New WSJ Article: Permanent "Doc Fix" proposal contains some troubling provisions

[BlueLabel]

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http://online.wsj.com/news/articles/SB10001424052702303293604579251951156481492

Although permanent SGR reform would obviously be welcome, the current proposal for a permanent "doc fix" contains language that would permit the federal government, specifically the Dept. of HHS, to set "appropriate use criteria" for outpatient services paid for by Medicare. Apparently, this will have the biggest impact on radiologists who have struck some sort of deal granting them a measure of control over these criteria, but the author opines that that control is minimal and ineffective. I'm definitely not an expert on these matters but I don't feel like limiting the ability of physicians to make the best possible decisions for their patients according to the whim of government bureaucrats will lead to better health outcomes.

In any event, it appears that a permanent solution will have to wait; the latest from Capitol Hill is lawmakers are struggling to put together yet another temporary "doc fix" before they adjourn at the end of the week. Hopefully enough common ground can be found by the end of the week to prevent a 20% drop in Medicare reimbursement on Jan. 1st.

http://www.nationaljournal.com/heal...-and-short-term-solution-isn-t-ready-20131210

What are your thoughts?

 

[Jabawocky]

My immediate thought is how I do not like the idea of government having ANY say in what medical decisions should be made and which ones shouldn't.

After stopping to think, I am 10x more confident in that feeling. The only logical result of this is some non-phycision, economists making decisions purely on a financial gain/loss ratio. The lower the ratio, the more they may feel a procedure is unnecessary or "inefficient". This is why I hate how this new ACA was made with seemingly zero medical community input. How can you make legislation that alters the way the healthcare system works without using the actual input of the practitioners of this system?

Im graduating with a pre-med focus like most others on this website. If I go into politics instead, how insane would it be to let me start telling NASA how to build their rockets?

 

[BlueLabel]

My immediate thought is how I do not like the idea of government having ANY say in what medical decisions should be made and which ones shouldn't.

After stopping to think, I am 10x more confident in that feeling. The only logical result of this is some non-phycision, economists making decisions purely on a financial gain/loss ratio. The lower the ratio, the more they may feel a procedure is unnecessary or "inefficient". This is why I hate how this new ACA was made with seemingly zero medical community input. How can you make legislation that alters the way the healthcare system works without using the actual input of the practitioners of this system?

Im graduating with a pre-med focus like most others on this website. If I go into politics instead, how insane would it be to let me start telling NASA how to build their rockets?

Agreed. I realize we need some kind of reform - specifically, moving the reimbursement model from volume-based to value-based. But I'm very uncomfortable with the whole idea of taking these decisions and putting them in the hands of bureaucrats. I'm sure that some of these decision-makers will be culled from the ranks of successful academics and clinicians, but I have little doubt there will be a palpable disconnect between the criteria they hand down and what the doctors in the trenches think would be appropriate. And it's particularly insidious how this transfer of medical decision-making ability to the bureaucracy is made compulsory by tying reimbursement to compliance.

 

[zacharyw]

Im graduating with a pre-med focus like most others on this website. If I go into politics instead, how insane would it be to let me start telling NASA how to build their rockets?

We do tell NASA how to build their rocket, in that we limit the money they get each year so that they can't build a $1 trillion Mars rover (I'm sure they'd love that). Medicine on the other hand, being a fee for service scheme, there needs to be some other form of control... and I think it's fair to place some control so that the $1 million procedure that extend a patient's life by 5 days won't be covered.

 

[calvnandhobbs68]

 

[BlueLabel]

We do tell NASA how to build their rocket, in that we limit the money they get each year so that they can't build a $1 trillion Mars rover (I'm sure they'd love that). Medicine on the other hand, being a fee for service scheme, there needs to be some other form of control... and I think it's fair to place some control so that the $1 million procedure that extend a patient's life by 5 days won't be covered.

I doubt most rational physicians would order that in the first place... or that it would be covered under the existing insurance scheme

 

[Jabawocky]

And it's particularly insidious how this transfer of medical decision-making ability to the bureaucracy is made compulsory by tying reimbursement to compliance.

Yes, its good you noticed that. Medicare seems like it was a trap in this instance. Yes, its good and helps those less fortunate pay for medical expenses but allowing reimbursment to be handled by the Fed has simply hamstrung doctors. How can doctors fulfill their oath to treat those in need while relying on payment that seems to be minimized at every corner? They then can't deny these patients because how else would they get paid if they're not private practice and set their own standards. This is one factor leading to the overpopulation of private practice doctors. No one wants to work for the system. Eventually, like we are seeing today, they will realize how few doctors they have direct control over and begin writing legislation that controls private practices.

