Two interesting and related items recently dropped into my inbox concerning the future availability of primary care clinicians.  As most people are aware, primary care services are becoming increasingly scarce - and has been seen here in Massachusetts expanding insurance coverage may only increase this strain.  In addition, there is some good evidence that a  major reason for our higher health care spending is having too many specialists and not enough primary care clinicians. So increasing the number of primary care clinicians might be part of the solution to controlling health care spending.

Incentives to Become a Specialist
The first article in my inbox was a Washington Post story stating that only 2% of graduating medical students were contemplating going into primary care.  However, what the JAMA study actually found is that 2% of those entering Internal Medicine residency programs were planning on going into primary care. The Wall Street Journal correctly noted that the study also found that 12% of students are planning on going into pediatrics, and 5% into family medicine.  However, that means that 8% of physicians in training who will be treating adults in the future are planning on being primary care clinicians…. And even if some of those specialists go into research or other non-clinical careers, the percentage of primary care clinicians for adults will likely not be more that 10%

The reason why so many graduating medical students were planning on becoming specialist was clearly stated in the opening sentence of the Wall Street Journal article: “Yes, higher pay is prompting many U.S. med students to choose lucrative specialties over primary care….”

Incentives to Become a Researcher
The second piece in my inbox was a notice from the NIH about their loan repayment programs for recent doctoral program graduates.  When I worked at the NIH in the early 1990s I helped start a loan repayment program for researchers working on AIDS related research.  At that time there was tremendous need for more people to focus on HIV and AIDS research, and that loan repayment program was restricted to NIH-based employees.  What struck me about the NIH’s notice was how much their loan repayment programs have grown: They now fund 1,600 researchers each year with a budget of $70 million.  While many of the individuals benefiting from these programs are not physicians, they do include pharmacists, psychologists and dentists.

Conclusions and Thoughts About Overall Priorities
What I found interesting – and somewhat concerning – is that if increasing the number of primary care physicians is a high priority, and Medicare is being advised to take steps increase financial incentives for primary care, (something I’ve written about previously), then why have the NIH’s loan repayment programs expanded to draw more clinicians into research?  Certainly research is a worthy endeavor and a great career, but the current structure of the programs given our national priorities, the expansion of NIH’s funding (which helps support researchers salaries), and the growth in the private biomedical research industry, all together beg the question about how these loan repayment programs fit into our overall national strategy and NIH’s funding priorities?

I’m sure that some people will criticize me for questioning these NIH programs, but I look forward to hearing their perspectives – both on the loan repayment programs and how incentives for primary care should be increased.

I’m also concerned about the JAMA study’s findings because they point out that changing financial incentives for primary care may not happen soon enough - and clearly today’s students haven’t gotten any messages that these incentives will likely change in the future.  However, they may be getting their information from their teachers - who likely directly and indirectly relate the financial and life-style attributes of primary care versus specialty careers.  While Medicare and other payers cannot make promises about how their reimbursements will be structured years or decades from now, perhaps there needs to be more educational efforts directed at medical students and residents about what the future financial incentives for physicians may look like.

Clearly there is much work to be done in this area to ensure a greater supply of primary care clinicians and to drive research efforts forward with appropriate priorities.

A political insiders poll conducted by the National Journal (and published in their August 2nd issue) shows that Republicans are not counting on health care to help their party in the November elections.

Among the 7 choices to the question, “Which two issues will most help your party in November’s election?” none of the 42 Republican insiders picked health care.  Compared to that 0%, Energy was chosen by 90%, and National security by 31%

The poll results were also interesting for what the Democrats chose.  It appears that they are giving up on Immigration and National security as the issues that will help them in the November election – those two issues were picked by none of the Democrats.  Rather, Democratic insiders chose Economy (87%), Energy (39%), Iraq (37%)…. And of course Health care (21%)

So what does this mean for the actual election?  Are these political insiders too myopic with inside-the-beltway perspectives?  I find it hard to believe that Republic voters won’t care at all about health issues – particularly many of the conservative physicians who may be peeved about the President vetoing the bill to avert the Medicare 10.6% cut - which Congress later voted to overide.

