my time and effort. I don’t come to your minimum wage jobs and ask you to work for free…THINK ABOUT IT!!!