Permanent SGR fix going through the House

[SoulinNeed]

Yesterday, a subcommittee in Energy and Commerce in the House passed a permanent SGR fix. It would cost $140 bil over 10 years, and would avoid the 25% cut that is scheduled to take hold in January.

Under this new bill, there would be a 0.5% increase each year from 2014-2018. Then in 2019, an "enhanced fee for service" model would be instituted where a doctor's fee increase would be tied to quality measures. If they measure highly, they get a bigger increase, and low measures could mean no increase or even a decrease in reimbursement rates. Doctors could also opt out of fee for service entirely into other payment plans, such as accountable care organizations or bundled payment options. Doctors will also have the option to remain in the current fee for service plan, but they would have to accept a 5% cut, in order to do so.

This bill has bipartisan support, and will likely get out of the whole committee in a few weeks.

http://www.californiahealthline.org...ittee-releases-bipartisan-doc-fix-legislation

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[xenotype]

quality measures are largely arbitrary bullsh*t

 

[Slack3r]

0.5% increase? Another 1.5% and we'll keep pace with inflation!

 

[SoulinNeed]

quality measures are largely arbitrary bullsh*t

You'll be measured relative to other physicians, not random benchmarks.

 

[SoulinNeed]

0.5% increase? Another 1.5% and we'll keep pace with inflation!

It's better than the 0% we've gotten over the past two years, or the actual 2% cut that occurred this year, due to the sequester.

 

[yehhhboiii]

You'll be measured relative to other physicians, not random benchmarks.

oh you mean like press ganey scores?

 

[evilbooyaa]

You'll be measured relative to other physicians, not random benchmarks.

You mean a subjective measure of how a physician is doing like Press-Ganey? Go check the Emergency Medicine forums for threads thrashing the worthlessness of Press-Ganey.

If you mean objective measures (like deaths within 30 days after surgery) that doesn't take into account the varying degrees of patient acuity that differing surgeons see. If severe enough, it's going to lead with surgeons not taking on any borderline cases that may contribute to their mortality numbers (something which happens in some sense already).

 

[notbobtrustme]

0.5% increase? Another 1.5% and we'll keep pace with inflation!

Beats 99.9% of America which hasn't kept up with inflation at all.

 

[xenotype]

You'll be measured relative to other physicians, not random benchmarks.

other physicians that have healthier and wealthier patient populations and thus better outcomes that have nothing to do with patient care provided

 

[SoulinNeed]

You mean a subjective measure of how a physician is doing like Press-Ganey? Go check the Emergency Medicine forums for threads thrashing the worthlessness of Press-Ganey.

If you mean objective measures (like deaths within 30 days after surgery) that doesn't take into account the varying degrees of patient acuity that differing surgeons see. If severe enough, it's going to lead with surgeons not taking on any borderline cases that may contribute to their mortality numbers (something which happens in some sense already).

Why are you guys mad at me? I'm just the messenger here. The proposed quality measures are in the article. They are.

Care coordination;
Clinical care;
Patient experience;
Patient population; and
Safety.

 

[evilbooyaa]

Not mad at you, just laughing at the subjectivity of these measures.

Care coordination - Would be interested to see how they determine this, as well as why it matters.
Clinical Care - Again, which actual categories they are looking at will be critical.
Patient Experience - AKA Press-Ganey for all specialties.... let the hate begin.
Patient Population - Might be useful in standardizing the top 2 categories.
Safety - Might go w/ patient population.

I think at the end of the day, it's not a terrible idea, but it's going to come down to the implementation and which specific categories (like 30-day survival after surgery, infection rates, PE rates, etc.) are going to be looked at.

 

[SoulinNeed]

Not mad at you, just laughing at the subjectivity of these measures.

Care coordination - Would be interested to see how they determine this, as well as why it matters.
Clinical Care - Again, which actual categories they are looking at will be critical.
Patient Experience - AKA Press-Ganey for all specialties.... let the hate begin.
Patient Population - Might be useful in standardizing the top 2 categories.
Safety - Might go w/ patient population.

