Vision for our healthcare
The Department of Health and Human Services, Centers for Medicare and Medicaid, just released proposed changes to its policies for paying doctors. The new rules will pay physicians based on the relative value of their services and adherence to performance measures, as determined by the Secretary of HHS. This affects more than one million medical professionals in our country who are paid under the Medicare Physician Fee Schedule, which determines the pay rates for medical care in doctors’ offices, hospitals and communities.
The media hasn’t widely covered this new policy and few Americans have gone to the Federal Register to read the 1,128-page proposed rule, but there are important reasons to pay close attention — not just because all of us will be on Medicare eventually, if we aren’t already, but this is the medical home model that the government and its stakeholders partners have been busy building for all us as they work to overhaul our health insurance system.
The Centers for Medicare and Medicaid (CMS) said its proposals were developed with Congress to adhere to the Administration’s proposal to cut $313 billion from Medicare over the next ten years. CMS provides managed healthcare coverage for elderly, disabled and low-income residents. Federal payments to hospitals are also being cut by about $200 billion over the same period. That’s in addition to the $635 billion “down payment” in tax increases and spending cuts announced earlier this year.
We are to believe that cutting payments for healthcare for the elderly, disabled and poor; cutting reimbursements to hospitals; and now, cutting physician pay; will improve quality of care.
How do they plan to do that? As readers learned, costs savings in the proposed healthcare reforms would ostensibly come by making care more efficient, primarily through integrated electronic medical records and e-prescribing, preventive wellness with treatment of risk factors and incentivizing healthy lifestyles, and start with reforming how medical providers are paid. We're to trust that quality will follow, although there is no evidence it does.
These latest proposals from the government give us the most troubling insight into what’s in store for us. Here are a few examples from the 1128-page proposal.*
Valuing medical care based on costs and a survey
The core of the new CMS proposals (described in section 1413-P33) was a new method for determining fees for services based on their costs (called “resource-based practice expenses”) and their relative value, as determined by a survey called the Physician Practice Information Survey (PPIS). This survey compiled the returned questionnaires from 3,656 physician and professional groups and had been conducted in 2007-8 by The Lewin Group, the contractor for the American Medical Association and the government.
Not reported to the public is that the consulting group, The Lewin Group, is part of Ingenix, owned by United Healthcare Group, the largest health insurer in the country. The Lewin Group was created in 1996 as part of Ingenix to promote the use of health IT and pay-for-performance (quality) measures in Medicare, Medicaid, third-party payer and employer health insurance programs.
Yes, this is the same Ingenix (recently covered here), that has been charged with using rigged data, engaging in unfair and deceptive acts and practices, and behind health insurance industry-wide consumer fraudulent reimbursement schemes. Ingenix also sells electronic medical records and its consulting clients include more than 300 national and regional and Medicaid/Medicare managed health plans; more than 100 federal and state government agencies, and more than 50 healthcare delivery systems, including pharmacy benefit managers (PBMs).
Its data has also been used in published medical research to claim skyrocketing costs of obesity, diabetes, depression, high blood pressure, high cholesterol and unhealthy lifestyles. It’s also the same Ingenix that former Senate Majority Leader and the President’s originally designated Health and Human Services Secretary and designer of the administration’s healthcare reform, Tom Daschle, worked as a special policy advisor.
Now, as we know, “survey says” is not necessarily what the evidence supports, but more often reflects lobbying, organizing and marketing efforts. The CMS document describes the PPIS as the “most comprehensive source of physician expense survey information available to date.” Its expenses per hour of various healthcare provider services, however, were quite different from the figures the CMS has been using. While these supposedly rank the relative value of these doctors’ services, what the government thinks are the most valuable might not be what you think.
Emergency medicine is valued at $38.36/hour, while chiropractors are at $65.33/hour (even 31% higher than previously) and osteopathic manipulative therapy is valued at $53.93/hour. Endocrinology (think especially diabetes and obesity) was valued by the PPIS at nearly twice what the CMS had been using to determine physician payments, and is now at $84.39/hour. Family medicine saw a similar increase and is now valued at $90.15/hour. In contrast, for example, Cardiologists’ value was cut nearly in half to $88.04/hour. Allergy and Immunology care was increased to $162.68/hour and Dermatology was increased to $184.62/hour.
When you’re injured or have a real medical emergency, or actually develop a disease, which of the best doctors will you hope are available to care for you: emergency medical physician, cardiologist, family medicine doctor, chiropractor or dermatologist?
Remember how cost comparative analysis will always find a lower return on investment for older people? The CMS’ new proposed relative value units (RVU) of physician work — used to determine doctor’s payments for 2010 Medicare beneficiaries — gives the initial first hour of adult critical care, for example, a RVU of 4.5, compared to 18.46 for neonatal critical care and 15.98 for pediatric critical care. How will this impact over time the numbers of doctors choosing to work in adult critical care and be available when Medicare recipients may most need life-saving medical care?
