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Two looming factors are set to ring the death knell for the small medical practice: 1) the sustainable growth rate formula; and 2) the Patient Protection and Affordable Care Act.
The former, set to kick in in December after numerous Congressional stays,* now dictates a 20-something percent drop in Medicare reimbursement to physicians. That alone could put the kibosh on many small physician practices that don't have the financial reserve to withstand such a precipitous drop in revenue. And while the Obama administration supports a financially responsible (if one exists) repeal of the SGR formula, Congress is unlikely to act. Repeal of the 12-year-old legislation would be viewed as an untenable increase in spending. Consequently Congress has repeatedly suspended the formula, while keeping the law "on the books" to avoid a monstrous increase in the already monstrous deficit.
Whether Congress will suspend the SGR formula yet again is a mystery, albeit a short-term one. General opinion appears to be swinging in the direction of allowing the legislated cuts to begin. In fact, Medicare's trustees recently issued a rosy financial report on the program's Part B service, which assumed the SGR-defined cut.
The second impending factor for small-practice physicians, PPACA, heavily promotes the consolidation of healthcare providers into large groups to withstand the number of legislated reforms, including investment in information technology. In fact, buried in an opinion/cheerleading piece for PPACA, newly published in the Annals of Internal Medicine, is the following forecast from White House health-policy advisors.
These reforms will unleash forces that favor integration across the continuum of care. Some organizing function will need to be developed to track quality measures, account for and manage shared financial incentives, and oversee care coordination. Consequently, the health care system will evolve into 1 of 2 forms: organized around hospitals or organized around physician groups. These coordinating functions, to the extent that they currently exist, traditionally have been managed by hospitals or health plans. Only hospitals or health plans can afford to make the necessary investments in information technology and management skills.
But the advisors spin not-so-different alternatives:
This is not inevitable. As physicians organize themselves into increasing larger groups—patient-centered medical home practices and accountable care organizations—they are, out of necessity, investing in information technology tools that are becoming both cheaper and more capable and investing in the acquisition or development of management skills that could provide these organizing functions efficiently for physicians groups.
They then make a promise or threat, depending on your viewpoint:
Physicians who embrace these changes and opportunities are likely to deliver the greatest benefits to their patients, the health system, and themselves. Physician practices that accept the challenge will be rewarded in the future payment system.
It's spoonful of PPACA medicine that not everyone's willing to swallow, however. Over at Medscape, reporter Robert Lowes found several physicians and/or health-policy leaders who argue against the seemingly inevitable vertical integration of healthcare. For some, like Dennis Smith, former Medicaid director under George W., the push is an "example of big government meddling," Lowes reported. Lowes also obtained a nice quote from Smith: "If a physician's only choice is to join a large corporation, we're going down the wrong path." There are plenty of physicians still around who remember not-particularly-happy experiences with large HMO-led practices in the 80s and 90s.
* Five or 6 in the last year; I've lost count.
Still from Black Narcissus trailer. Here Kathleen Byron (in a sinful red dress) plays the role of PPACA, and Deborah Kerr (in a nun's habit) is the physician in a small medical practice.
Last week's report of a beta-lactam-resistant superbug in the United Kingdom,* which was likely imported from India, highlights the infectious risks associated with medical tourism, according to an accompanying editorial. The growing trend of traveling to get medical care in non-Western countries—particularly for procedures not covered by insurance (eg, gastric bypass)—is expected to grow in India at an annual rate of 30%, says a 2009 news report. By 2015, medical tourism in India will be a 95-billion-rupee or $2-billion industry (if I'm calculating correctly).
At least one Indian doctor is accusing the report's corresponding author, who happens to be from the UK, of fear mongering and racism (despite the fact that multiple nationalities are represented by the listed investigators).
* Specifically Klebsiella pneumoniae and E. coli containing New Delhi metallo-beta-lactamase 1.
Scanning electron micrograph of E. coli bacterium from CDC/Janice Haney Carr.
A pattern of 3 markers in CSF—beta amyloid 1-42, phosphorylated tau, and total tau—appears to strongly predict Alzheimer disease in people with mild cognitive impairment (MCI), according to a newly published and highly publicized study from the US Alzheimer's Disease Neuroimaging Initiative. But the study findings, which can be found in the Archives of Neurology (subscription required), do not necessarily mean that the CSF assay should be incorporated immediately into clinical care—despite the fact that 1) the authors are lobbying hard for the test to be included in the diagnostic criteria for AD and 2) an accompany editorial urges clinical use of the CSF assay with the wince-inducing title, "Sharpen That Needle."
