The Risk of a Physician Boycott of Medicare, Congress' Duty, Enterprise Risk Management & What MedPAC Should Do

The Disease Management Care Blog thinks of Medicare as a large health insurance company overseen by a Board of Directors that just also happens to be called "Congress." As a Board, Congress' job is to provide oversight, including approving the benefit, premium levels and the provider fee schedules. Like other Boards, it's also supposed to be ultimately responsible for the appointment of executive leadership. Last but not least, it should engage in "enterprise risk management" (ERM). More on this later.

Medicare's "Board" has struggled with the cumulative costs of repeatedly delaying the Sustainable Growth Rate (SGR) reductions for the Part B fee schedule. A perfect storm of election year politics, deficit spending concerns and partisan brinkmanship has led to another "temporary fix" of the scheduled 21% cut. The day of reckoning has been pushed back to November 30, 2010. While grumpy organized physician organizations are publicly concerned about the SGR's impact on patient "access" and "choice," the real threat is that many physicians who currently accept Medicare will "go Texan" and boycott the Medicare if the SGR goes through.

Should Medicare's "Board" be concerned?

As the American College of Physician's* (ACP) Advocate Blog's Bob Doherty points out, physicians have been repeatedly warning for years that Medicare's payment rates are unsatisfactory. In the meantime, the Medicare Payment Advisory Commission (MedPAC), which uses surveys of Medicare beneficiaries to gauge whether physicians really really mean it, remains unmoved. According to MedPAC's data, the vast majority of Medicare beneficiaries still have adequate access and most docs still accept Medicare. Liberal pundits, such as Maggie Mahar, think that threat of a physician boycott is an "overblown" paper tiger unsupported by facts on the ground involving real docs, like hospitalists, cardiologists and geriatricians.

Yet, the ACP's Bob Doherty wonders if things could be different this time. His anecdotal conversations with docs makes him think that substantial - if unquantifiable - numbers of physicians are really thinking about dropping out of Medicare.

Which brings the DMCB back to the topic of "ERM." This is defined as the systematic and objective quantification of all significant risks to a business. ERM typically includes identifying what risks exist, their individual likelihood, their potential magnitude, strategies for their mitigation and assessing progress in keeping them at bay.

Congress' Medicare ERM issues are multiple and include the growing number of baby boomer beneficiaries, their considerable appetite for pricey technology, looming government debt and the involvement of sophisticated organized crime networks in Medicare fraud. But one important risk that continues to languish is the SGR and the potential for a physician backlash.

The DMCB thinks Medicare's Board, i.e., Congress should perform its fiduciary duty and use ERM to carefully examine the issues raised by Mr. Doherty.

What is the risk of a physician boycott?

While the prospect of a wholesale nationwide exodus of physicians from Medicare participation is still small, it is not zero and, given Mr. Doherty's credible suspicions, the risk is growing. The risk is probably greater among the smaller physician owned practices with access to alternate sources of patient care income. It's likely to first show up in refusals to accept new Medicare patients. It'll occur regionally (Texas may be a good example) and vary by practice specialty. The risk is highest among the "cognitive" physicians who a) can't make up for lost revenue with additional patient volume, and b) are dealing with payment rates that have been widely regarded as inadequate.

What is the potential magnitude?

There are two dimensions: operational and political.

It's operationally moderate because of two factors:

1) the relationship between the threat of an SGR reduction and a physician boycott is not linear. While current physician Medicare non-participation rates are low, reaction to inadequate payment rates could quickly cascade under a classic self-reinforcing phenomenon. This is discussed by the DMCB in greater detail here,

and

2) the interplay between spotty regional access issues and other parts of the health care system - even if access is maintained - could lead to further stressors. While low numbers of Medicare beneficiaries per primary site may not be able to receive primary care, the phenomenon at a regional level across multiple sites could easily lead to delays in care, emergency room crowding and spikes in avoidable hospitalizations.

It's politically high because even spotty regional access problems could be spotlighted by the news media and used by opponents of health care reform to further gum up the President's agenda.

How can it be mitigated?

It's going to take either a) finding new money or b) moving money from other sources. That's the topic for another DMCB post but two additional points should be made:

1) thinking that "savings" from efficiencies, prevention, wellness or the electronic medical record, medical home and accountable care organizations demos and pilots will solve the SGR is fanciful thinking. Don't even bring it up, because the doctor-audience won't believe you. They're too smart.

2) Just the threat - real or not - of an SGR reduction is undoubtedly causing physicians to plan for the possibility of a boycott. Accordingly, "the SGR" needs to be removed from the public spotlight and replaced by a credible signal that Congress and the Administration are taking Medicare payment rates seriously.

How should progress be measured?

In addition to regularly reading the ACP and DMCB blogs (and being skeptical about the can-do-no-wrong loyalty of liberal media sycophants), MedPAC should reinvigorate its reports (like this one that said no problem) and reexamine access from the perspective of ERM with special attention to specialty, region, practice size, non-linearity and worse case scenarios.