I think at the end of the day, it's not a terrible idea, but it's going to come down to the implementation and which specific categories (like 30-day survival after surgery, infection rates, PE rates, etc.) are going to be looked at.

To be fair, CMS is already using quality measures to incentivize payments through PQRS. At least through this plan, we could actually see some payment increases. Over the past few years, we haven't seen any increases, and a 2% cut.

 

[sazerac]

Not mad at you, just laughing at the subjectivity of these measures.

Care coordination - Would be interested to see how they determine this, as well as why it matters.
Clinical Care - Again, which actual categories they are looking at will be critical.
Patient Experience - AKA Press-Ganey for all specialties.... let the hate begin.
Patient Population - Might be useful in standardizing the top 2 categories.
Safety - Might go w/ patient population.

I think at the end of the day, it's not a terrible idea, but it's going to come down to the implementation and which specific categories (like 30-day survival after surgery, infection rates, PE rates, etc.) are going to be looked at.

Doctors are smart. I'm sure they will figure out how to game this system for maximum revenue, just like all the previous systems.

It will quickly devolve into antibiotics for colds and opiates for back pain if that's what it takes to boost our patient satisfaction ratings and therefore our reimbursements.

 

[punkedoutriffs]

Doctors are smart. I'm sure they will figure out how to game this system for maximum revenue, just like all the previous systems.

It will quickly devolve into antibiotics for colds and opiates for back pain if that's what it takes to boost our patient satisfaction ratings and therefore our reimbursements.

Which paradoxically increases overall cost. Sigh...

 

[evilbooyaa]

Doctors are smart. I'm sure they will figure out how to game this system for maximum revenue, just like all the previous systems.

It will quickly devolve into antibiotics for colds and opiates for back pain if that's what it takes to boost our patient satisfaction ratings and therefore our reimbursements.

Exactly. Patient that is a drug-seeker w/ LBP and a URI has to be satisifed for me to not get penalized? Zithromax and 10 days of q4 Percocet! Oh wait, Percocet doesn't work for their 10/10 w/o tenderness to palpation back pain? 20 days of 20mg Oxycodone IR!

 

[xenotype]

Doctors are smart. I'm sure they will figure out how to game this system for maximum revenue, just like all the previous systems.

its called cash only, and the sh*ttier M&M gets, the more it will happen

 

[SoulinNeed]

Some sources are now reporting that the .5 percent increase will continue in 2019, for a total of 10 years (that's how long the bill lasts). However, starting in 2019, that's when the quality incentives will begin.

Here's the bill. The part about incentives and .5% increases are in the early part of the bill.

http://docs.house.gov/meetings/IF/I...LLS-113DiscussionDraftpih-DiscussionDraft.pdf

 

[SoulinNeed]

OK, after reading through more relevant portions of the bill, here's how the incentive system would work. The quality measures would amount to a score. If you get a score above a 67, you get a 1% payment increase (I'm guessing on top of the .5% increase guaranteed for that year.) If your score is between a 34 and 67, your payment doesn't change. If your score is below a 34, you get a 1% cut.

The cuts or increases don't compound. There is a .5% increase for 10 years on the base rate, but these cuts or increases apply on top of that. Essentially, if I'm reading this right, you could be looking at a 1.5% increase, .5% increase, or a .5% cut each year.

If someone could help me understand this, the incentive part is on page 26-27, and the .5% increase from 2014-2024 is on page 3, in section 15 and 16A.

I hope I'm reading this right.

http://docs.house.gov/meetings/IF/I...LLS-113DiscussionDraftpih-DiscussionDraft.pdf

EDIT: OK, now I'm more confused. I think it may just be a 1% increase, 0% increase, and a 1% cut. The .5% increase starting in 2019 would just apply to those who opt out of service for fee, and instead use an Alternative Payment Model. Though, I'm not sure. It depends on what they mean by "adjustment".

Here is the relevant info.

‘‘(16) UPDATE BEGINNING WITH 2019.—‘‘(A) IN GENERAL.—Subject to subparagraph (B), the update to the single conversion factor established in paragraph (1)(C) for each year beginning with 2019 shall be 0.5 percent.