 

[Jabawocky]

We do tell NASA how to build their rocket, in that we limit the money they get each year so that they can't build a $1 trillion Mars rover (I'm sure they'd love that).

I mean more to the idea of me going in there and designing it myself.

 

[circulus vitios]

brb matching into a specialty that is conducive to cash-only practice

 

[NickNaylor]

Whether it's the government or a professional organization, someone is largely going to be telling you how to practice medicine. This trend is only going to continue as evidence-based medicine grows.

 

[Reckoner]

Interesting that the National Journal article makes no mention of a requirement for poorly performing physicians to "seek the advance permission of the government through a "prior authorization" process administered by a government website before they can order services for their patients," like Gottlieb's does. I can't find the actual text of the legislation anywhere, so it's hard to make a judgement. I personally have no problem with incentivizing good, efficient care by tying reimbursement increases to measurable outcomes (like what the NJ article describes), although coming up with good metrics is a challenge. But yeah, if what Gottlieb is claiming is true, that's a little frightening.

Yes, its good you noticed that. Medicare seems like it was a trap in this instance. Yes, its good and helps those less fortunate pay for medical expenses but allowing reimbursment to be handled by the Fed has simply hamstrung doctors. How can doctors fulfill their oath to treat those in need while relying on payment that seems to be minimized at every corner? They then can't deny these patients because how else would they get paid if they're not private practice and set their own standards. This is one factor leading to the overpopulation of private practice doctors. No one wants to work for the system. Eventually, like we are seeing today, they will realize how few doctors they have direct control over and begin writing legislation that controls private practices.

This post makes no sense to me. 1. Medicare provides healthcare for the elderly, not just the "less fortunate." 2. If insurance through Medicare is being provided by the government, who else would pay for it? I'm assuming when you say "the Fed" you mean the federal government. 3. What does "relying on payment that seems to be minimized at every corner" even mean? 4. They can refuse to take Medicare patients, although that could change in the future. 5. An overpopulation of private practice doctors?? Data please. Also, people apparently do want to work for the system, because the number of physicians accepting Medicare is on the rise (source: http://aspe.hhs.gov/health/reports/2013/PhysicianMedicare/ib_PhysicianMedicare.cfm)

 

[BlueLabel]

Interesting that the National Journal article makes no mention of a requirement for poorly performing physicians to "seek the advance permission of the government through a "prior authorization" process administered by a government website before they can order services for their patients," like Gottlieb's does. I can't find the actual text of the legislation anywhere, so it's hard to make a judgement. I personally have no problem with incentivizing good, efficient care by tying reimbursement increases to measurable outcomes (like what the NJ article describes), although coming up with good metrics is a challenge. But yeah, if what Gottlieb is claiming is true, that's a little frightening.

I realize it was confusing because I posted 2 articles. The first article discusses nascent legislation working towards a permanent doc fix. The second article mostly concerns itself with the proximate legislation pending this week enacting another short term doc fix for 2014. Does that clear up the confusion?

I fully agree that outcomes (or at least "value") should be incentivized by the reimbursement system, rather than simple volume. But I'm not sure that's exactly what's entailed.

 

[Reckoner]

I realize it was confusing because I posted 2 articles. The first article discusses nascent legislation working towards a permanent doc fix. The second article mostly concerns itself with the proximate legislation pending this week enacting another short term doc fix for 2014. Does that clear up the confusion?

I fully agree that outcomes (or at least "value") should be incentivized by the reimbursement system, rather than simple volume. But I'm not sure that's exactly what's entailed.

Yeah I realized on a second read of the NJ article they mention a "bill aimed at an eventual permanent fix Thursday," rather than an actual permanent fix. My bad.

 

[Lucca]

My immediate thought is how I do not like the idea of government having ANY say in what medical decisions should be made and which ones shouldn't.

After stopping to think, I am 10x more confident in that feeling. The only logical result of this is some non-phycision, economists making decisions purely on a financial gain/loss ratio. The lower the ratio, the more they may feel a procedure is unnecessary or "inefficient". This is why I hate how this new ACA was made with seemingly zero medical community input. How can you make legislation that alters the way the healthcare system works without using the actual input of the practitioners of this system?