The "AD signature" of low beta amyloid 1-42 and elevated tau levels was found in 90% of AD patients (n = 102), 72% of MCI patients (n = 72), and 36% of cognitively normal subjects (n = 114). Consequently the sensitivity of the test is 90% (the rate of positivity in AD patients), and the specificity is 64% (the percentage of cognitively normal subjects who don't show the AD CSF pattern [ie, 100% - 36%]).
Among a subset of 68 people with autopsy-confirmed AD, 64 (94%) showed the AD CSF pattern, which correlates well with the 90% sensitivity measure in clinically diagnosed AD patients (via the MMSE). In another subset of 57 patients with MCI who developed AD during 5-year follow-up, all exhibited the AD CSF pattern for a sensitivity of 100%.
Rather than view a positive CSF assay in cognitively normal people as a failing of the test (ie, it has limited use in normal subjects), the authors conclude that these people are at risk of AD. This conclusion may well be true, but it seems that further study is warranted before such a bold statement can be made. The authors did find an "enrichment" of the apolipoprotein E ε4 allele, a recognized genetic risk factor for AD, in this population, but the finding was not uniform.
At least ABCNews, unlike many other news sources, found medical commentators who advise against the whole-hearted embrace of this assay. Cliff Saper, who is one of the most level-headed neurologists I've ever met, said there is no reason to perform the test until there is a successful treatment for AD. "This test shows up positive in presymptomatic individuals, and Alzheimer's disease is a common disorder," Saper was quoted. "The main value would be to detect [Alzheimer's disease] in atypical cases." For what it's worth, I agree.
The CSF assay currently appears to be most useful in the context of research—as an additional tool to reinforce the diagnosis of MCI or AD in clinical studies. Assay results may also inform the use of investigative therapies at different stages of cognitive decline. One of the most intriguing findings from the study is that there appears to be a distinctive pattern change as MCI progresses to mild AD and then to advanced disease: CSF beta amyloid levels fall while tau levels rise. Anti-beta-amyloid therapies like bapineuzumab, may provide relatively greater benefit in MCI or very early AD, while anti-tau therapies may have their place in more severe dementia.
In the meantime, Innogenetics, which employs or employed several of the authors, provides the tripartite CSF assay (Inno-Bio AlzBio 3) for "research use only." Information on the cost of the assay, after several Google searches, remains elusive.
CSF = cerebrospinal fluid.
Photograph of atrophied brain from person with AD: National Institute on Alcohol Abuse and Alcoholism.
The improved outlook for Medicare's solvency, which increased from 2017 to 2029, is due to PPACA, say Medicare's trustees* in their newly released summary report (the full report can be found here). The trustees essentially borrowed on the projected savings (or really anticipated cost-cutting measures) from legislated healthcare reform to extend the life of Medicare's Hospital Insurance Trust Fund specifically.
The life of Medicare's Part B service, which covers outpatient and prescriptions costs for seniors, was also extended. But the trustees' current projection on Part B assumes that the SGR-defined cut in Medicare reimbursement to physicians will kick in December 1, reports MedPage Today. The cut now stands at 23%. Congress has repeatedly voted to stall the cut but is yet to repeal the formula; to do so would add substantially to the deficit. (One healthcare expert recently predicted in the NEJM that Congress will never repeal the formula.)
The trustees' report, in some ways, is a veiled warning to those Republicans (and Republican states—lookin' at you, Missouri) who would attempt to mess legislatively with PPACA. You repeal PPACA, they might say to detractors, you doom Medicare (and Social Security) to an earlier death.
PPACA = Patient Protection and Affordable Care Act; SGR = sustainable growth rate.
* Timothy F. Geithner, Secretary of the Treasury; Kathleen Sebelius, Secretary of HHS; Hilda Solis, Secretary of Labor; and Michael J. Astrue, Commissioner of Social Security.
Yesterday Missouri voters, assumed to be mostly Republican, tried to nullify the federal mandate to purchase insurance or pay a tax penalty, as dictated by the Patient Protection and Affordable Care Act. But the approved state measure, known as Proposition C, is largely seen as an empty Republican nose-thumbing to the Obama presidency and PPACA.* By the time the insurance mandate goes into effect in 2014, courts will have already decided on the constitutionality of the federal law. And federal law usually trumps state law, when the challenge arises.
Voters in 2 other Republican-heavy states, Arizona and Oklahoma, will vote on similar paper tigers this year.
The NYT has a limited story. The St. Louis Post-Dispatch reports that Proposition C passed by a margin of 3 to 1 and that the Missouri Hospital Association attempted last-minute opposition.