‘‘(B) ADJUSTMENT.—In the case of an eligible professional (as defined in subsection (k)(3)) who does not have a payment arrangement described in section 1848A(a) in effect, the update under subparagraph (A) for a year beginning with 2019 shall be adjusted by the applicable quality adjustment determined under subsection (q)(3) for the year involved.''

And here is the info on the adjustments.

‘(A) QUALITY ADJUSTMENT.—For purposes of subsection (d)(16), if the composite score computed under paragraph (2)(A) for an eligible professional for a year (beginning with 2019) is—
‘‘(i) a score of 67 or higher, the quality adjustment under this paragraph for the eligible professional and year is 1 percentage point;
‘‘(ii) a score of at least 34, but below 67, the quality adjustment under this paragraph for the eligible professional and year is zero; or
‘‘(iii) a score below 34, the quality adjustment under this paragraph for the eligible professional and year is -1 percentage point.

‘(B) NO EFFECT ON SUBSEQUENT YEARS'
QUALITY ADJUSTMENTS.—Each such quality adjustment shall be made each year without regard to the update adjustment for a previous year under this paragraph.

Now, here's what makes me think that it could be my first numbers secanario. In this section, it says that a new doctor in their first year would have their quality adjustment be 0%, but they can't mean that they wouldn't get a .5% conversion factor increase as stipulated from 2014-2024.

(4) TRANSITION FOR NEW ELIGIBLE PROFES-
17 SIONALS.—In the case of a physician, practitioner, or other supplier that first becomes an eligible professional (and had not previously submitted claims under this title as a person, as an entity, or as part of a physician group or under a different billing number or tax identifier)—
‘‘(A) during the first performance period, with respect to a year, during any part of which the physician, practitioner, or other supplier is an eligible professional, the quality adjustment
under this paragraph shall be, for each such year, 0.

 

[evilbooyaa]

I think your 1.5%, .5% and -.5% numbers are the ones it seems like. Everyone gets a 0.5% increase every year, with the incentives in 2019 possibly augmenting/damaging that?

 

[punkedoutriffs]

And is the scoring done on a curve? If not, then they could just make getting 67 abominably hard.

 

[SoulinNeed]

And is the scoring done on a curve? If not, then they could just make getting 67 abominably hard.

Since you're being compared to other physicians, I think so. I honestly think "getting above a 67" means being in the top 1/3rd of physicians for scoring in that year. However, that's just random speculation for my part, and remember, the "adjustments" don't compound.

 

[SoulinNeed]

I think your 1.5%, .5% and -.5% numbers are the ones it seems like. Everyone gets a 0.5% increase every year, with the incentives in 2019 possibly augmenting/damaging that?

The more I think about it, the more I think that's correct. It just makes sense. Otherwise, someone who opts out of the enhanced fee for service system would see a higher rate in 2024 than someone who stayed in, since the adjustments don't compound from year to year.

So, everyone gets a .5% increase each year, and you could see this go up by 1%, not change, or go down 1% (so, 1.5%, 0.5%, or -0.5%).

 

[SoulinNeed]

Looks like it is 1.5%, 0.5%, and -0.5%, according to ACP's Robert Doherty.

http://www.medscape.com/viewarticle/808180

This is Doherty's blog post, and it does a great job of explaining the bill. The quality reporting seems like it will be a comparison tool. The top 1/3rd in a certain specialty will get a 1.5% increase, the middle 1/3rd will get 0.5%, and the bottom third will get a 0.5% cut for that year.

http://advocacyblog.acponline.org/2013/07/house-sgr-bill-promotes-medical-homes.html

 

[FIREitUP]

Exactly. Patient that is a drug-seeker w/ LBP and a URI has to be satisifed for me to not get penalized? Zithromax and 10 days of q4 Percocet! Oh wait, Percocet doesn't work for their 10/10 w/o tenderness to palpation back pain? 20 days of 20mg Oxycodone IR!

i dont get it; why would you give someone oxycodone after giving them percocet, which is essentially oxycodone + acetaminophen?