Im graduating with a pre-med focus like most others on this website. If I go into politics instead, how insane would it be to let me start telling NASA how to build their rockets?

lolwut? I dispute the idea that you have to be a medical practitioner to make sound judgement about public policy and legislation. Most physicians don't know (or care to know, sadly) jack about political science or policy implementation, especially a full-time practitioner. Out of the five first titles of the ACA, two deal directly with physicians and the rest are just policies meant to impact the public.

Title I - Government waves a magic wand and makes the uninsurable insurable. Nothing to see here.
II - Government subsidizes those who cannot afford to pay for insurance. Nope.
III - Improve health care delivery. Yup, this actually means physicians. This part of the legislation was meant to tackle the large amounts of unnecessary spending in current practice. No, "unnecessary" doesn't mean "expensive", it means "unnecessary." Physicians are not the paragons of reason you believe them to be, they make mistakes, title III takes aim at reducing those mistakes and curbing the need for defensive medicine.
IV - Improve Public Health. I would say this partly falls on the physician but mostly this is a question of public education.
V - Reforming the Health Care Workforce. This means you and me (pre-professionals) and all current health care professionals. This is more about how we train our workforce. This includes funding scholarships and loan repayment plans for students interested in health care and it means expanding the workforce. Sadly, no mention of reforming education is here but I hope that arises naturally from this part of the act.

As a nation we are stuck on implementing Title I and II, mostly because this country is absolutely divided on its values and arguably delusional about the sustainability of a non-federally funded system in the future.

That being said, I agree with the general sentiment of the article that adding more bureaucracy, paperwork, and artificial hoops for physicians to jump through isn't the best way to improve health-care delivery. Overall, the article seemed to imply that this kind of micromanagement would one day apply to every medical decision ever which is just alarmist and unrealistic.

 

[Jabawocky]

lolwut? I dispute the idea that you have to be a medical practitioner to make sound judgement about public policy and legislation. Most physicians don't know (or care to know, sadly) jack about political science or policy implementation, especially a full-time practitioner. Out of the five first titles of the ACA, two deal directly with physicians and the rest are just policies meant to impact the public.

Yeah, sorry if I'm not making any sense. Im running on little sleep, fighting a cold, and trying to study for a class that I care very little for. My mind is in a very cloudy place.

 

[Variante Ascari]

Yeah.. lets find an unbiased article to base facts off of.

 

[Lucca]

Yeah.. lets find an unbiased article to base facts off of.

It's an opinion piece.

 

[Variante Ascari]

It's an opinion piece.

indeed.

 

[zacharyw]

I doubt most rational physicians would order that in the first place... or that it would be covered under the existing insurance scheme

Oh, of course not. But recently there was an article where there are ~1000 physicians in the US who prescribe pretty much all brand name drugs and cost medicare millions of dollars a year. Now should there be some sort of limit to these actions? I do hope so.

 

[BlueLabel]

Yeah.. lets find an unbiased article to base facts off of.

The article is an op-ed, but if the claims made about the contents of the permanent doc fix proposal are true, then I think there's some cause for concern.

Whether it's the government or a professional organization, someone is largely going to be telling you how to practice medicine. This trend is only going to continue as evidence-based medicine grows.

I'm not necessarily against someone telling me what do to, but it does depend on who and why. Now, this opinion is informed by a general suspicion and disapproval of certain public endeavors, but it seems to me that regulations or criteria established by the bureaucracy would tend to deviate more significantly from best practices than what might be established by a professional organization of doctors. I'll admit I don't have anything to back that up right now.

Oh, of course not. But recently there was an article where there are ~1000 physicians in the US who prescribe pretty much all brand name drugs and cost medicare millions of dollars a year. Now should there be some sort of limit to these actions? I do hope so.

Agreed

 

[SunsFun]

The article is an op-ed, but if the claims made about the contents of the permanent doc fix proposal are true, then I think there's some cause for concern.


I'm not necessarily against someone telling me what do to, but it does depend on who and why. Now, this opinion is informed by a general suspicion and disapproval of certain public endeavors, but it seems to me that regulations or criteria established by the bureaucracy would tend to deviate more significantly from best practices than what might be established by a professional organization of doctors. I'll admit I don't have anything to back that up right now.


Agreed

So you think that self-regulation is better than government regulation?

 

[slopes23]

So you think that self-regulation is better than government regulation?

