09 July 2008

Inside Baseball

By now, most of you have heard that the Senate today passed HR 6331, the "Medicare Improvement for Patients and Providers Act of 2008" by a veto-proof 69-30 margin, with the great lion of health care, Teddy Kennedy, receiving a standing ovation from his colleagues on both sides of the aisle as he returned from his brain surgery to cast the decisive vote.   Now that both chambers have passed this bill by veto-proof majorities, it goes to still-president Bush's desk.   Will he sign it, or veto it and dare Congress to overrule his veto?    Hard to say -- he's never been the compromising sort, and I suspect he might veto it just out of spite.  But then, being over-ruled would be pretty humiliating, so he may allow it to become law to avoid that embarrassment. Either way, it looks like the iceberg has been staved off of the hull for another eighteen months.

Here are some things you may not know about HR 6331:
  • Of course, it freezes the 10.6% cut in Medicare payments to doctors for 2008, and provides a (paltry) 1.1% increase for 2009.
  • PQRI is extended another two years and the bonus for participation is increased to 2%.
  • Encourages the use of qualified e-prescribing systems through a variety of incentives.
  • Reapplies budget neutrality adjustment for the 2007 RVU changes to the conversion factor, rather than work RVUs, effective 2009. 
The last point is probably the most significant.   We all know that P4P is not going away, but is not ready for prime time, so it's no surprise that PQRI was extended.   It kicks the ball down the field to the next HHS administration to figure out how the hell to implement P4P for physicians.

But the RVU adjustment is more important.  As you may recall, in 2007 the value of the cognitive RVUs for physicians increased substantially, about 15% for ER physicians.  But the requirement that the changes be budget neutral pulled about 10% of that back, and CMS applied this to the value of the work RVUs.   Changing this to apply to the conversion factor helps because many of our commercially contracted payor rates are based on the RVU work value, and these RVUs will now increase as they were intended to.   I believe that Tricare and Medicaid rates should also increase proportionately, but I am not certain about this.  So that will provide a nice bonus to ER docs, and I suspect to other office-based physicians as well.

Oh, one other fun fact.   The only senator who did not bother to show up to vote on the Medicare bill?   John McCain.   He was even too mavericky to say whether he supported the bill or not.  As I mentioned, he hasn't cast a vote in the Senate since April, nor did he bother to vote on the FISA bill.   Why is he still in the Senate?   At least Bob Dole had the integrity to resign in 1996 when he decided that the demands of the campaign would interfere with his duties in the Senate.   I guess McCain figured that with all his straight-talking, nobody would notice he wasn't showing up at the day job any more.


  1. shadowfax:

    My intitial thought was applying the budget neutrality correction to the conversion rate worsened the situation for all of us. My reasoning (with easy numbers):

    for a service, assume 2wrvus and 2pe/malprac rvus. total RVU billed medicare is 4. Multiply that x conversion rate of 40 (rounding up here) is 160 paid for the service.

    When 10 percent taken off wrvus, 2 goes down to 1.8, but everthing else stays the same. payment is then 3.8(40)= $152.

    If we instead take the 10% correction off the coversion rate, then we get (2+2)(36)= $144.

    So medicare then pays 144 instead of 152.

    Seems to me like a 5.2% cut with that slight of hand by medicare.

    (Even if I work in a system that directly translates medicares wrvu x CF into my payment per service (unlikely), it's a wash. 1.8(40) is the same 72 as 2(36). )


  2. The RVU boost doesn't help those of us who's hospitals just jacked up our RVU threshold. Apparantly our contract's wording allowed this to happen to all 150 physicians they employ. I hope they die.

  3. pcb --

    The 10% is the bottom line difference -- neither the work RVU change nor the CF change would be exactly 10%, I think, but the bottom line estimate must result in a 10% decrease in dollars expended in order to offset the increased value of the cognitive RVUs.

    Absent that fact, your calculations would otherwise be right.

    Bear in mind, though, that most private payers pay by the RVU, not off the medicare CF. So if you can choose one to cut, you would want to cut the one that would not suppress your commercial revenue, which is essentially your profit margin.

    Also, one final point -- this is much more salient to ER docs, since our work RVUs account for about 85% of our total, since our practice expense is essentially calculated at zero.


    I don't quite follow -- what is your rvu threshold and what does that mean? I am not familiar with the concept...

  4. Kennedy is an icon of hypocrisy.

    His end-of-life choices exemplify futility.

    Robert Cohen, a New York City internist involved in public health issues, stated he wished Teddy Kennedy had issued this statement instead of opting for surgery:

    “Because I am not a young man, the cancer in my brain will progress rapidly and is likely to incapacitate me in the near future. I trust that my doctors will do everything they can to prevent further seizures and to keep me in comfort. I will not endure extraordinary excess pain and suffering, while hundreds of thousand of dollars will not be spent on surgical debulking, radiation, and chemotherapeutic regimens which do not work.

    Modern medicine cannot cure my cancer, but it can keep me comfortable and free of pain. I have already contacted the Massachusetts General Hospital Hospice program.” “I’m not suggesting that Kennedy has an obligation to choose hospice rather than therapy, but I do think it would be very reasonable for him not to adopt the false valiant "struggle against death."

    Even the Vatican is hypocritical.
    In 1951 a statement was issued defining futility as less than 50% cure. When Pope John Paul II was resuscitated after a respiratory arrest associated with Parkinson's, he was later propped up by his henchmen like a semi-dead puppet.


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