Compulsory wellness screenings - BMI screening for seniors
The CMS proposed, starting January 1, 2010, to increase the pay for an initial preventive physical examination (IPPE). Also called the "Welcome to Medicare" visit, these are given to new beneficiaries their first year in Medicare enrollment to identify “high impact” risk factors for targeted intervention. The IPPE benefit was first mandated by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 to pay for an initial assessment of beneficiaries enrolling in Medicare Part B. The IPPE “includes a broad array of components and focuses on primary care, health promotion, and disease prevention.”
As page 271 of the proposal describes, the new pay-for-performance measures — that have never been part of the mandatory Physician Quality Reporting Initiative (PQRI) measures before — will focus on “high impact” measures that “support CMS and HHS priorities for improved quality and efficiency of care for Medicare beneficiaries:”
These current and long term priority topics include: prevention; chronic conditions; high cost and high volume conditions; elimination of health disparities [which doesn’t mean what the public probably thinks it does]; healthcare-associated infections and other conditions; improved care coordination [as examined here, none of 15 programs were shown to reduce Medicare costs or had favorable effects on any of the quality of care indicators examined]; improved efficiency; improved patient and family experience of care; improved end-of-life/palliative care; effective management of acute and chronic episodes of care; reduced unwarranted geographic variation in quality and efficiency; and adoption and use of interoperable HIT.
In addition, the P4P measures included in the PQRI — that must support the priorities of the CMS and the HHS, and will be funded through Medicare — “must be NQF-endorsed by July 1, 2009.” The NQF refers to the nonprofit group, the National Quality Forum, funded by various stakeholders, with the largest founding grants from the Robert Wood Johnson Foundation.
Under the CMS’ new proposal, Section 101(b), the IPPE exam has been changed. It added measuring BMI and end-of-life planning. [No, the guidelines have not been changed to reflect the fact that higher BMIs are protective and a survival advantage after middle age, in men and women, or that voluntary weight loss after middle age increases risk of mortality by as much as twice. Can you see yet what is happening?]
The proposed CMS rule, as the press release explains, contains a number of provisions to enforce and monitor compliance with pay-for-performance measures through e-Prescribing (electronically writing prescriptions through an integrated computer network linking pharmacies, governmental and stakeholder databases) and the PQRI, as well as adds more performance measures that eligible healthcare providers must document through qualified electronic medical records.
Section 1848 (m, 3, C, i) of the Act requires the Secretary of the HHS to establish a process to determine which professionals are eligible in a group practice (also as defined by the Secretary) to be considered as having satisfactorily submitted documentation of compliance with pay-for-performance measures for the PQRI. In lieu of reporting P4P measures, the group can report “measures determined appropriate by the Secretary, such as measures that target high-cost chronic conditions and preventive care, in a form and manner, and at a time, specified by the Secretary.” Beginning in 2010, group practices would also be given an incentive reward of 2% of their pay for complying with the P4P reporting.
According to Section 1413-P-260 of the CMS proposal, the P4P (“quality”) measures were developed under the direction of the CMS by various professional organizations, including the American Medical Association’s Physician Consortium for Performance Improvement, the American College of Cardiology, the American Heart Association, the National Diabetes Quality Improvement Alliance, the National Committee for Quality Assurance and the Veterans Health Administration. These P4P measures are grouped into four disease modules: diabetes, heart failure, coronary artery disease and preventive care services.
The Preventive Care measures adopted this year (on May 1st by the NQF and January 31st by the AQA) included mammograms, colonoscopies, tobacco use, alcohol use, osteoporosis screening, and BMI screening and follow-up.
The CMS has required cardiac rehab programs to include “cardiac risk factor modification,” which include “smoking cessation counseling or referral, nutritional education and meal planning, stress management, prescription drug education...and any other education, counseling and behavioral intervention.” Providers must also measure and report health indices and patient compliance with the treatment plan at the beginning, every 30 days and at the end of the intervention. These measures, according to the CMS proposal, should include weight, BMI, medications required, self-reported quality of life, and behavioral measures, such as smoking cessation and increased exercise levels.
In order for these provider programs to be qualified for Medicare coverage, they also have to demonstrate statistically significant reductions in patients’ health risks factors that include “low density lipoproteins, triglycerides, body mass index, systolic blood pressure and diastolic blood pressure and the need for cholesterol, blood pressure and diabetes medications.” These are metabo, risk factors together called the metabolic syndrome, and they each have a pill.
* Health risk factors
Years ago, JFS readers were cautioned that the single most important thing to understand is risk factors, which merely mean a correlation was seen between two variables. Risk factors are not a measure of actual risk, not a disease and not a cause of death. The popular health risk factors have not been shown to tenably correlate or credibly predict heart disease, cancers or all-cause mortality. So, not surprisingly, randomized clinical trials have failed to find that treating these popular risk factors has much of an effect on health outcomes, in reducing mortality or saving medical costs.
