04 December 2007

A New Blogger

Blogging has now gone mainstream, as evidenced by bureaucrats like Secretary of Health and Human Services Mike Leavitt having blogs. (h/t to Roy at Health Care Renewal) I have to give him credit for stepping into the waters, addressing contentious issues, and allowing comments (though moderated). If only all of our government officials were so forthcoming....

Today's post involves the Sustainable Growth Rate, or SGR, which is the formula Congress established to determine how much physicians should get paid under Medicare. It's an unmitigated catastrophe. Sec Leavitt tries to explain the problem, and for such an arcane issue does a good job of succinctly doing so. Roy points out some of the problems with the SGR, but I also have some opinions. (shock!)

My $0.02:
The SGR was adopted as a mechanism to cap the growth in expenditure for physician services under Medicare. (ironic note: no other service line is subject to this sort of cost controls; facility expenses can and have increased exponentially. I have never heard a good explanation why physician compensation was singled out for this sort of limitation.) In essence, the Medicare budget for doctors cannot increase faster than the GDP per capita.

BUT, the number of new retirees eligible for Medicare increases every year. And they live longer. And they have more chronic illnesses. And we have more things we can do to/for them. So the total amount of services provided increases faster than the GDP. Since the total amount of dollars available is fixed, and the number of services increases, the value of a given service, year to year, must go down. Sec Leavitt implies that this is somehow our fault, that doctors just do "too many procedures," but really it's a fact of demographics and the advance in medical science. Last year physician reimbursement was scheduled to go down 5% under the SGR, but we got a reprieve (in exchange for accepting the imposition of "Pay for Performance"). This year, we are scheduled for a 10% pay cut. Sec Leavitt has proposed another last-minute reprieve; however, in the linked post, he proposes that this freeze in payment cuts be conditioned on the requirement that physicians adopt electronic medical records and prescribing.

Now, I'm a gadget guy, and I love our ER's electronic tracking system. This sometimes makes me a pariah among physicians, but I can live with that. But it's expensive. And for some, it can be slow and cumbersome, and cut productivity. And the medical records generated by these products are not exactly user-friendly. So while I am a big proponent of the EMR in general, there's a legitimate question of whether they are ready for prime time, and where the money to cover the costs will come from.

Yet the Secretary of HHS wants to make them a national standard as the price for averting an undeserved pay cut for doctors, caused by the short-sightedness of Congressional policy-makers. Nice. Here's the comment I left on his blog (in case the moderating staff kills it):

Sec Leavitt,

I applaud that you recognize that the SGR is indeed a fatally flawed mechanism for determining physician compensation. However, given that you admit fully and candidly that the formula for determining the value of physician services has failed, you then propose that, in order to obtain the deserved compensation for the services rendered, physicians must jump through expensive hoops in adopting EMRs? It makes no sense, and it smells of extortion, to piggyback onerous, unproven, and unpopular new regulations onto fixing the SGR.

To deal with this crisis fairly, the two items should be de-linked. Congress screwed up with the SGR, so Congress should fix it. If as a matter of public policy, the administration thinks that EMRs or P4P or whatever "initiative of the week" should be made law, then let's have a open and unrestricted debate on the issue on its own merits.

But don't insult us by making fair payment for our services conditioned upon physicians rolling over and accepting irrelevant restrictions and regulations. It's an abuse of power, and not the way good policy is developed.

I rather doubt it will do any good, but it does feel good to tell those in power what you think.

5 comments:

Matlatzinca said...

I think that the SGR was Congress' response to the previous efforts by the AMA to maintain a fee-for-service model under Medicare, which led to ballooning costs in the 70's and 80's.
Presumably you can read a good analysis in "The Social Transformation of American Medicine" by Paul Starr. I'm going to send you an interesting lecture specifically addressing EMRs, which is where I got the reference to that book.

The Happy Hospitalist said...

This is what happens when you have a single payer controlling the money. You do it their way or you don't get paid. Period.

shadowfax said...

Happy -- I actually agree with you, that this is the biggest problem with single payor, and probably the main reason I am not a supporter for single payor.

embi said...

I am happy to see that your excellent comment was indeed posted. You hit the nail on the head, as did many of the other commenters.

Anonymous said...

Sec. Leavitt,
CMS corrupted the "medical" record into a billing checklist. The Hx, ROS, and p/e are now "garbage in/ garbage out." EMR will never be true unless you give us back our records.