Well it seems that the Democrats and the Republicans both have some validity in their positions:  According to Gallop’s June 15-19 issues poll, the Democrats do have a big edge on healthcare and the economy:

And according to CNN’s issue tracker from June 4-5 polling, the most important issue for registered voters was:

• Economy 42%
• War in Iraq 24%
• Health care 12%
• Terrorism 11%
• Immigration 8%

Taking all this together it looks like Democrats have the edge in the issues that are most important to the voters.  How this changes between now and November 4th as voters respond to new events and the campaigns’ messages will likely determine the election – assuming neither candidate makes major missteps.

The leadership of HHS had a tele-conference on Monday to highlight the new Medicare incentives for physicians to adopt e-prescribing systems.  What the Washington Post and Kaiser Family Foundation reported about this press briefing that wasn’t in the HHS press release was that the Acting Administrator of CMS said that the per physician cost of e-prescribing systems is about $3,000 up front, and then $80-400/month for operation and maintenance.

These numbers caught my eye, because with the incentives in the Medicare bill, the break-even point for physicians is as follows:

First, let’s assume that the per month cost is $240 (the mid-point between $80 and $400), or $2,800 per year. Since the Medicare incentives for e-prescribing are a net 2% of Medicare reimbursements, that means to break-even the physician has to have $144,000/year in Medicare reimbursements – just for the operation and maintenance costs.  Additionally if the up front costs are spread over two years ($1,500/year), that raises the break-even point another $75,000, to $219,000/year.

For some clinicians, this amount of revenues from Medicare might be low, and therefore, it would make sense to get an e-prescribing system. However, if the doctor only sees a minority of Medicare patients, then the incentives could be a penalty.  Which is exactly what Congress expects the financial effects of the e-prescribing incentives to be. According to the Congressional Budget Office, “CBO estimates that the net budgetary effect of the electronic prescribing provision will be to reduce Medicare spending by $0.2 billion over the 2008-2013 period and $2.1 billion over the 2008-2018 period.”

Of course, if other insurers were to match (or exceed) Medicare’s incentive payments for having e-prescribing systems, then obviously the break-even point for physicians would come down, since the calculations wouldn’t balance solely on Medicare revenues.  However, I’m not aware that other insurers are rushing to provide financial incentives for physicians to use e-prescribing systems.

Additional Points
There are additional important points about e-prescribing that need to be made.  First, e-prescribing can have additional costs for physicians’ offices in the form of training time and lost productivity, and unlike electronic medical records, e-prescribing itself is unlikely to improve the office’s billing accuracy and revenues.  Second, e-prescribing can certainly provide clinical benefits by reducing medical errors with better communications about individual prescriptions.  I wrote about these issues a couple of weeks ago (see “Challenges to Making E-Prescribing Increase Efficiency and Improve Quality”), but want to reinforce one point here: Going from paper to computer communications can also introduce new opportunities for medical errors – particularly if people rely on the computer generated information while they might question the legibility or accuracy of a hand-written prescription. That is, technology is great, but its appropriate role needs to be understood by the users, who also have to use it correctly for it to provide real value.

The focus on Medicare payments to physicians for the last six months has been on the 0.5% increase Congress enacted for the first 6 months of 2008 to replace the 10.1% reduction that would have occurred under Medicare’s Sustainable Growth Rate (SGR) formula. Legislation to continue this rate for the rest of the year failed a required procedural vote in the Senate last week.* This leaves Medicare physician payments after June 30th uncertain – although it is expected that Congress will do something in the next week, or three.

However, beyond the impending Medicare 10.6% reimbursement reduction for all physicians, the Graham Center of American Academy of Family Physicians published a short report on June 13th that expands the analysis to include pending change in how Medicare reimburses physicians in Physician Scarcity Areas (PSAs), and Health Professional Shortage Areas (HPSAs). As the report’s summary table below shows, the PSA 5% reduction would effect about 25,000 primary care physicians and over 7.5 million Medicare beneficiaries. And these payment reductions would be on top of the impending 10.6% Medicare payment reduction.

With the general consensus being that we have a shortage of primary care clinicians, cutting Medicare payments to physicians in underserved areas seems truly unwise. And doing it at the same time that Medicare’s overall reimbursement formula for physicians is being so contentiously debated is really a bad idea.

If the PSA and HSPA programs would benefit by being adjusted to redefine their geographic or other targeted goals, then that should be done as part of comprehensive strategies and plans for improving Medicare’s payment system to ensure Medicare beneficiaries have continued access to physicians – particularly those providing primary care services. Making reductions to the PSA and HSPA programs right now seems like the right and left hands of government don’t know what they are doing.