The Federal government failed to adequately assess the environmental risks of deep water oil drilling and the systemic financial risks from the easy money and housing bubble. It's not unreasonable to ask if MedPAC is on the verge of committing the same mistake in a key part of healthcare policy.

(Addendum: Interested in this debate? There's more here)

*an organized physician group that represents internists, who focus on prevention, diagnosis, and treatment of adult diseases. The DMCB not only a proud member of the AMA, it is an internist and an ACP Fellow.

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The Paradox of Workplace Posters in Healthcare Facilities: Don't Mean It? Then Don't Post Them.

The Disease Management Care Blog received this posting from an experienced nurse with a background in clinical and administrative medicine. Ouch!

We’ve all seen them. Those vacuous workplace posters exhorting teamwork, creativity and other forms of inspiration and accomplishment. A version has begun to creep into our nation’s health care facilities. reminding everyone of the need for privacy, how infections can be spread and the importance of patient service. And if my experience is any indication, they can also amply demonstrate to patients just how badly broken the health care system can be.

During a recent visit to a local medical center, I noticed the elevator posters of the really cute child saying “shhh” with a finger over her mouth along with a tag line about patient privacy. As I was waiting for my elevator, I could hear a overhear a resident dictating a surgical summary about a named patient’s a bowel resection, low blood pressure, blood loss and signs of malignancy. Good thing the patient is not my neighbor.

And how about the signs telling patients to remind providers to wash their hands before touching them to help stop the spread of infection? During another visit, my mother's physician seemed was surprised when I pointed out the poster and asked him to wash his.

My primary care physician has a poster that tells me to ask my doctor 3 things before I leave: what is my major problem; what do I need to do to manage it; and how are they going to help me manage it. After my physician’s office staff grudgingly gave me a "sick appointment" for my pleurisy, I had x-rays and a cursory examination. I asked the doctor the 3 questions the poster told me to. He told me we would discuss that the next time I see him. While I wait for the x-rays results, there is no follow-up scheduled at this time and no treatment has been prescribed.

While these and other posters are intended to educate consumers and remind providers, I’m running into doctors who are ignoring them. Paradoxically, these posters are reminding patients of lax privacy, the risk of avoidable infections and lousy customer service.

Here’s a suggestion for you well meaning hospital administrators: until you really fix these problems, don’t inflame things with posters. Put up pictures of what you’re apparently really all about: cash.

Coda: After this post appeared, the DMCB subsequently got an email from a colleague that pointed out that there are other opportunities for poster-addled hospital administrators to display their leadership and patient education skills.

Don Berwick Becomes Part of the Problem

According to the New York Times, a "recess appointment" will be used to install Don Berwick as the CMS Administrator. It seems this was the only way the Obama Administration could bypass those obstreperous Senate Republicans, who were apparently planning to abuse the confirmation process with toxic puffery, "gotcha" politics and other forms of unpleasantness.

There are plenty of good arguments in favor of the recess appointment, including fixing an obvious leadership vacuum at the worlds largest health insurer, accessing Dr. Berwick's considerable skills in implementing countless details of the Affordable Care Act (ACA) and capitalizing on his widespread support from the multiple corners of the health care industry. As my liberal colleagues like to point out here and here, this is also an opportunity for the Administration put its reasonable centrism on display while reminding its base of its commitment to health reform and simultaneously poking the eye of a bullying opposition.

While the non-liberal contrarian Disease Management Care Blog was among the first to endorse Dr. Berwick, it respectfully if naively disagrees with the strategy of a recess appointment. Here's why:

1. The Body Politic: While he's well known among physician and policy types, this was an opportunity to use a visible forum to introduce Dr. Berwick to other constituencies less familiar with him and his important ideas. Our nation's healthcare dialog did not end with the passage of ACA.

2. Transparency: Dr. Berwick's academic record, obvious leadership record and considerable rhetorical skills are more than a match for the Senate's scrutiny. Who is afraid of who?

3. Seizing the High Road (OK, it is the oxymoron of politics, but....): Republicans threatening to behave badly and remind Americans about their dysfunctions is a problem for the Democrats? In the few months until the election, it may be time for the Dems to start rolling the dice on acting honorably.

4. It stinks! Speaking of dysfunction, is the outcome of expediency worth short circuiting merits of a Senate supermajority? Will Dr. Berwick's credibility over the next two years be hampered by the recess appoointment? The Obama Administration is one-upping the opposition's political maneuvering with their own. The whole thing brings discredit to both parties.

5. Bloggery: The confirmation hearings promised to be a cornucopia of detailed analysis, second guessing and extreme wonkism. Darn.

