September 5, 2006

Editor's Column:WhyThe Rush?
CMS Chief Steps Down Amid Turbulent Times For Agency
Docs End Up Big Winners In Britain's P4P Foray
Capitol Check Up
Third-Party Payer Day
The Benefit Of Paying Dues Early
MSMS Health Care Reform Symposium

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Editor's Column:
Why The Rush?

By JOSEPH WEISS, MD

The American Medical Association, the Michigan State Medical Society and our Wayne County Medical Society of Southeast Michigan are of one voice: Act now, if we don’t harass our congressmen immediately, we will remain under the yoke of SGR (Sustained Growth Rate) and feel the lash of a 4.5 percent decrease in our Medicare reimbursements. Our sky is falling down.

We have heard this threat for the past five years and always at year’s end or slightly beyond, Congress passes a resolution that stays the decrease.

Our leadership says this year is different. Bills exist in Congress that will tie Medicare reimbursement to a Medicare Economic Index and give us an increase in payment. The trouble is that the formula is set to give us increases that on average range from 1 percent to 1.5 percent.

If you express skepticism about such an arrangement, the critics will scornfully reply: “Isn’t a 1 percent increase better than a 4.5 percent decrease,” and then point out, as if dealing with a simpleton, “You are really 5.5 percent better off.”

No, we will not be better off. If Congress passes the legislation we are urged to support, we will place ourselves in a trap. A 1 percent-1.5 percent increase in reimbursement does not come close to meeting our costs: our expenses are rising 4 percent to 5 percent per year: technology, employee benefits (including their health care), and even rents are going up at a 5 percent rate or more. Accepting the 1 percent to 1.5 percent locks us into a formula that does not reflect the expenses we face, let alone allow any better compensation.

The better alternative to what our leadership calls for, is to take our chances with Congress. It will do again what it has done every year in the last five: at the end of the congressional session, or the start of the next one, pass a resolution instructing CMS to stop the implementation of the SGR mandate. Our leadership should use that stay to continue the search for an approach to Medicare reimbursement that is realistic, flexible and equitable. We serve our best interest not by running to whatever deal we can make now, but by exercising patience and persistence. We should look for what will support the profession for the next five years and beyond.

CMS Chief Steps Down Amid Turbulent Times For Agency

By PAUL NATINSKY

CMS Administrator Mark McClellan announced his resignation Sept. 5 after shepherding in the new Medicare prescription drug benefit and proposing a 5.1 percent cut in Medicare payments to physicians for 2007, leaving a new administrator to work out contracts between Medicare and private insurance companies that sponsor the drug plan. A new CMS administrator also will be left to face recommended policy that cuts physician reimbursement from Medicare for several years beyond 2007.

McClellan, an economist and medical doctor, has worked for the Bush Administration for six years including as CMS director beginning in 2004 and as FDA commissioner from 2002-2004. He replaced Tom Scully. Prior to his government service, he taught economics and medicine at Stanford University.

McClellan told the San Francisco Chronicle regarding his resignation that, “It’s just time. We’ve gotten a lot accomplished, and I’m very confident about the track the agency is on.” He said he looks forward to spending more time with his family. Expectations are that he will take a position with a health policy think tank.

Several newspaper reports speculated that CMS Deputy Administrator Leslie Norwalk is a leading candidate to replace McClellan. CQ HealthBeat reports that Herb Kuhn, director of the Center for Medicare Management at CMS, is also a possible replacement.

Docs End Up Big Winners In Britain's P4P Foray

By PAUL NATINSKY

Britain and its National Health Service (NHS) took the jump into pay-for-performance in 2004 through a program called the Quality and Outcomes Framework (QOF). The results weren’t what were expected. General Practitioners ended up increasing their salaries by 30 percent after scoring a mean of 91 percent on clinical guidelines, according to an interview appearing in the online version of Health Affairs with a top British researcher who helped advise the government on QOF plan. The result for government coffers was a Family Practice Budget that expanded 20 percent while paying doctors an extra $700 million.

The British experience has differed from early P4P experiences in the United States in many ways, including that it involved one payer (the national government) and was not expected to be budget neutral or zero sum as many of the early incarnations are in the United States. Another key aspect of the QOF is that it allowed physicians to engage in “exception reporting,” which skirted the problem of practices treating a disproportionate number of very sick patients being penalized for their higher degree of difficulty in meeting the guideline targets.