* This legislation would have also implemented a 1.1% increase for 2009 instead of the SGR formula’s reduction of 5%

The Medicare Payment Advisory Commission released its annual report to Congress on Friday. In chapter 2 of its report, MedPAC makes two significant proposals for improving the financial incentives for primary care providers.

Great Incentives for Primary Care Practitioners Not Just Primary Care Services
First, it recommends changing Medicare’s reimbursement system for “evaluation and management” (E&M) services. While last year Medicare increased payments for E&M services, they couldn’t differentiate between types of physicians providing these E&M services, i.e. the Medicare system doesn’t distinguish between a family physician and a cardiologist if they are providing the same type and level of intensity of service.

Therefore, MedPAC recommends that a subset of primary care related E&M services, (e.g. office visits, home visits, long-term care patient visits), provided by clinicians who meet a minimum percentage threshold of a clinician’s total Medicare billing, (and thus would be identified as being “primary-care-focused practitioners”), should receive higher Medicare payments. (MedPAC choose to identify primary care clinicians based upon a percentage of primary care services - rather than specialty designation - because it would be administratively simpler and ensure that the incentives would be directed towards clinicians actually providing primary care services.)

The specific recommendation from the MedPAC report is:

The Congress should establish a budget-neutral payment adjustment for primary care services billed under the physician fee schedule and furnished by primary-care-focused practitioners. Primary-care-focused practitioners are those whose specialty designation is defined as primary care and/or those whose pattern of claims meets a minimum threshold of furnishing primary care services. The Secretary would use rulemaking to establish criteria for determining a primary-care-focused practitioner.

This is a sea-changing proposal in that it seeks to differentiate how Medicare Part B reimburses primary care providers versus subspecialists – and thus makes Medicare Part B payments more granular than was done when the RBRVS system was first installed in the early 1990s. (Back then, the fight was between so-called cognitive and procedural services.) This refinement will enable Medicare in the future to use its payment system as a more managerial tool for shaping the healthcare delivery system to increase the supply and access of primary care practitioners. The need for such changes is evident by the shrinking number of medical school graduates going into primary care:

However, because the proposal is intended to be budget-neutral it explicitly pits the financial interests of primary care practitioners against subspecialists, which means that the subspecialists will not eagerly welcome these changes to Medicare since they would be getting a smaller piece of a same-sized pie. (Note – MedPAC’s analysis shows that using the a cut-off of 65% of primary care services for clinicians to receive a 10% increase in payments for these services, would increase reimbursements for these services by a total of 6.2%, and would require a reduction for all other services of 0.9% to achieve budget neutrality.)

Build a Medical Home
MedPAC’s second proposal to promote more primary care is to increase the number of Medicare beneficiaries with medical homes.

Medical homes are the latest name for initiatives to give patients a single clinical practice or practitioner to ensure that their care is coordinated with the goal of improving the quality of care, and controlling costs by avoiding unnecessary complications and unnecessary testing. Medical homes are particularly important for people with chronic conditions for ensuring appropriate compliance with recommended treatments, disease monitoring and preventive testing. As the MedPAC report states, “Unlike the current fee-for-service (FFS) payment system, which emphasizes treatment for acute conditions and face-to-face care, medical home programs encourage practitioners to coordinate their patients’ care between visits and among providers. In improving care continuity and coordination, medical homes can enhance the role of primary care practice … [and] … increase our health system’s quality and efficiency.”

Medical homes are not new concept, as care coordination has been discussed since the original concept for HMOs several decades ago. Recently they have been promoted by primary care associations, and Medicare will start a medical home demonstration project in January 2009. MedPAC’s proposal builds off of the planned pilot, and would provide additional monthly payments to medical home practices providing the care coordination services. (Signing up with a medical home would be voluntary for Medicare beneficiaries and they would not have to pay any additional co-payments or premiums.)

MedPAC’s specific medical home proposal, which goes beyond the planned pilot project, is:

The Congress should initiate a medical home pilot project in Medicare. Eligible medical homes must meet stringent criteria, including at least the following capabilities:

• furnish primary care (including coordinating appropriate preventive, maintenance, and acute health services) [and medication management]
• conduct care management
• use health information technology for active clinical decision support
• have a formal quality improvement program
• maintain 24-hour patient communication and rapid access
• keep up-to-date records of beneficiaries’ advance directives, and
• ‘maintain a written understanding with each beneficiary designating the provider as a medical home.