But, of course, they are inordinately profitable for those selling pills and interventions to keep each number in line — those same government-private stakeholders building our medical homes.
A recent analysis of clinical trials found no difference in BMIs or waist circumference, fasting blood sugars or triglyceride levels between adults who did or didn’t develop heart disease.
The Cardiovascular Health Study found that after 15 years of follow-up, there was no tenable relative risks associated with the risk factors commonly called metabolic syndrome and death.
The American Heart Association’s new Guidelines for Cardiovascular Disease Prevention in Womenfound virtually all heart disease occurs in women without risk factors. And even a study of data from 541 hospitals led by the chairman of the Get with the Guidelines Steering Committee found that most heart attacks occur in people with low cholesterol levels.
The latest Cochrane Collaborative systematic review of the evidence from 39 clinical trials conducted over three decades on Healthy Heart Programmes, that encourage people to reduce their risks for developing heart disease by addressing the risks factors that include high cholesterol, salt intake, high blood pressure, obesity, diet, smoking, diabetes, and a sedentary lifestyle, found: “Contrary to expectations, these lifestyle changes had little or no impact on the risk of heart attack or death. Recent trials examining risk factor changes have cast considerable doubt on the effectiveness of these multiple risk factor interventions... The pooled effects suggest multiple risk factor intervention has no effect on mortality.”
Healthcare determined by the government and third party payers and stakeholders is no assurance it is based on careful, objective evaluations of sound evidence, unencumbered by political or financial interests. Not only are their P4P measures not necessarily best for patients, as we’ve seen in numerous clinical trials, they put significant numbers of patients at greater risks.
For recipients of Medicare, the consequences of P4P measures leave them no-win choices: Care provided by doctors who do what the government and third-party payers say… or… less access to medical care as doctors who feel ethically obliged to provide the care they feel best for their patients no longer accept Medicare patients. Stop and think about that for a moment. Which type of doctor would you want taking care of you? And why are the government and stakeholders working so hard to restrain individual practitioners?
Less specialized and advanced care
The CMS is proposing to stop paying for consultations, which are typically billed by specialists and paid at a higher rate. Primary care providers will be paid 6-8 percent more, while specialists will be paid less. Payments for cardiology services, for patients with heart problems, will be cut by 11 percent this year, alone, and cardiac diagnostic and treatment services are scheduled for cuts of 25 to 42 percent.
Payments for services that use high-tech equipment, such as diagnostic imaging, will also be reduced under the government’s proposal, in order to redistribute the money to primary care.
Of course, fewer doctors will go into, or remain in, specialty fields if the extra education, training and expertise will mean they’ll make a poorer living. But, as we know, healthcare reform is founded on primary care, and being marketed to the public with the belief that preventive wellness is more cost effective than caring for sick people. “Wellness care, not disease care,” the slogan goes.
In the managed care model (now called medical homes), a general practitioner also serves as the gatekeeper in controlling health care usage and costs. If you ever get sick, injured or develop a serious medical problem that calls for specialized care and want to get a referral to a specialist or get a special test or treatment, you may miss those specialists and advances of modern medicine. Of course, if you never get sick, injured or develop a medical problem, you won’t.
The new CMS proposal also calls for all suppliers of advanced imaging services to be accredited and undergo administrative oversight. There’s no evidence that will ensure quality of patient care, either. It will, however, increase out-of-pocket costs and reduce availability of modern technology for people who may need them. The unintended consequences could be poorer outcomes for elderly sick people.
The popular belief, rigorously spread by the growing lifestyle medicine movement, is that chronic diseases of aging; such as cancers, heart disease and diabetes; can be prevented and are to blame on unhealthy diets and lifestyles and failing to control health risk factors. The actual fact is that the best randomized controlled trials (the gold standards of medical evidence) continue to fail to support such premises behind lifestyle medicine, as we’ve seen time and again. The 64 percent drop in age-related deaths from heart disease over the past 50 years, for example, is largely attributed to our modern, advanced medical care and coupled with the survival advantage of a better fed, immunized and overall healthier population. Even mainstream medicine is finally realizing lifestyle medicine is more pseudoscience and ideology than sound, evidence-based science.
The government’s new proposals for what medical care for our nation’s elderly and poor will be covered, monitored and enforced under Medicare is poignant evidence that government and third-party-provided or funded healthcare is influenced by those with the most political and financial power. It is not reliably based on careful, objective evaluations of sound evidence or what you and your individual doctor may feel is best for you.
© 2009 Sandy Szwarc
* Public comments on the proposed payment policies for the Medicare Program are being accepted by the Department of Health and Human Services up to 5:00 pm on August 31, 2009. The final rule will be issued by November 1, 2009 and go into effect January 1, 2010.