* Pronounced fondly as puh-PACK-uh.
Seal of the state of Missouri from http://www.sos.mo.gov/symbols/default.asp, where it can be learned that the state fossil is the crinoid.
According to early-release 2009 data from the CDC.
A big HT to the WSJ Health Blog for showcasing this intriguing study in Health Affairs. Against the otherwise commonsensical preference for screening colonoscopy (to prevent and detect colorectal cancer), researchers at RTI International showed that yearly testing for fecal occult-blood leads to more life years saved. The result held even when adherence to CRC screening guidelines dropped to 40% and follow-up compliance was only 65%.
The context of the study was a fixed budget for a CRC-screening program ($1 million), and the assumed costs for guaiac testing and colonoscopy were $23 and $699, respectively. (Although the Healthcare Blue Book price for colonoscopy [no biopsy] is much higher, at $1658.) Consequently fecal occult-blood tests allowed the hypothetical program to screen more individuals and lead to a greater number of life-years gained.
The authors warned that the study only assessed life-years gained, not quality-adjusted life years (QALY), and that the test selection was made in the context of a fixed budget. "If there were no budget constraints," they wrote, "a different screening test might be preferable."
But really: When are there no budget constraints?
Addendum: At the WSJ Health Blog, one commenter raised the issue that the authors only assessed a hypothetical population-based screening program. The results do not necessarily indicate that fecal occult-blood tests are preferable screening tools for individuals who are at high risk for CRC (eg, people with Crohn disease or a family history of CRC).
Photo of Olympus standard video colonoscope: price, $3500. (Avoiding Olympus standard video colonoscope: priceless.)
As predicted, more or less, by Yale's Jack Balkin in January's NEJM, the T word is hauled out to defend the constitutionality of ObamaCare's health-insurance mandate.
In fact, in one of the many legal cases protesting the insurance mandate (and the associated penalty for not having insurance), Balkin and others rebutted with an amicus brief that argues the T point. The NYT has the story.
When it comes enforcing or repealing the SGR formula, the legal fix that was designed to reduce Medicare growth way back in 1998, don't look for decisive action from Congress any time soon. So says Henry Aaron of the Brookings Institute* in this week's NEJM.
Congressional enforcement of the SGR formula is untenable because it means making increasingly draconian cuts in physician reimbursement (~21% this year). But the abomination (as Aaron calls it) won't be repealed because the Congressional Budget Office will view the act as an increase in spending. So for now, Congress repeatedly suspends the formula, while keeping the law "on the books" to avoid a monstrous increase in the already monstrous deficit.
However, Aaron offers hope—albeit faint hope. The Patient Protection and Affordable Care Act (aka ObamaCare) offers several provisions that allow for the study of pilot programs (eg, accountable-care organizations) that may [yeesh—tugging at neckline] streamline healthcare and cut costs. Physicians could someday be sufficiently motivated to participate in one or more of these programs, Aaron argues, if the alternative is sustaining a very-deep SGR-defined gash in Medicare reimbursement. Aaron evokes the near-future image of Congress as Vito Corleone ("make physicians offers they can't refuse), but I've got a more vivid picture: Luca Brasi and the Johnny Fontane contract.
SGR = sustainable growth formula.
* Not Henry Aaron of the MLB.
Photo of weathered can from magannie at Flickr.
Two studies* have now documented that Medicare spending per beneficiary varies widely on the basis of geographic location. The latest study, published in today's NEJM, indicates a difference of up to 52% between the highest- and lowest-spending areas in the United States. But reasons for a big portion of this spending difference remain a mystery.
While the authors conclude that some regionally based differences in Medicare spending per beneficiary can be explained by baseline health and demographic characteristics (like age, sex, and race), explanations for 60% of the spending difference are unknown. The researchers speculate that differences in Medicare spending might be influenced by a number of factors, including what boils down to fraudulent Medicare billing (eg, "providers' profit-seeking behavior" and "rates of inappropriate Medicare payment").
My own view, given a recent hospitalization, is that rampant billing fraud by in-hospital physicians (whether targeting Medicare, insurance companies, or patients) plays a substantial role. If my experience is any indication, it seems the rule,** rather than the exception, for physicians to greatly exaggerate their services—both in terms of level of care provided and time spent. Unfortunately this type of billing fraud is difficult, if not impossible, to detect, unless a very granular survey of physician billing can be compared with a reliable account of services actually rendered. And a reliable account probably requires the input of an unusually savvy patient—like a hospitalized physician.
* The first is Sutherland et al. NEJM. 2009;361:1227-1230.
** At least in my neck of the woods.
