Friday, September 19, 2008

Health Care Reform: Time for American Medical Leadership to Start Thinking Ouside the Box. Part Two

Now we'll look at another Perspective article in the New England Journal of Medicine, titled Collective Accountability for Medical Care – Toward Bundled Medicare Payments. It was written by senior members of The Medicare Payment Advisory Commission (Medpac).

Let's be clear upfront that Medicare's underpayment of primary care services has had a devastating effect on the supply of primary care physicians and their services over the past 43 years. The family doctor is disappearing. Only a third of all U.S. physicians are primary care doctors - the reverse ratio of all other countries that spend much less on health care than we do but have far superior results.

The article is a well-written scholarly discussion of a proposal to bundle hospital and physician services for each admission. The authors correctly state that Medicare spending is excessive and unstable and is far from delivering value for the dollar. However, the authors do not address Medpac’s role in causing this situation. They claim that the incentives in a fee-for-service system are the root cause of this problem. Their solution is a bundled payment system, where Medicare would pay a consortium of hospital and physicians a fixed amount for 30 days of care for each hospitalization. The goal of this proposal would be to better coordinate hospital and later outpatient care.

As I see it, this proposal has two major flaws:

1)It in no way addresses inappropriate care. Should the patient have been admitted to the hospital in first place and were the services in the hospital appropriate considering the patient's overall condition? Inappropriate care accounts for about a third of all administered care in the U.S.

2)There is no mention of the critical importance of the primary care physician and the significant adjustments to their reimbursement so that they can spend a minimum of thirty minutes with their patients at each visit and be able to follow their patients once they are admitted to the hospital. However, in Medpac’s submission to Congress in which it discussed bundling of care, an increase to primary care providers was suggested. This increase would be accomplished by an adjustment to the complex formula now being used to insure budget neutrality. When attempted in the past within the present system, this approach has proven inadequate.

Although in the Congressional report it was mentioned that many specialists do provide some primary care services, there was no mention of how dramatic the undersupply of primary care physicians is, nor of their vital role in chronic disease management. There was also no mention that it will take years of significant payment increases to rectify this shortage.

In my opinion, the answer to this problem at this time is to have internal medicine sub-specialists who are consulting on the patient’s major medical problem assume primary care responsibility for that patient if the patient has no primary care doctor. They would be reimbursed at the new higher primary care rates, but not the much higher subspecialty procedural rates for those primary care services.

I believe it is time for Medpac and Congress to admit the obvious-the present system is irrevocably broken and should be replaced with a Federal Reserve type Health Care Bank. The Bank, with expert advice, would adjust physician payments to adequately fund primary care as its first priority, then fund subspecialty and procedural care. This difficult task should take place without political interference. That would be thinking outside the box.

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