I think you are missing the point. There is a difference between regulation and enforcement. I think what he is trying to say is that the reforms (read - regulations) that need to be implemented should be created by doctors, and people actually in the health care industry, and not bureaucrats. This applies to the actual writing of the law. I don't think anyone here has much of a problem with the government enforcing the law, as long as it is written correctly.

 

[Jabawocky]

I think you are missing the point. There is a difference between regulation and enforcement. I think what he is trying to say is that the reforms (read - regulations) that need to be implemented should be created by doctors, and people actually in the health care industry, and not bureaucrats. This applies to the actual writing of the law. I don't think anyone here has much of a problem with the government enforcing the law, as long as it is written correctly.

This was what I was trying to explain earlier. Now that I Aced my final, I can relax and say this.

 

[ninjaman22]

I am waiting for ruralsurg4now to come in here and turn this into how everything is Obama's and liberals' fault.

 

[SunsFun]

I think you are missing the point. There is a difference between regulation and enforcement. I think what he is trying to say is that the reforms (read - regulations) that need to be implemented should be created by doctors, and people actually in the health care industry, and not bureaucrats. This applies to the actual writing of the law. I don't think anyone here has much of a problem with the government enforcing the law, as long as it is written correctly.

I am not confusing anything here. The government enforcement is a different topic that I am not trying to discuss and I don't think anyone else is either.

I am asking whether healthcare as an industry that is heavily dependent on government funds should be self-regulated or regulated by the elected officials (ideally by the public albeit indirectly)?

 

[slopes23]

I am not confusing anything here. The government enforcement is a different topic that I am not trying to discuss and I don't think anyone else is either.

I am asking whether healthcare as an industry that is heavily dependent on government funds should be self-regulated or regulated by the elected officials (ideally by the public albeit indirectly)?

It is obvious by the tone of your question where you stand in that regard. Phrasing it self-regulation vs. government regulated is tacitly implying self enforcement vs government enforcement. I don't think anyone is saying what you are implying in so far as either doctors make the rules (which again by the way you phrased your question seems as if you feel it would be self serving) or whether it should be uncle sam by himself since he foots a large part of the bill. What seems to be being suggested here is a "council" of sorts or doctors in general working with the government to come up with a much better plan for health care reform. Your method of attempting to back drop your argument by asking a loaded question using extremes is not conducive towards a constructive conversation. Realize that not everything needs to be so polarized, and extreme. As a future healthcare professional, and an expert in your field do you not feel that it would be beneficial to be involved in laws that directly affect you and your patients? And if not you directly being involved, at least having colleagues who have experience in the health care field consulting with politicians on what would or wouldn't work, from a quality perspective, logistics perspective, and ethical perspective?

If you truly believe government should be solely in charge of the health care industry and that doctors know nothing about implementation of public policy, then thats fine its your belief to have. But at least phrase your opinion in a less inflammatory way.

 

[SunsFun]

It is obvious by the tone of your question where you stand in that regard. Phrasing it self-regulation vs. government regulated is tacitly implying self enforcement vs government enforcement. I don't think anyone is saying what you are implying in so far as either doctors make the rules (which again by the way you phrased your question seems as if you feel it would be self serving) or whether it should be uncle sam by himself since he foots a large part of the bill. What seems to be being suggested here is a "council" of sorts or doctors in general working with the government to come up with a much better plan for health care reform. Your method of attempting to back drop your argument by asking a loaded question using extremes is not conducive towards a constructive conversation. Realize that not everything needs to be so polarized, and extreme. As a future healthcare professional, and an expert in your field do you not feel that it would be beneficial to be involved in laws that directly affect you and your patients? And if not you directly being involved, at least having colleagues who have experience in the health care field consulting with politicians on what would or wouldn't work, from a quality perspective, logistics perspective, and ethical perspective?

If you truly believe government should be solely in charge of the health care industry and that doctors know nothing about implementation of public policy, then thats fine its your belief to have. But at least phrase your opinion in a less inflammatory way.

You're arguing against a point I didn't make. I just had a simple question. It is only as loaded as you make it to be.

In the end of the day it is fairly obvious that the government should obtain information from all the sources (including healthcare providers) and then make a final decision. This is actually what was done with ACA. Do you seriously believe that not a single MD/DO had any input on that law? The mechanism in place for constructive open with public discussion may not be perfect but that is besides the point.

The key is about who makes the final call the industry or the government. Self-regulating means to leave it up to the industry to set the standards (and sometimes enforce them too). Government has a minimal role often through judicial system. So this is essentially the question. Who makes the final call?