Of course, even the DMCB isn't too sure that, if it were Dr. Berwick, it would have been able to resist the sure bet of a recess appointment in lieu of bruising Senate confirmation. There's something to be said, however, for the selfless heroism of the third option: respectfully declining the CMS post with the option of reconsidering when one of three things happen: 1) both sides get serious about putting the people's business over politics or 2) the bums get replaced by politicians who know how to compromise or 3) the Feds realize that intelligently centrally controlling health care is a myth.

Unfortunately, accepting the recess appointment continues business as usual.

As for things changing, the DMCB isn't holding its breath.

Coda: It didn't occur to the DMCB that the confirmation process posed election risks for some incumbent Democratic Senators. One small consolation is that at least Senator Baucus (D-MT) understands the bigger picture.

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More on the (Non)Death of Small Independent Physician-Owned Primary Care Practices

Somewhere in the Obama Administration, there is an elitist central cabal that operates with the support of the highest organs of our central government. It conspires in windowless basement rooms to plot the gun control, mass vaccinations and the nationalization of key U.S. economic sectors like automobile and chardonnay manufacturing.

Healthcare, however, is its maximum target. Much like pieces on a chess board, and with the support of renegade organizations like the Commonwealth Fund, the New England Journal and UNICEF, it wants to arrange hospitals and providers into regional klepto/monopolies that coordinate care, deprive us of access to breathing as well as dialysis machines and suck up tax dollars faster than Ms. Pelosi can say "but we're saving money!"

Just kidding, but it does seem to the Disease Management Care Blog that a lot is riding on the concept of large, regional and risk-bearing "accountable care organizations" (ACOs) that can reconcile cost and quality. And don't think that there isn't a hospital CEO, academic medical center Board or a medical school Dean that isn't lusting over the prospect expanding and consolidating their local empires under the guise of Obamacare and enlightened not-for-profit community service. Ask these healthcare potentates, and they'll tell you that this is the wave of the future, where size, access to capital and rationalized central planning will finally break the back of health care inflation and those evil insurers. It's Wal-Mart, it's Amazon, it's the electronic record, it's inevitable, right?

It's easy to think that is the conspiratorial purpose of the Central Committee's minions when it comes to small independent PCP clinics. And thanks to the travails of managed care, Medicare's SGR, competition over Botox parties, poaching of patients by Convenience Clinics and dismay over Concierge Practices, what's left of primary care is ready to be swept up into ACOs, right?

Maybe not so fast, according to an article appearing in the July 3 issue of The Economist. Dubbed "The Click and the Dead," it describes the double whammy of transparent E-Commerce pricing and economies of scale that slaughtered smaller book stores and travel agencies. However, it turns out that the very smallest book and travel shops with low numbers of employees, lean overhead and special service niches thrived despite the fierce competition from the Internet and big business.

Which is why the DMCB thinks some primary care practices will consolidate and many will become aligned with bigger health care systems. However, a considerable percent that remain small, minimize costs and, most of all, provide high customer value (defined as a combination of service and quality) could continue to thrive.

The DMCB has opined before about reports of the death of small practices being an exaggeration. Maybe it's wishful thinking, but this article in The Economist is another reason to keep an open mind.

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flying by the seats of our pants

In a couple of days, my little family is heading to Florida.

We'd been planning our road trip for some time. The decision to drive was partly about affordability but we also enjoy watching the scenery change and interacting with folks in the different states through which we pass.

This time, we were planning on doing the trip a little more slowly in order to take in more than the outskirts of cities along the way. We'd been thinking of taking a detour to Gettysburg on our way down and visiting Savannah on our way back (we have twice stayed in chain motels on the outskirts without going into the city. This notion breaks my heart).

The trip is long though (24 hours of driving) and exhausting (especially for T., who does all the driving) and while we have many great memories of our family road trips the whole thing can be a bit of a grind.

Last year, we had a great drive to PEI. The return trip was a different story. Before the keys had turned in the ignition, the boys were screaming at each other. While there were brief truces along the way (and I spent a fair bit of time in the back seat, so as to separate the siblings), I lost count of the number of times we had to pull over until calm could be restored.

The boys are both a year older now, so we were feeling optimistic.

But I couldn't help doing a little online search for cheap flights. And, after playing around for a while (it was rather like playing a game of Scrabble, or piecing together a puzzle), I was able to find a way for us to fly that was no more expensive than driving (it involved two of us flying on points and two of us going on cheap tickets but while we aren't flying together, we are, miraculously leaving and arriving at close to the same time).

We called a family meeting to discuss the pros and cons.

We were pretty evenly divided as to what we should do. There were lots of good arguments on both sides.

And then the boys started to bicker about whose fault it was that they'd fought so much on last year's road trip.

T. and I looked at each other over their heads and made our decision.

We're flying.

But I'll miss the corn bread at Cracker Barrel, the biscuits at Pop Eye and the road-side barbecue in the Carolinas and Georgia.

Maybe we'll go on a mini road trip while we're in Florida.