 

[witzelsucht]

percocet is 5mg of oxycodone plus 325 of apap. evilbooya is saying that a doctor could be penalized for "not treating" this patient's pain with an appropriate dose of medication. instead, the doctor is held hostage by the patient satisfaction system until he offers doses of oxycodone which can be ground up and railed up the shnoz by a dope feen

 

[SoulinNeed]

For some numbers, since 1992, the cost of running a medical practice has gone up by about 57% (as measured by MEI), but medicare reimbursements have gone up by 45% during that same time period.

Under this new bill, things will also not keep up with the increasing cost in running a medical practice, but Doherty is suggesting that docs opt out of FFS and go with ACO's and PCMH.

 

[Kevin Baker]

This isn't a solution. It's the same crap that is sgr. Pay raises don't even come close to keeping up with general inflation, let alone the inflation in health care prices

 

[SoulinNeed]

This isn't a solution. It's the same crap that is sgr. Pay raises don't even come close to keeping up with general inflation, let alone the inflation in health care prices

No offense, but this is just nonsense. Medicare pay raises have rarely ever kept up with general inflation, even before SGR, and if that's what you want, you will never get it, especially when we are just discussing medicare here, not private insurance. The cost to run a medical practice is also usually lower than inflation, not higher.

Year Physician update
1992 1.9%
1993 1.4%
1994 7.0%
1995 7.5%
1996 0.8%
1997 0.6%
1998 2.3%
1999 2.3%
2000 5.5%
2001 5.0%
2002 −4.8%
2003 1.7%
2004 1.5%
2005 1.5%
2006 0.2%
2007 0.0%
2008 0.5%
2009 1.1%
2010 1.3%
2011 0.9%
2012 0.0%
2013 0.0%

These are the increases (or cuts, in the case of 2002) since 1992. Very few years kept up with inflation, and those were usually followed by major slow down in rate increases. Practically no job in the US keeps up with general inflation, and if you're looking for that in medicine, you should focus on getting more out of private insurance, not medicare. While I certainly hope that the final bill has more than 0.5% increases per year, which is pathetic, expecting 2-3%+ per year increases has just never been possible, and isn't even feasible from medicare.

 

[xenotype]

The cost to run a medical practice is also usually lower than inflation, not higher.

source?

 

[SoulinNeed]

source?

The measure of inflation for Medicare physician costs is the MEI (flawed, but it is what it is). Here's the MEI since 1992.

Year Physician MEI increase
1992 3.2%
1993 2.7%
1994 2.3%
1995 2.1%
1996 2.0%
1997 2.0%
1998 2.2%
1999 2.3%
2000 2.4%
2001 2.1%
2002 2.6%
2003 3.0%
2004 2.9%
2005 3.1%
2006 2.8%
2007 2.1%
2008 1.8%
2009 1.6%
2010 1.2%
2011 0.4%
2012 0.6%
2013 0.8%

http://en.wikipedia.org/wiki/Medicare_Sustainable_Growth_Rate

Here is the inflation rate for those years.

http://inflationdata.com/Inflation/Inflation_Rate/HistoricalInflation.aspx

Generally, the MEI is less than inflation, especially in the past few years. The main exception was the early 2000's.

 

[DrBodacious]

Medicare... The New Medicaid!

 

[DrBodacious]

Hi

The measure of inflation for Medicare physician costs is the MEI (flawed, but it is what it is). Here's the MEI since 1992.

YearPhysician MEI increase
19923.2%
19932.7%
19942.3%
19952.1%
19962.0%
19972.0%
19982.2%
19992.3%
20002.4%
20012.1%
20022.6%
20033.0%
20042.9%
20053.1%
20062.8%
20072.1%
20081.8%
20091.6%
20101.2%
20110.4%
20120.6%
20130.8%

http://en.wikipedia.org/wiki/Medicare_Sustainable_Growth_Rate

Here is the inflation rate for those years.

http://inflationdata.com/Inflation/Inflation_Rate/HistoricalInflation.aspx

Generally, the MEI is less than inflation, especially in the past few years. The main exception was the early 2000's.

