Medicine
The one major problem that has faced primary care for the past three decades has been cost of delivery rising faster than payment. Each "fix" has not really been a fix as steadily fewer enter and remain in primary care from all six sources.
MACRA is the new design and CMS has already projected the impact for decades. Here is what the Chief CMS Actuary says in his April 9, 2015 report:
That is for those doing well in the largest and most organized practices that have the most advantaged patients.
For the smallest practices where care is most needed, MACRA will pay less.
Discrimination By Design
Readmission penalties and Pay for Performance cannot help but pay less where care is more complex and most needed. The same social determinants, situations, and conditions that have shaped shortages of clinicians and access barriers also shape lesser outcomes. Lesser pay will add insult to injury.
It is most likely that MACRA will join Medicare Advantage as paying more for the care of populations that have advantages. Populations in need of care are left behind by MACRA and populations in smaller and less organized settings cannot access the favored payment plan - Medicare Advantage. The new designs do not work well for small hospitals, small practices, and care where needed. Lack of awareness continues to add consequences by design.
Accelerating Recruitment and Retention Costs
Where care is needed, there are more storm clouds. Even if patchwork programs survive, primary care delivery faces more problems. Insufficient payment is a primary reason for the rapidly rising cost of recruitment and retention bonuses, locums payments, broker fees, consultant costs, and other special programs.
A major consequence of insufficient payment is greater turnover of the teams and clinicians to deliver the care. The costs of turnover now include learning new software and other applications. There is little encouraging about the most important determinants of primary care at the current time.
SGR has been defeated. Congress did get a payment plan through. But more than two miracles are needed to recover primary care delivery capacity.
Variation in the Ecology of Health Care
Revisiting Physician Distribution by Concentration Coding
Ecology of Health Care for a Disadvantaged Population - Native Americans
Basic Health Access Blog
World of Rural Medical Education
- Medicare And Medicaid At 50 And Beyond
When did M and M design change from support for health access to against health access and why? Government and Foundations are currently celebrating the accomplishments of Medicare at Age 50 - but which Medicare? Claims of improving the cost of care are...
- The History Of Good Deal Bad Deal Payment Designs
The various leaders of medical associations are lining up to defend the latest "Good Deal" as the reality of a not so good trade is apparent. Our designers and our leaders understand history so poorly that they are doomed to repeat it over and over, especially...
- Should Hhs Take From The Poor And Give To The Rich?
I find it interesting that CMS overpays for high risk or complex patients, even when there is overcoding and fraud via Medicare Advantage. Yet CMS will not pay more for truly complex patients across rural and underserved areas. The largest do well and...
- Distribution Failures Behind By Many Designs
The 3138 US Counties can be coded by physicians, by types of physicians such as active family physicians seen here, by population and by other demographics, including those age 65 that are increasing rapidly and even more in health care demand. As previously...
- What Health Insurance Corporations Do
When given a chance to operate the entire payment package, what do Health Insurance Companies (HICs) do? For the past 8 years HICs have been given the freedom to operate Medicare Advantage - the high prestige seniors plan from CMS. HICs helped design...
Medicine
Oops We Did It Again for Too Little Payment By Design
The one major problem that has faced primary care for the past three decades has been cost of delivery rising faster than payment. Each "fix" has not really been a fix as steadily fewer enter and remain in primary care from all six sources.
MACRA is the new design and CMS has already projected the impact for decades. Here is what the Chief CMS Actuary says in his April 9, 2015 report:
"While H.R.2 avoids the significant short-range physician payment issues resulting from the current SGR system approach, it nevertheless raises important long-range concerns that would almost certainly need to be addressed by future legislation. In particular, additional updates totaling $500 million per year and a 5 percent annual bonus are scheduled to expire in 2025, resulting in a payment reduction for most physicians. In addition, this bill specifies the physician payment update amounts for all years in the future, and these amounts do not vary based on underlying economic conditions, nor are they expected to keep pace with the average rate of physician cost increases. The specified rate updates would be inadequate in years when levels of inflation are higher or when the cumulative effect of price updates not keeping up with physician costs becomes too large. We anticipate that physician payment rates under H.R.2 would be lower than scheduled under the current SGR formula by 2048 and would continue to worsen thereafter. Absent a change in the method or level of update by subsequent legislation, we expect access to Medicare-participating physicians to become a significant issue in the long term under H.R. 2."