Medicare should provide medical homes with timely data on patient utilization. The pilot should require a physician pay-for-performance program. The pilot must have clear and explicit thresholds for determining whether it can be expanded into the full Medicare program or should be discontinued.

MedPAC recommends an enhanced pilot project - rather than a national initiative -because there are administrative and technical factors that still need to be worked out, including, how to structure monthly payments to medical homes, and how to provide medical homes information about services provided to their patients by other providers so they can do care coordinating. The good news proposals for specialist physicians in MedPAC’s is that the pilot is not being proposed as budget neutral, but would cost between $250-750 million over 5 years.

Conclusions
Most experts think these proposals will be effective in improving the healthcare delivery system in the US, and I agree – provided that they are structured and implemented so they actually change the actions of physicians and patients. To be successful they need to change physicians’ practice patterns to focus more on primary care and care coordination, and to change patients’ behaviors so they use their primary care clinicians for more of this care management. In addition, as is reflected in the charts above, these proposals face the logistical challenge of finding enough primary care clinicians to provide these services. These changes will take time - it takes years to alter patient-physician relationships, shift how physicians practice or increase the supply of primary care clinicians – but this is not a reason for further procrastination.

p.s. I’m writing this from the road, so my editing and grammar may be somewhat deficient – my apologies.

Placing health reform in an historical context shows how the debate has evolved. For example, the National Bipartisan Commission on the Future of Medicare was formed to address Medicare’s projected insolvency - at a time when the overall focus for health reform was on cost containment. However, while the Commission met and deliberated, the booming economy shifted the debate away from cost containment towards access and coverage expansion, and the Commission’s 1999 final report, proposed adding an expensive outpatient drug benefit to Medicare.

Comparing two more recent perspectives on the future of the US healthcare system also illustrates how thinking about health reform evolves.

In June, 2003, (6 months before Congress passed the Medicare Modernization Act), I gave a presentation to the Presidents of the State Medical Associations about the future of the US health care system. My conclusions were:

1. We will continue to have a patchwork system of private and public delivery and financing
2. Innovations – primarily genetics/individualized medicine and information technology – will change how medicine is practiced
3. Budgetary pressures will be a prime driver of change
4. Individual empowerment will continue to increase the role patients play in their own healthcare
5. There will be growing emphasis on demonstrating actual clinical and economic outcomes as a prerequisite for payment or regulatory approval.
6. There are (were) three directions the US healthcare system can go:
   A. “Consumer Opportunity”
   B. “More Medicare”
   C. “Comprehensive Care Management”

I posited that “Comprehensive Care Management” was the most likely outcome, and that integrated care management organizations that would be responsibile for the cost and quality of a patient’s entire range of healthcare services would become more prevalent and be the best way to improve the healthcare system.

I recently had the opportunity to reflect on this presentation while listening to Dr. David Blumenthal (Director of the Institute of Health Policy at Massachusetts General Hospital) give brief keynote remarks about the future of US healthcare to a group of policy interested medical residents. His top-line comments about where the US healthcare system is heading in the next several decades were:

1. The economy is a key indicator of healthcare spending – countries with higher per capita GDP spend a higher percentage of their GDP on healthcare.
2. Technology is changing the nature of clinical medicine as well as patient-physician interactions and relationships. In the future, these relationships will likely be more collaborative.
3. The private insurance market will change over the coming decades, with movement away from the current employer-based model to more individual based insurance decisions.
4. Making changes in Federal laws and programs will be very different after the 2008 election, and changes in Congress may be more important than changes at the Presidential level
5. Globalization will affect medicine, with more international delivery of medical care.
6. Change is going to be more of a constant feature of healthcare. Success in the future will require being ready for change, embracing change, and managing change.
   

First, Dr. Blumenthal’s comments where much more coherent than mine. And second, although I disagree with his views on the eventual demise of the employer based insurance system, it is valuable to see how the health reform debate has evolved because of real-world changes over the last 5 years:

• The use of information technology by physicians in care delivery is no longer speculation
• Genomics-based diagnostics and therapies are now realities
• Safety and quality are much more prominent issues in the public debate
• Budgetary issue are still important, and the pendulum is in the process of swinging from how do we pay for universal coverage to how do we contain costs as part of an overall strategy for promoting economic growth.

