tv American Enterprise Institute Discussion of Medicare Payment Rule - Panel CSPAN November 28, 2018 1:13am-2:51am EST
. >> good morning thank you for coming to the beginning of our program continuing with a distinguished panel and before i get started on the introduction a couple of observations this is interesting and important this issue really goes back decades talking about the questions of spending time with those complex problems this is obviously something that is dated when they put in place
to have more volume around those types of reimbursement programs so we should go into those topics because it is complicated and it's hard to predict the outcomes of policy changes. in particular congress intervened in 2015 the intervention was designed to spine the despite the sustainable growth rate and a lot of people thought that was the beginning and with that predecessor program called the
volume performance standard. and this has a long history in 2015 the curious thing i'm still scratching my head about and what had been looming for many years. the end result was in a lot of people do not understand that because the updates and then.2 5 percent and if you're lucky enough to find your way.
what was probably realistic so even as we correct these problems with a massive long-term problem one way or the other i hope we can talk about that in our discussion and and then over meeting the long term but so one way or another the system will be changed over time. so now i will give each one a minute to talk about their
background and then i will introduce them first but the full biography is available online they all have a very distinguished professional records i will summarize some of the points but the materials handed out there full bios are there in online. the first panelist is bob was a fellow at the urban institute and in the vice chair. and practice for 20 years and serving in many distinguished roles in government including cms and then to oversee the entire payment system with that regulatory approach contracting with the medicare choice program with the carter
administration and domestic policy council. followed by doctor john goodson associate professor of medicine at the harvard medical school administrator consulted with him on various aspects of physician payment and a practicing intern the massachusetts general hospital with a lifetime interest to build a robust workforce and their interesting points to make in that regard. those at the laura and jonah arnold foundation serving as executive director from 2002 through 2017 a long tenure but more importantly and also at
cbo and a cms and they have a long industry to take care of those issues and around medicine and from 2017 to maintain a geriatric primary care practice and with those resource -based update committee. another great program. and finally the last panelist and he served as coo director of policy and regulatory oversight. and then coventry to be bought
alternative? that cmi cannot find alternatives they are willing to do. and with that hit the administrator and from the entitlement program. i was doing primary care application in the eighties and for physicians to take that plate payment model. so right now i will talk about the challenge to speaker pelosi and this is where we are right now. so i agree with the administrator about all of the negative impacts of the documentation guidelines and the internal perspective from
comprehensive history and moderate decision-making. the second surgeon with that focused history of physical as was appropriate. that it was only one number difference in paying those first surgeon $180 and then the longer more satisfactory and the 90-dollar difference goes right to the bottom line if you figure out they saw 20 patients then you can do the math how much medicare was
paying but i want to make a different point as well. i am looking on the bright side but the actual code he should have used is not paid adequately for his expertise getting what he thought he deserved so the point that i'm making here is the entire category of evaluation management services is undervalued to those interpretations and really should be addressed and the second point which is somewhat modified but basically exist
in the final regulation to permit the limitation of the documentation guidelines over time but i would argue that the cure is worse than the disease there is a reason i'm moving to a code that the beneficiaries would be shortchanged and the deacons offices would be quicker for which they would be overpaid in the beneficiaries would be harmed there is good evidence those are at different amounts and some routinely up code because they can and we can
talk about that later if you want i think with additional data it would be to combine for those aficionados but we can talk about i want to make a plea that we read gain that control to have a standard that they all can be judged by right now the current descriptions of these codes try to find a common denominator with that decision-making and in fact, by the range of specialists all over the place to do a very complex history and
physical spending a long time to work with the patient with dementia ten or 15 medications somebody else giving the bad news over life-threatening illness it is all over the place to describe all of those variations in simple generic terms what is the common denominator? with simplified coding with time being auditable and universal so with two final points that frank analysis has shown it actually predicts
80 percent of the work to be a major component of the fee which is the work which is the value of physicians time. so medpac estimates the bill based on estimates that were first provided by specialties would be the recipients of the estimate sometimes they are wildly inflated but they massaged those time estimates and do not accept them all but as the basis to establish what the correct time is a just a couple of examples to follow the marx brothers who will you believe?