“Exception reporting was introduced on the basis that if you have some form of evidence-based guideline, nobody would ever suggest that it should be applied to all patients,” stated Martin Roland, director of the National Primary Care and Research and Development Centre, at the University of Manchester in the interview, which was conducted by Robert Galvin, director, Global Health Care at the General Electric Company. “In a pay-for-performance scheme, you’ve really got two options. You either set the upper limit somewhere below 100 percent, so that you are not constraining doctors to give patients inappropriate treatment, or you take the approach that the UK has taken, which is to allow doctors discretion to take such patients out of the equation. So the average of 91 percent guideline compliance does not relate to all patients with, say, diabetes; it relates to all patients except those whom the doctors took out.” In some cases, exceptions were as high as 85 percent of a practice’s patients. Physicians were permitted to exclude patients, for example, who repeatedly missed appointments.

On the surface, the results of the QOF seem to indicate that the P4P program dramatically increased physician compliance with practice guidelines – they were generally at 60-80 percent before the program. But a quality improvement program featuring monitoring and feedback was underway at the time of the QOF initiation and compliance rates were on the rise. The result may be that the government was paying incentives for what it might have got without them.

Still, the fact that compliance was on the rise without the incentives was regarded as a good sign. According to Roland, a big part of the pre-QOF quality program was making performance data available to the medical community on a regular basis and to the general public sparingly, suggesting a peer-review style quality improvement strategy can be effective on its own.

To download the entire interview, visit www.healthaffairs.org

Capitol Check Up

Radisson Hotel - Lansing
September 13, 2006, Noon to 4 p.m.

Join MSMS, the MSMS Alliance, the Michigan Medical Group Management Association, and public health officials to meet with lawmakers and explore these topics:

Future of Health Care in Michigan
Safe, High-Quality, Accessible Care for All Patients
Insurance Reform
Scope Creep
Election Preview
Future of Michigan Medicaid
More!

Fees: $10. MSMS may be scheduling visits with legislators prior to the formal program. This is your chance to let your legislator know how current issues are affecting you personally in your day-to-day practice. Take this opportunity to meet with your local legislator and share your thoughts on pending legislation. MSMS will provide briefing materials to assist you in your meetings.

For more information or to register:
Contact Angie Kemppainen at MSMS at (517) 336-5724 or akemppainen@msms.org

Third-Party Payer Day

Group Managers: Save the Date for Third Party Payer Day!
Friday, November 17, Lansing

Sponsored by MSMS, the Michigan Medical Group Management Association, the Michigan Medical Billers Association, and the Michigan Osteopathic Association, Third Party Payer Day features all the major payers of Michigan, who will present expected changes for the coming year, give feedback on how to get claims paid in a timely manner, and answer questions about claims processing and reimbursement.

The Medicaid claims department also will be on hand to meet one-on-one with attendees to discuss problem claims and answer questions. (Bring your Medicaid claims and the remittance advice that had the rejection on it for each claim.)

For details, visit www.michmgma.org
or contact Sherry Barnhart at (517) 336-5786 or sbarnhart@msms.org

The Benefit Of Paying Dues Early

Pay your 2007 Membership Dues by December 31 to receive free CME! Paying your dues in full by December 31, 2006, will enable you to receive one free registration to any MSMS educational program or conference in 2007 (excluding the MSMS Annual Scientific Meeting). Upon receipt of your dues, you’ll receive a coupon for which to use when registering. And don’t forget, up to 86% of your dues may be tax-deductible!

Symposium Will Address
Medicaid Reform, Disease Management, RHIOs & More

Returning for a third year, the MSMS Symposium on Health Care Reform – scheduled for Wednesday, October 4, at the Hotel Baronette in Novi – will bring together a broad range of speakers and participants, including physicians, policymakers, legislators, state government employees and health care administrators, to share their knowledge and background on issues related to health care. Developed to stimulate change within the health care community, this conference will provide an excellent opportunity for participants to exchange ideas and stay in touch with the latest health care trends and topics. The conference will include panel discussions on:
• Disease Management
• Access to Health Care
• Medicaid Reform
• Wellness and Prevention
• Medicare Reform
• Regional Health Information Organizations (RHIOs)

Among the many great speakers and panelists will be Thomas W. Arnold, Deputy Secretary of Florida’s Medicaid Agency for Health Care Administration; Michael Ditmore, MD, Interim Director, Division of Medical Services, Missouri Department of Social Services; Kimberlydawn Wisdom, MD, Michigan’s Surgeon General; and Sandra S. Marks, Assistant Director, Division of Federal Affairs, American Medical Association.

Cost of the program is $110 for MSMS and MMGMA members, $150 for non-members. Continental breakfast and lunch will be provided.
This program has been approved for a maximum of six hours of Category I CME credit. The program will be held from 9:00 a.m. to 3:30 p.m. Registration begins at 8:30 a.m.

For more information
contact Melinda Sandford at MSMS at (517) 336-7575 or msandford@msms.org.

To register
contact the MSMS Registrar at (517) 3365784 or abatten@msms.org.

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