There will continue to be lots of debate about health reform – particularly during this election year, and in the next Congress. I don’t think we’ll see the singular focus on health reform like we had in 1991-94, but it will certainly be a big topic for the President, the Congress and the Country, and as Dr. Blumenthal noted (and I wrote last month), the economy will be a major influence on public and private health reform discussions and actions.

What do you think will happen, and when?

Electronic medical records (EMRs) have been touted as one of the solutions for healthcare’s cost and quality problems. But why haven’t we seen more benefits from EMRs?

Disconnect Between Costs and Benefits
The simple answer is that there is a disconnect between those who have to pay for EMRs and those who benefit from them. For example, many (if not most) national health reform proposals call for investing billions of dollars in EMR systems claiming that EMRs will save the healthcare system lots of money. However, these savings projections hide many important factors related to the timing of any potential savings, and how different stakeholders would be affected. Three specific questions should be asked about investment for any new technology such as EMRs:

1. What are the direct and indirect costs and savings for the innovation?
2. What are the expected time-frames for each of these effects?
3. How do each of these effect different stakeholders?

For EMRs the answers to these questions are:

• There is a very large upfront costs for hardware, software, training, and converting paper records into an electronic format. Installation costs in outpatient settings have been estimated to be $40,000-50,000 per physician. In addition, clinical specialties that see patients more episodically (like surgeons), may find it easier to convert to EMRs than clinicians whose patients have chronic conditions (like diabetes) where it is important to have their long-term medical information in the EMR.
• EMRs can increase physicians’ billing revenue by enabling them to provide more accurate and complete information to payers, and thus get paid for more of the services they are actually providing and have fewer claims returned because of insufficient information. (Clinician’s increased revenues would also represent increased costs for payers.)
• EMRs ability to increase the efficiency of processing payments could reduce the staffing needs for clinicians and payers.
• EMRs can reduce the need for repeating tests when patient’s medical records cannot be found. This would result in savings for payers and patients, but might also result in lost income for the clinicians that provide those tests and related services.

The table below illustrates how each of these effects of EMRs falls into different types of costs and saving for different stakeholder groups:

Direct & Indirect Costs & Savings by Stakeholder Groups for EMR Adoption

One of the significant challenges of EMR systems is convincing people (particularly physicians and payers) that they will have real benefits that are worth the costs. Two articles have questioned the size and scope of benefits EMRs can produce: Linder et. al. in the Archives of Internal Medicine from July 2007 found that EMRs didn’t correlate with better quality indicators based upon a national survey of ambulatory care sites. The other was a April 2008 perspectives piece by Hartzband and Groopman in the New England Journal of Medicine. They noted that EMRs can “force doctors to give “standard” rather than “customized” care,” and concluded that, “We need to make this technology work for us, rather than allowing ourselves to work for it.”

Recent EMR Adoption Initiatives
Recognizing these potential pitfalls of EMRs, two recent initiatives to increase EMR use in doctors’ offices are taking different approaches – one in the State of Massachusetts and the other by Medicare:

The Massachusetts program is funded primarily by $50 million from Blue Cross and Blue Shield of Massachusetts to a non-profit third party organization (Massachusetts eHealth Collaborative) that is providing direct funding and technical assistance to three pilot areas in the state. The Massachusetts pilots are also being evaluated as they are implemented. (More about that below.)

In contrast, Medicare’s demonstration program will pay physician practices for installing EMR systems based upon the number of Medicare patient they see, and it also ties future year payments to reporting of quality information (year 2) and then being able to demonstrate actual quality improvements (years 3, 4, and 5). Medicare has called these additional requirements as “Pay for Reporting” for year 2, and “Pay for Performance” for years 3, 4, and 5.

The challenge for Medicare’s demonstrations is about money. With estimates of more than $40,000 per physicians for installation and training for a new EMR system, physicians may take a Missourian “show me” attitude – or maybe it’s more Jerry Maguire “show me the money” attitude. However, the Medicare demonstration projects are not guaranteed money and the payments are made retroactively. According to Medicare’s Acting Administrator in April:

“…the total potential payment over the five year course of the demonstration is up to $58,000 per physician, up to $290,000 per practice. And again the degree to which a practice scores on the Clinical Quality Measures and scores higher on the Office Systems Survey will determine the level of incentive that they get. Also I want to point out that, again, payments are retrospective and practices can, again, use the funds as they feel appropriate for their practice.”