me or your own eyes? those that may have experienced as a giver or receiver has anybody seen the nitrogen canister? the estimate based on recommendations would take more than 20 minutes which never happens i just had it done the other day that to be on this wildly exaggerated time the position does have to look at it and in my case over two or three minutes that generally is not required and research at the urban institute it takes on average
about 15 seconds. these are fairly dramatic across the board to let me finish with this point that cms needs to invest in the empirical time data not only how many coats are needed in the offices if there is a national break between level three and level four but i will go with that empirical data to currently generate $23 billion of spending in a year out of about 90 billion. this is a big deal. cmm i on the other hand, has been appropriated to spend 10 million over ten years and
the center for medicare spends nothing on research and development and as a result but we are still basing a lot of policy decisions on estimates with that empirical time data with that institute with that feasibility study to cut that feasibility that is now a cms needs to do as it is considering whether brake should be to get the empirical
time data for the entire fee schedule i will stop with that. . >> it is such opportunity to be with you to where we are and where we need to go and how we got here in the first place i don't know to understand the origins so going back into the 1980s a free forearms system practice because people charged widely for that feature so they had to tame the monster that's how the system evolved so there
would be a fee schedule and services to find and each are included national standard that is now the fee schedule so there is the key assumption in this model that needs to be addressed and this is the perfect moment to go back and decide if the whole system needs to be reevaluated so one assumption is there is this relatively within the practice of medicine my father has two sons. one is a surgeon and one is a physician. that speaks to the contrast of these two worlds you start and you and the world of the physician is the matrix world
like sherlock holmes on pbs where he is grasping to pull things into formulate a plan those that live entirely in the world of cognition this is the essence of the work but with those original proposals that this was an incomplete process those services were not fully defined or appropriately valued that was in 1982 and nothing has changed. there were codes this was all compressed into a tiny number that is our medicine has practiced in almost three
decades. that cms is ultimately responsible they own this and the definitions of those services. one that started now there is 9000 so every year cms publishes the values they will pay for those services that are used by the commercial industry that is the way things are priced within medicine but it had some worry some consequences though congratulations to the administration because i think it's time to open this up and look at it. it began with an attempt but
that fundamental definition of services and evaluation talking about one notion to redefine services based on time the other way this could be addressed it is the perfect moment to think about the consequences of what we have done before and what we are proposing there is no set solution. but now we have everybody's attention to focus on this want to spend a few minutes what we have been looking at to demonstrate the consequences of the current system of the workforce. we use medicare payment data for every specialty and look
at every single county in america. so the cdc reports the cluster the death rates due to specialties. but it turns out i'm not alone with those workforce challenges or those specialties that are cognitively intense. so let's take a look at our slides. we will pull them up one moment looking at the first map.
the death rates are attributable that you will notice there is a denser area into the ohio river valley and the appellation area. there are massive areas in this country but no infectious disease at all. this is diabetes and all the complications and where the endocrinologist are. these are strokes and so forth. where the neurologist are. maybe this is just the way doctors distribute themselves so take a look. ophthalmologist. orthopedic surgeons.
you altogether. there is a difference. what are the ratios? the specialty per 100,000 of medicare beneficiaries? six.six orthopedic surgeons as a.2 one.six under can knowledge a one.68 infectious disease specialist. it is a consequence of the system gone awry too many incentives making a ton of money. the distribution of the talent for those that come out of medical school. you can say there is something going on so here is the ratio of the counties that have the lowest density to the highest.
so orthopedic in ophthalmology the top to bottom about four / one and some of these other specialties, those three clusters you can see that something is going wrong here and those consequences of the status quo. why is this? the talent is not going in so they are unfilled programs for specialties for this year. and just to point that out infectious disease one third did not fill. think about any normal - - any amount will we have the talent?
