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Thursday, February 07, 2013

Will the 'doc fix' revolutionize U.S. healthcare?

I'm new to this, and so lack important context, but it looks to me as if a pending 'doc fix' -- a long-term replacement for the failed Medicare reimbursement formula (part of the Balanced Budget Act of 1997) that Congress patches up every year --could transform our healthcare delivery system at least as sweepingly as the Affordable Care Act.

Modern Healthcare's Rich Daly reports that two rival bills have been introduced. A bipartisan bill all but phases out fee-for-service, while a GOP bill preserves but modifies it. The first,  introduced by Rep Allyson Schwartz (D-Pa) and co-sponsored by Rep. Joe Heck (R-Nev.), an osteopath, is summarized by Daly as follows:
Schwartz's bill (PDF) would mostly unravel the fee-for-service system by requiring physicians to adopt one of several replacement models that the CMS would test and approve over five years. Physicians who did not do so would face successive payment cuts, although a small number of physicians could remain in a modified fee-for-service system if they met certain quality benchmarks or were near retirement.
The bill directs CMS to  "aggressively test and evaluate new payment and delivery models" and would phase out most fee-for-service by 2019. The AMA opposes this one, but the American Academy of Family Physicians approves it. 
 
The bill introduced by Ways and Means Health subcommittee Chairman Kevin Brady (R-Texas) moves more slowly and equivocally to change payment systems:
The Republican alternative (PDF), according to a Ways and Means Committee memo, would continue wide-scale use of a modified fee-for-service system while offering extra payments for physicians that undertook efficiency improvements.

Brady's anticipated bill also was expected to give physician groups a bigger role in determining which replacement payment models the CMS would utilize. His bill would require physician groups to endorse the quality and reporting activities Medicare would use to determine individual physicians' fee-for-service payment increases.
The (pardon the expression) Brady bill does bear marks of letting the foxy physicians guard the payment henhouse.  Nonetheless, it acknowledges that "reform is needed to maintain a viable FFS system," envisioning payment updates "based on performance on meaningful, physician-endorsed measures of care quality and participation in clinical improvement activities," with pay for performance "based on both relative rankings amongst physician specialty peer groups and improvement on quality over time."  Brady emphasizes the difference in who controls the performance measures: "The CMS would have more authority in the Schwartz bill to determine on its own which alternative payment models tested over several years should serve as replacement payment systems."

Again, I lack context.  Perhaps long-term doc fix bills are introduced all the time, and the two parties are too far apart to get anywhere. Perhaps Republicans are determined to basically hand the process to doctors.   Maybe I shouldn't be surprised that major change is proposed: it seems logical that the legislation setting reimbursement rates would have much to say about the basis for payment. But I am still surprised that the doc fix is looked to as mechanism for changing that basis so thoroughly -- and that Republicans at least acknowledge the need for change that they might denounce as "bureaucrat-controlled" medicine.  And to the untrained eye, on the face of it, a compromise amalgamation of the rival bills seems conceivable.

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