Part of the reason Medicare is structuring it’s demonstration this way is because under Federal law it must be budget neutral so that the demonstration’s costs will be offset by savings to the Medicare program.

Before looking at how the value of EMRs are being evaluated, it is worth mentioning the EMR system used by the Veterans Administration’s health program. The VA’s VistA System is reported to be clinically useful , but it does not support billing which is a big problem for non-VA users. That is the primary reason why although the VistA system is free, it hasn’t been adopted by non-VA users.

Evaluating the Value of EMR Adoption
Massachusetts’ EMR initiative was started based upon the widespread belief that EMRs can produce overall clinical and economic value. However, as noted above, there have been some analytical and academic questions raised about this general premise. To demonstrate the clinical and economic effects of the EMR pilots in Massachusetts, their initiative has at least six components to evaluate the economic and clinical value by measuring both quantitative and qualitative outcomes. These are being rolled out in a logical fashion, and are summarized below:

Evaluations of Massachusetts EMR Pilot Projects

* HIE: Health Information Exchange – a system being implemented in coordination with the EMR pilots to enable physician offices to have access to all of a patients’ medical information from all clinicians within the community.
Source: Conversation with Micky Tripathi, President and CEO of Mass eHealth Collaborative, and Mass eHealth Collaborative Spring 2008 Newsletter

Conclusions: (Sorry about the very long posting)
Electronic medical records systems have the potential to improve quality and reduce costs, but there are significant barriers to their adoption by independent and small groups of physicians. The results of Massachusetts’ evaluations and the success (or “lessons learned”) of Medicare’s demonstration program will be important for guiding future Federal, State or private sector efforts to promote (or require) the use of EMRs in the US.

Any other thoughts about EMRs?

The Institute of Medicine put out a report yesterday titled “Retooling for an Aging America: Building the Health Care Workforce.” The report discusses how the aging of the baby-boom generation will create greater needs for health care providers (of all types) who are trained in caring for the elderly with chronic conditions. The report’s recommendations fall into three categories: training, system transformation and financing. Like many reports about health system improvement, their recommendations all make sense - particularly within the context of the three categories. However, like many IOM reports, the writing by Committee process is a bit evident in that, (at least from the Executive Summary), it doesn’t seem to describe a complete plan, nor does it prioritize any of its recommendations - either in terms of funding or which actions should be done first.

In addition, while the report recognizes that the elderly in the coming decades will be healthier than those of 20 or 30 years ago, it doesn’t seem to fully address how this will change the healthcare services needed by the future elderly.

It seems to me, that one of the major challenges facing the healthcare system of the future is how to better manage chronic conditions - regardless of the patient’s age. Thus, rather than retrain clinicians (or train more caregivers) in geriatrics, there needs to be more across the board efforts in chronic care management and coordination among all levels of caregivers. This would benefit the growing elderly population - many, but not all of whom will have multiple chronic conditions - as well as the non-elderly with chronic diseases like diabetes, and the many neuromuscular degenerative diseases like MS or rheumatoid arthritis. This type of system-wide transformation seems like a better use of resources than segmental/specialized retraining and recruitment.

What are your thoughts?

Yesterday, when I wrote about “Ensuring Enough Primary Care Clinicians,” I didn’t realize that public radio station WBUR would be doing a story this week on the same topic. (The WBUR story can be heard/read on their web-site.)

Nor did I know that this was an agenda item for today’s Medicare Payment Advisory Commission (MedPAC) meeting. While the one-page MedPAC briefing summary doesn’t include their draft recommendations, Modern Healthcare reports that they are recommending budget-neutral adjustments to Medicare’s fee schedule to increase payments to physicians who provide primary-care services – including office and home visits, and visits to patients in non-acute facilities. (Presumably they are recommending Congress enact these payment changes to start in 2009.)

According to Modern Healthcare:

HHS would establish criteria to determine which physicians would be eligible to receive the adjustment. Specialty physicians could stand to lose financially under this proposal, however, and some specialty societies are hoping that Congress will pursue other avenues to improve primary-care payments. In rewarding some physicians under a budget-neutral proposal, “You also have to be careful about who you hurt,” said MedPAC Commissioner Karen Borman, a surgeon who voted against the recommendation.

[Disclosure note: Many years ago I worked with MedPAC’s Executive Director Mark Miller at the White House Office of Management and Budget, but we are not related.]

