Better doctors will get paid more (or will they?)
The House recently approved a bill that would have Medicare pay better doctors more money. Although the bill is exceptional in and of itself – what with it being a rare occurrence of bipartisan cooperation – the fact remains that the GOP/Democratic crossover that led to it might turn out to be as impractical as Alien vs. Predator (but with somehow scarier protagonists in John Boehner and Nancy Pelosi). For starters, doctors would be paid accordingly to how good or bad they are. If this were TV it would be a no-brainer; Scrubs would have been paid much more than Grey’s Anatomy. But in real life the government is not very adept at telling the good from the bad, nor does the bill say anywhere how the distinction would be made.
The new bill would replace the defective current payment system known as the Sustainable Growth Rate (SGR), which has been in place since 1997’s Balance Budget Act. SGR was meant to limit how much Medicare pays physicians in the aggregate by decreasing the fees paid for thousands of medical services later on. Unfortunately, whoever came up with that system grossly underestimated the rate at which Medicare costs would grow. As a result, pay cuts in the double digits were required for Medicare doctors every couple of years or so – or at least would have been required had Congress not always found a way to bail out doctors’ salaries. In fact, lawmakers have passed 17 so-called ‘doc fix’ bills since the early 2000’s. Additionally, many physicians performed more tests and procedures to compensate for the reduced fees. Currently, doctors are paid a specific amount for every episode of care, which can potentially promote overtreatment.
According to the new bill, doctors’ payments would not be based on the sheer amount of procedures they perform but how well they perform them and how good the outcome is. That is, a surgeon would be paid more or less depending on whether a surgery – say, hip replacement – was successful or led to complications. Healthcare providers can either join the Merit-Based Incentive Payment System (MIPS) which assigns physicians scores – the higher their score the higher their reimbursement rates – or sign up for an Alternative Payment Model. The former adds bonuses and penalties to a system that also pays a specific amount for each service, while the latter – and the one Congress and the White House are pushing – allots doctors a lump sum of money for them to administer as best they can. This is riskier for healthcare providers, so they get a 5% signing bonus as a mode of persuasion.
That’s all well and good, except that the 265-page long bill does not specify what exactly an alternative payment mode is. Furthermore, it’s not clear what the criteria to assess doctors are going to be. For example, the MIPS program requires the Health and Human Services Secretary to use doctor-suggested quality indicators. The Secretary can add her own indicators, but physicians get to pick and choose which indicators they would like to be judged on. And it might not even make a difference either way. According to Medicare’s Physician Feedback Program /Value - Based Payment Modifier – a program that allows the government to increase or cut the amount it reimburses doctors depending on how well they do on quality measures and how much their patients cost Medicare – only 14 out more than 1,000 medical groups with at least 100 health professionals will get increased payments this year, and only 11 will be penalized for poor quality or too much spending.
In spite of everything, the bill is a step in the right direction; a road that will not officially start until 2019, giving this administration as well as the next ample opportunity to streamline the law. If it does indeed become law, of course. The next step is the Senate which left for Spring break on March 28th and won’t convene until April 15th. But given that the House approved it 392 to 37 and is endorsed by President Obama, chances are that it’s only a matter of time for this bill to be serenading the Capitol steps.