we know how difficult it is to get a primary care physician that we now know is becoming increasingly difficult to find somebody who can help with the difficult infection or neurological problem or diabetes not managed well. so as a consequence of what we have now what has been proposed is not address this issue it doesn't get to those services that are a non- procedural list so think of the world of medicine the advent of an extraordinary number of interventions we are more aggressive about the attempt to manage diseases
to take the opportunity to collect as much information to see it fall into categories that our discrete - - discrete time may be the best indicator but right now it's speculation but then fundamentally you can be sure the most complicated cognitive activities are on par with complicated procedures that a surgeon can earn as much that i earn in the entire week is a fundamental problem that must we addressed. finally the electronic health records has opened the opportunity to do things we haven't been able to do before right now it is a hodgepodge but the extension before that
they are glorified word files we need them to focus the most important part that goes on in the world of medicine so there is an opportunity to create a new set of expectations for electronic health records with the new definitions of services in the fee schedule. thank you very much in the fee schedule. thank you very much a couple things shouting out to jim i am seriously damaged by that experience. [laughter]
another complaint is ancient history this is my career. [laughter] i do not appreciate it. [laughter] i will start off with the typical angry rant i am known for also third in line i said everything so i don't have to make up new stuff all this make it sound like i'm saying something original so there are a few things here want to emphasize because some things have come up that i want to do -underscore it is important to remember some things what happens to the fee schedule jibes to manage care bundles physician order bundled payments with that those who
go to medical school so it is important to talk about. so to say a few things that will pivot off to a larger point it is a good step they are trying to reduce documentation i agree with the notion that bob was talking about the notion to use time for the fee-for-service fee schedule as a measure make sense that is the direction i would go to stay within the context of the fee schedule. the big missing point is the comment and several others is the imbalance of the fee schedule it was intended to
correct way back in the day and that has not happened there is enough evidence if you look at the procedural side of the fee schedule versus the cognitive and primary care there is ample evidence those time assumptions are incorrect and with that hourly and aggregate compensation data is restorative enough to take large deliberate steps to rebalance the fee schedule. you can collect information but i wouldn't wait for that there is enough action to take deliberative action to increase that conversion factor of primary care services on the cognitive specialty or the differential
update for the cognitive care side and what do you do about all these updates that leads to a budget neutral framework you could pay certain physicians you want to see grow more than you would under current law and they say that very directly that we should go with the fee schedule in the meantime to come up with a more accurate time estimate would make sense there is enough evidence to move now there is enough evidence to move now but that primary care and stop paying on the basis
of the fee schedule so my comments were in the context of the fee schedule but i will start to make up her patient basis to the primary care physician. so you have a payment that gives the patient the flexibility to have medical and social services and interact more completely with the patient outside of the context of the office visit. and then to pay for that with the peace phone - - with the fee schedule and to pay on a block service that would require a beneficiary to have that designated relationship with their primary care
physician is probably not a bad thing to have. a lot of that motivation today is about documentation and to the point of that credit i was going to make if you are interested than what about this situation? you could go into the advanced payment model and then you are paid for the quality measurement process that process is broken it would be abandoned those measures tended to be process measures for a comparison unfair or irrelevant along those lines
this is a tremendous amount of burden we should be that zero burden on that provider and that vision that i see population -based outcome measures and patient experience measures and the outcomes measure from claims and comparable measures for the service market and managed care and the data collection process is providing information we have much more focus on outcomes including value of service. those are most of my comments. i could probably stop here but a couple of shout outs i strongly endorse the site
neutral payments as a policy that came out several years ago i think there are some other directions that cms could pursue there but i also want to point out in the comment of rebalancing the fee schedule that would involve legislative action but that same leadership they're trying to take in the documentation should also be expressed in legislation on the hill to pursue these directions because i don't think you can get what you want to be without that legislative action. site neutral and the only other thing i will mention is telemedicine there was some changes they started to pay services on a fee for service basis but all four of those transactions i get a little bit of concern building that into a pay fee-for-service
environment i think you want to do that more of a block payment so my idea primary care by the way you could engage in telemedicine or consultations or the risk-based environment this make sense to provide the service that results in a better outcome for the payment. >> asking for comments for substance use disorder for opioid addiction this is definitely something we need to talk about. i'm done. [laughter] samet good morning i also would like to thank you to be invited to speak with you
today you may want to take my remarks with a grade of salt we are the experts on down coding and basically my problem with teaching my colleagues they are simple patients everybody else is complicated and they have a tendency to return it one - - reset that framework. besides a being a practice and during that time i told the people that work there not to use those documentation guidelines because i don't think they are useful or valuable and i agree with those comments made but i don't care about the documentation guidelines and i'm still tortured every single day over the entire weekend and i spent last night
in the airport to document a couple of visits i finished and i could not get online very easily i was sitting there for five minutes. there is a lot of issues that makes this a challenging situation we do owe gratitude to cms to take a look positions over paperwork. and looking at the third rail of the amputee which is the emf codes. i also appreciate cms has taken the time to collaborate from 170 specialties asking not to implement those changes in fact, they listen with those more positive aspects
even with those coding changes but that flat pricing is the wrong solution it creates incentives they spend less time with patients caring for the most complicated that's exactly what we need to have people focused more on so you have heard from the other presenters i am here because i'm the cochair for the group put together by the chairs of the cbt editorial panel the system has lots of flaws and it is something that we are familiar and we know the
drawbacks and thinking of the solutions to ameliorate it has been continuously refined to some degree and ideally it reflects to provide that service but there is a lot of misconception about the relative value system with that relative value the way we use that term is it medically necessary? is their social value? that isn't exactly what it was designed to achieve. it is important we work to be a better system. so if you treat a patient that is very sick you want the diagnosis for certain in the emergency situation and then if you take that action to save somebody immediately that