I don’t see Congress doing anything significant with this problem this year, but with a new Presidential Administration, it certainly could be a very hot issue in 2009 and beyond. Any other perspectives on when or how this should be addressed?

In a previous post I was somewhat critical of evidence-based medicine (EBM) when it is used to make payment decisions. One of the points I was trying to make is that EBM is not a passing fad. The staying power of EBM was recently reinforced by two recent developments.

First, the Medicare Payment Advisory Commission’s (MedPAC) March 2008 Report to Congress cites their own 2005 report recommending EBM as a touchstone for comparing physicians’ practices as one way to improve quality of care and value for the Medicare program:

In the March 2005 Report to the Congress, the Commission recommended that CMS measure physicians’ resource use over time and share the results with physicians (MedPAC 2005). Physicians would then be able to assess their practice styles, evaluate whether they tend to use more resources than their peers or what evidence-based research (when available) recommends, and revise their practice styles as appropriate.(13) Moreover, when physicians are able to use this information in tandem with information on their quality of care, they will have a foundation for improving the value of care beneficiaries receive.

Private insurers increasingly measure resource use to contain costs and improve quality (MedPAC 2004b).(14) Evidence on measuring the effectiveness of resource use in containing private sector costs is mixed and varies depending on how the results are used. Providing feedback on use patterns to physicians alone has been shown to have a statistically significant, but small, downward effect on resource use (Balas et al. 1996, Schoenbaum and Murray 1992), but, when paired with additional incentives, the effect on physician behavior can be considerably larger (Eisenberg 2002).

This report also notes that dialysis care is one area most ready to make use of EBM for payment purposes:

The dialysis sector is ready for pay for performance: Evidence-based measures are available, providers can improve on these measures, data are available to risk-adjust the measures, and systems are available to collect the information. CMS already collects some clinical information—dialysis adequacy and anemia status—on providers’ claims. CMS is developing additional data infrastructure that will permit the agency to collect information about quality of care from all facilities.

Any nephrologists our their have any thoughts about this?

The second new development related to EBM is the launch of “the updated, expanded, and searchable Tufts Medical Center Cost-Effectiveness Analysis (CEA) Registry website.” According to an email from the Peter Neumann, the Director of the Center for the Evaluation of Value and Risk in Health at the Institute for Clinical Research and Health Policy Studies at Tufts Medical Center, (Peter - get a shorter title), this registry “provides public access to a comprehensive online database of cost-effectiveness ratios from the published medical literature.” And has the “mission is to identify society’s best opportunities for targeting resources to save lives and improve health and to help standardize cost-effectiveness methodology.”

What distinguishes the CEA registry from the proposal to create a Center for EBM that MedPAC made in February, is that the registry is a resource for understanding the “evidence” part of EBM without any direct ties to using this information for changing payments. A colleague recently agreed with my off-line assessment that one of the challenges is that EBM - and its cousin pay-4-performance - are almost always directed at clinical areas where there is believed to be costly overuse or misuse. Very rarely are these same potentially quality improving tools directed towards clinical situations where there is documented underuse - situations where quality could be improved, long-term cost savings achieved, but there also might be short-term cost increases. This is one of my touchstone secrets for evaluating the intentions of “quality improving” initiatives - do they target any practices where there is documented underuse?

And one other interesting observation about the CEA registry. It classifies its information into 4 categories depending upon the conclusion of the research:

1. Increases Costs/Improves Health
2. Increases Costs/Worsens Health
3. Decreases Costs/Worsens Health
4. Decreases Costs/Improves Health

Doing a quick assessment of the registry revealed an interesting landscape: There are about 27 more sources for #2 than there are for #3. (Types #1 and #4 are midway between, with 8 and 10 times as many pieces of information as #3.)

There could be several possible reasons for this lopsided distribution: There really could be a LOT more clinical practices that waste money and worsen health. Or this could be the area that healthcare payers will pay for research to be conducted. Or researchers know that these types of findings will bring more research funding from payers.

I believe that the second of these scenarios is the most likely since payers are primarily concerned about reducing care that increases costs and worsens health. However, I also believe that these ratios don’t reflect the full picture of clinical care, and that there are many clinical practices that if used more would improve health - whether they increase or decrease costs….. of course that calculation often depends upon what time-frame and scope of society is considered, which leads back to the old question “costs to whom?”

What do you think?