Temporary Fixes
- The initial Medicare and Medicaid design initially was a great boost to primary care and care where needed. In a few years the design proved insufficient to keep up with staggering inflation, malpractice, personnel, and other costs in the 1980s.
- The RBRVS fix in the 1990s was also short lived.
- SGR left all physicians hanging under the Sword of Damocles - so much so that anything seemed tolerable.
- The MACRA gets away from SGR, but whether it is a fix is questionable.
- Note that the actual payment process has yet to be determined and this could be powerful in who survives and who thrives, but much will happen in the next ten years and MACRA does not have the flexibility.
That is for those doing well in the largest and most organized practices that have the most advantaged patients.
For the smallest practices where care is most needed, MACRA will pay less.
Discrimination By Design
Readmission penalties and Pay for Performance cannot help but pay less where care is more complex and most needed. The same social determinants, situations, and conditions that have shaped shortages of clinicians and access barriers also shape lesser outcomes. Lesser pay will add insult to injury.
It is most likely that MACRA will join Medicare Advantage as paying more for the care of populations that have advantages. Populations in need of care are left behind by MACRA and populations in smaller and less organized settings cannot access the favored payment plan - Medicare Advantage. The new designs do not work well for small hospitals, small practices, and care where needed. Lack of awareness continues to add consequences by design.
Accelerating Recruitment and Retention Costs
Where care is needed, there are more storm clouds. Even if patchwork programs survive, primary care delivery faces more problems. Insufficient payment is a primary reason for the rapidly rising cost of recruitment and retention bonuses, locums payments, broker fees, consultant costs, and other special programs.
A major consequence of insufficient payment is greater turnover of the teams and clinicians to deliver the care. The costs of turnover now include learning new software and other applications. There is little encouraging about the most important determinants of primary care at the current time.
SGR has been defeated. Congress did get a payment plan through. But more than two miracles are needed to recover primary care delivery capacity.
Variation in the Ecology of Health Care
Revisiting Physician Distribution by Concentration Coding
Ecology of Health Care for a Disadvantaged Population - Native Americans
Perverse Health Payment Dividing US - More for Fewer and Less for More, and Penalties for Those Caring for Those Most in Need
Open Season Upon Small Health Care
Improving Health Care is Not Likely for 2600 CountiesPreventing Rural Workforce By Design
Starting to Solve Societal Inequities - Support for a SMART Start from the Very Beginning of Life
Global Fails Local But Local Focus Succeeds Globally
Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed...
Best of Basic Health Access
Blogs indicate that primary care can be recovered and should be recovered.
Robert C. Bowman, M.D. [email protected]
Basic Health Access Blog
World of Rural Medical Education
Dr. Bowman is the North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and the long term chair of the STFM Group on Rural Health.
- Medicare And Medicaid At 50 And Beyond
When did M and M design change from support for health access to against health access and why? Government and Foundations are currently celebrating the accomplishments of Medicare at Age 50 - but which Medicare? Claims of improving the cost of care are...
- The History Of Good Deal Bad Deal Payment Designs
The various leaders of medical associations are lining up to defend the latest "Good Deal" as the reality of a not so good trade is apparent. Our designers and our leaders understand history so poorly that they are doomed to repeat it over and over, especially...
- Should Hhs Take From The Poor And Give To The Rich?
I find it interesting that CMS overpays for high risk or complex patients, even when there is overcoding and fraud via Medicare Advantage. Yet CMS will not pay more for truly complex patients across rural and underserved areas. The largest do well and...
- Distribution Failures Behind By Many Designs
The 3138 US Counties can be coded by physicians, by types of physicians such as active family physicians seen here, by population and by other demographics, including those age 65 that are increasing rapidly and even more in health care demand. As previously...
- What Health Insurance Corporations Do
When given a chance to operate the entire payment package, what do Health Insurance Companies (HICs) do? For the past 8 years HICs have been given the freedom to operate Medicare Advantage - the high prestige seniors plan from CMS. HICs helped design...