Dancing Elephants and the P4P

From the President’s Message in The Bulletin of the Humboldt-Del Norte County Medical Society, by Luther F. Cobb, M.D:

“The elephants are dancing in Washington, but it’s a minuet, not the jitterbug. As I write this, only two months remain until the SGR (Sustainable Growth Rate) formula is due to operate to reduce Medicare reimbursement by about 5%. As you probably know, the SGR formula links Medicare reimbursement to the gross national product, which basically has nothing to do with the growth of the Medicare population or their medical needs. The good news, we are told, is that Congress really, truly does understand that this is a bad formula and doesn’t want to let this reimbursement rate fall at the level that is scheduled. The bad news is that Congress is demanding ‘something in return.’ This appears, will be Pay For Performance, or P4P for you lovers of hip-hop style acronyms.

“Paying For Performance. That sounds like something we should all get behind, like apple pie, motherhood, and the flag. (Come to think of it, even those are controversial these days). The basic underlying idea is that, as Medicare is currently run, every ’provider’ (I hate that word!) is reimbursed at the same rate for the same (CPT –coded level of service, Of course with fudge factors added in for geographic variations, etc. (And again those are the source of much consternation as well — see GPCI.) So, shouldn’t we reimburse the ones who do the very best work at a higher rate? Won’t that save lives, add to quality, and reduce all those preventable deaths we all know are out there being killed by less competent ’providers’?

“Well, to re-use a very trite phrase, the devil is in the details. How exactly do we measure ‘quality’? It’s not as if it is a new concept, or that physicians and lay groups haven’t been trying for a very long time to do exactly that. Now, of courts, if it’s going to be worth MONEY, it’s going to be worth a fight too. I have talked with folks at the CMA who are intimately involved with this process, including Ron Bangasser, M.D., a former CMA President and a really smart and energetic guy…

“Well, Ron confessed, the working groups couldn’t come up with a single criterion for surgery that they thought would withstand scrutiny. So, there will be NO criteria for surgery, at least as things currently stand. Well, maybe that’s a good thing…

“Because these criteria must be objective and verifiable, they almost have to be limited in impact. I also think they’re highly likely to be unfair. I could be wrong, and maybe this really is the best thing that could happen. But it reminds me of the debate at the time of he original passage of the Medicare legislation. When AMA representatives expressed concern about the control that was being given up over the practice of medicine, they were reassured that ‘“the only thing that will change will be the signature at the bottom of the check.’”. I think we all know how that turned out. What will be reimbursed under these rules will be things that will be quantifiable and clear-cut, which will practically demand electronic medical records and data retrieval. This could well be a huge unfounded mandate, because whatever the P4P reimbursements, I really doubt they’ll cover the cost of the currently available EMR systems, which still, of course, aren’t interoperable. A lot of this information will go whizzing over the Internet also. Despite HIPAA, I suspect a lot of this information will get out; after all, we hear almost weekly of equally sensitive information, like credit card numbers being stolen by hackers. This criteria may be simple and straightforward now, there’s a huge potential for creeping imperceptibly into more basic areas that may threaten our independence as physicians. In a lot of ways, this concept reminds me of the ‘“No Child Left Behind’” federal education legislation, which is wreaking havoc in public education as we watch from the sidelines…

“So, maybe I’m just a technophobic curmudgeon. Certainly my skepticism won’t be the deciding factor in whether this gets through Congress or not, because it’s pretty much a done deal. I just suggest we watch out, pay attention, and consider whether there is some level beyond which our tolerance for intrusion will be exhausted.”

The full article is on the society’s website. Go to www.humboldt1.com/~medsoc/images/bulletins and click on November 2005.

Placer-Nevada’s first 100 years

Excerpts from a Foothill Medical Bulletin,  by Ted Bacharach, MD, .First Centennial Edition of the History of the Placer- Nevada County Medical Society 1889-1989:

“In the annals of medicine and surgery, 1889 was not a particularly memorable time, but it was the year Physicians in Placer County organized a local medical society comprised of Placer and El Dorado counties. Nevada County had its own organization, the Grass Valley Medical Association, founded in 1865. They merged with Placer County to form the Placer-Nevada Society in 1904.

“In the years to follow membership extended…into Sierra County, and the society was renamed the Placer, Nevada, Sierra, El Dorado Medical Society. In those days, the meetings were held at noon because the doctors had to come by horseback or by horse and buggy, and many of them stayed overnight in Auburn. Because the roads were so poor, physicians in El Dorado County joined the Sacramento Society for Medical Improvement in 1940 and in 1961 Sierra County doctors became affiliated with the PlumasModocPlurnasModoc Medical Society….

“Physicians apparently were preyed upon by insurance companies even during the l800s, as evidenced by a resolution passed in 1896 refusing to examine candidates for life insurance for any fee less than $5 per applicant.”

The full article, at www.pncms.org/mc/page.do, unfortunately can be accessed only by society members — an increasing hindrance to a wider audience for physicians’ messages.

MBC’s Growing Licensure Fees

Excerpted from New Laws 2006: Elimination of Medical Board Cost-Recovery, by Catherine I. Hanson, Esq.

“CMA was also successful in eliminating the ability of the Medical Board of California (MBC) to charge individual physicians for the costs the MBC incurs in investigating and prosecuting disciplinary actions. After monitoring the impact of this practice for over a decade, CMA determined that ’cost recovery’ improperly increased the potential for abusive prosecutions and unfair settlements, as the financial stakes were increased to the point that it was virtually impossible for physicians to challenge even baseless accusations of wrongdoing. The revenue impact on the MBC will be moderated by a modest increase in fees spreading the amount previously collected in cost recovery across all physicians.”

My comment: CMA supported the astronomical increase in licensure fees to $600 some years ago because that would cover the cost of physician investigation and prosecution. It was justified because it would distribute that cost among all physicians. Almost immediately, the MBC began extracting the cost of physician investigation and prosecution from individual physicians, in addition to these exorbitant fees. Let’s hope this increase in license renewal fees again by nearly $200, under the same pretense, isn’t a replay of past subterfuge.