This is propaganda. The amount of money a doctor or group of doctors spends on "providing care" does depend on how much they get reimbursed. Doctors have been tight wads the last few years because already worsening fee schedules and all of all the Obama care stuff coming down the pipe. This means less investment and replacement of equipment. Fewer building improvements. Less wage increases for staff.

Sub 1% increase is not is not "sustainable" for a practice. I wonder how many of the employees at my practice will be okay with a 0.5% pay raise each year.

The end result is there will be diminishing resources to treat the elderly. I don't know how a doctor could support that plan.

Perhaps there was fat that needed to be trimmed at one point, but it close to the point where we are squeezing a dry rock.

 

[ajs321]

quality measures are largely arbitrary bullsh*t

Truth.

 

[SoulinNeed]

Hi

This is propaganda. The amount of money a doctor or group of doctors spends on "providing care" does depend on how much they get reimbursed. Doctors have been tight wads the last few years because already worsening fee schedules and all of all the Obama care stuff coming down the pipe. This means less investment and replacement of equipment. Fewer building improvements. Less wage increases for staff.

Sub 1% increase is not is not "sustainable" for a practice. I wonder how many of the employees at my practice will be okay with a 0.5% pay raise each year.

The end result is there will be diminishing resources to treat the elderly. I don't know how a doctor could support that plan.

Perhaps there was fat that needed to be trimmed at one point, but it close to the point where we are squeezing a dry rock.

Firstly, I don't see how it's "propaganda", but alright. I do get your point, but this is just the reality. Doctors need to act more like businessmen, and less like doctors. If the low inflation rate has been because doctors are spending less, then continue to do so. Your staff wants bigger pay raises? Consider a layoff or two, and distribute the savings. Make the rest of the staff pick up the slack (it's what all businesses have to do). Consider replacing some of the staff with automated services and third party vendors. Consider merging with another group, or joining an ACO or PCMH. I know I'm just a med student saying this, but I don't feel Congress will change anything, until they see some actual ramifications in quality and service for their constituents.

 

[notbobtrustme]

Sub 1% increase is not is not "sustainable" for a practice. I wonder how many of the employees at my practice will be okay with a 0.5% pay raise each year.

This current economic cycle is an employer's wet dream. Wages are being pushed down, not up nowadays.

Use wages like a business would, to keep talent, not to reward employees.

 

[evilbooyaa]

i dont get it; why would you give someone oxycodone after giving them percocet, which is essentially oxycodone + acetaminophen?

percocet is 5mg of oxycodone plus 325 of apap. evilbooya is saying that a doctor could be penalized for "not treating" this patient's pain with an appropriate dose of medication. instead, the doctor is held hostage by the patient satisfaction system until he offers doses of oxycodone which can be ground up and railed up the shnoz by a dope feen

Exactly this.

 

[DrBodacious]

This current economic cycle is an employer's wet dream. Wages are being pushed down, not up nowadays.

Use wages like a business would, to keep talent, not to reward employees.

I don't think the recent stagnant wage rate (over the past 4 years) applies to health care as much as people think. Sure, it is easy to retain a factory worker with all the layoffs and outsourcing going on. But, the demand for heath care is ever increasing. The problem is that with extra hoops to jump though (like the ACA, quality measures, considering managed care, etc) and falling reimbursements you need to keep employees working at a very high level. I. E. You don't want some hood-rat M. A., you want someone good. You need a good business manager. Nowadays, you have to hire an experienced IT company, which is expensive.

The calculated cost of business that CMS proposes doesn't take these things in to account. And, if the solution is to plan the future increases in reimbursement based on the last 5 years of recession, and pass it off as improvement in a wasteful system, then I call that propaganda, to explain my above gripe.

The shame is that there will always be a demand for doctors, so I think we'll be fine, in a relative sense, although it will decrease our earnings, on average. It's the Medicare population I am worried about, as the funding is reduced.

This plan is GOP supported, because it is essentially slashing entitlements, and Democrat supported, because it seems to advance the progressive notions of the ACA. But let's not fool ourselves, besides substituting for a regular doc fix (which should be passed anyway) it is planning to screw doctors and patients in the future.

 

[DrBodacious]

.