May, 2015

Triple-Edged Sword

By Michael J. Katin, MD

...what damned error, but some sober brow
will bless it and approve it with a text,
hiding the grossness with fair ornament?
William Shakespeare, The Merchant of Venice, Act III, Scene II

A collective sigh of relief was heard on April 16 as President Obama signed the Medicare Access and CHIP Reauthorization Act of 2015, finally ending 18 years of suspense over the implementation of draconian cuts in the Medicare fee schedule mandated by the Sustained Growth Ratio calculations as decreed in the Balanced Budget Act of 1997.

This was hailed as a masterpiece of bipartisanship and an example of the ability to government to resolve problems. In reality, praise for this accomplishment should be no greater than that for the repeal of Prohibition, i.e., the undoing of government action that was hideously stupid in the first place It would be similar to praising Exxon's efforts to clean up Prince William Sound after the Exxon Valdez debacle, or congratulating the Army Corps of Engineers for diligent repair of the levees after Hurricane Katrina had already had its way with New Orleans. The SGR idea had been not much better than the Fugitive Slave Law of 1850, which was also passed to try to avoid a crisis, and one can see how well that worked out.

It should be noted that if the SGR decrements had been implemented, it would have accomplished the goal of making Medicare economically sound. When about 90% of physicians had dropped out of the program, annual Medicare billings would have decreased dramatically, and the system would have been financially solvent indefinitely.

Physicians may be taking the opportunity to celebrate, but, unfortunately, it's appropriate to remember that "There's no such thing as a free lunch " (and, even more appropriately, "There's a sucker born every minute ). The mindset of the same government that has run up a national debt of over $18,000,000,000,000.00 is that all legislation must be evaluated by the Congressional Budget Office as to its cost and that cost must be compensated by reductions elsewhere (unless it's decided not to care about it). The CBO estimated the cost of eliminating the SGR at $174.5 billion over ten years -- interesting, since it puts a price on a program that was never implemented in the first place, making one wonder who may other programs have contributed to bookkeeping maneuvers.

One way of paying for it is to drive physicians in Alternative Payment Models (APMs ). Some of these programs will be much more easily accomplished by hospital-based physicians rather than those in freestanding centers, and will be almost impossible to do by solo practitioners. Another is to continue to augment the Merit-Based Incentive Payment System (MIPS), in which inappropriate and/or irrelevant criteria of practice quality will determine payment. A physician's performance will be assessed by non-clinicians, many of whom are being paid far more to develop and then evaluate these systems than are the physicians. We have to concede that we have often been remiss in addressing lifestyle changes in patients with metastatic lung cancer who have a high BMI, but it is difficult to ascertain what a patient's vaccination status or ethnic background has to do with the selection of treatment in the vast majority of cases. We recognize, however, that it's a matter of time before the workup will require ascertainment of birth order, color preference, and digit ratios. Other ways to make up for the cost of SGR repeal include reforming post-acute care coverage, adjusting co-payments for Medicare beneficiaries with higher incomes, changing details of Medigap coverage, and altering several types of hospital Medicare payments.

This all brings us to the Oncology Care Model and the Oncology Medical Home. On February 12, the Department of Health and Human Services announced it was launching a "better care, smarter spending, healthier people" program, implying that the existing medical care system included none of these. Although it might be difficult to totally disagree with this, it still needs to be recognized that an attempt to repair a flawed system may result in an even more flawed system. Letters of intent for the OCM had to be submitted by April 23. If you're using this column as the source of information on medical practice transformation, you've already missed the proverbial boat. By June 18, applications have to be submitted, telling the HHS administrators what they want to hear. The five-year-plan (where have we heard that before?) has the goal of upgrading coordination of services, guaranteeing appropriateness of care, and optimizing access for patients. It's also designed to be appropriate for medical oncology-related practices, with radiation oncology apparently considered an adjunct service, similar to nutritional counseling or occupational therapy. The Oncology Medical Home is even more inappropriate for freestanding radiation oncology centers. This system promotes patient engagement, expanded access, evidence-based medicine , comprehensive team-based care, and quality improvement, among other goals which none of us have ever sought previously.

All this upgrading is taking place in a climate in which ICD-10 has been postponed multiple times (now anticipated for October 1) because of the concern about the difficulties involved in conversion, even though everyone agrees it has to be done to catch up to the rest of the world. It might therefore be appropriate to go all the way and start using Mandarin Chinese for all medical records, since within the next thirty years it will be the predominant language. After all, the Global Cancer Project Map Project was launched on March 25, 2015, bringing the world further together for correlation of cancer data and to facilitate progress in determination of treatment techniques that will be universally unaffordable.

Even though most of us agree that it is desirable to deliver cancer care more cheaply, efficiently, and intelligently than in previous generations, it is necessary to address the concept that medical costs are unnecessarily too high. It seems that too many specialty societies are ready to concede that less is more. Early detection and aggressive treatment of advanced disease are always accepted as desirable but, of course, result in increased expense than if patients live a much shorter time. At least one patriot, Bibb Allen, Jr., Chair of the Board of Chancellors of the American College of Radiology, had the fortitude to challenge that "Appropriate Use of Medical Imagery Shouldn't Always Mean Less Imaging." Presumably Dr. Allen will be appropriately disciplined, but it would be good for leaders in all specialties to call to the public's attention that 1. advances reported by Dr. Oz will not be available unless someone is willing to pay for them, and 2. paying for medical care to keep people as functional as possible and to keep them alive with a reasonable quality of life as long as possible should be a high priority and not one that is always under fire.

In fact, the public is convinced that Medicare costs are too high and that there are multiple reasons. As was reported in "Making Cuts to Medicare: The Views of Patients, Physicians, and the Public " a survey of 326 patients, 250 oncologists, and 891 "members of the general public " showed that drug companies and insurance companies were blamed for high Medicare costs and, interestingly, 33.7% of patients, 22.4% of oncologists, and 45.8% of the general public responded to the item "patients ask for unnecessary tests and treatments" that it adds "a lot" to costs. Presumably tests and treatments become less unnecessary when one is directly involved. The most amazing finding was that 77.6% of patients with cancer, 90% of oncologists, and 85.6% of the general public felt that Medicare should refuse to pay when a "less expensive test of treatment has been shown to work just as well." The amazing part is, why would anyone think it's all right to pay for a more expensive treatment if a cheaper one is available? It's like thinking it's ok to pay for a first-class airline ticket rather than coach when both get you to the same place. Parenthetically, the last author on this paper was Dr. Ezekiel Emanuel, continuing his mission to prove that we're doing everything unnecessarily, inefficiently and expensively.

Unfortunately, it is improbable that spending priorities will change, and we need to give credit to the current Secretary of Health and Human Services, Sylvia Mathews Burwell, and the acting head of the Centers for Medicare and Medicaid Services, Andy Slavitt, for doing the best they can under the circumstances. It will now be up to the future heads of HHS and CMS under the next administration to finish the job.

Emanuel Countdown: Dr. Ezekiel Emanuel's biographies list his birth year as 1957 but, interestingly, do not list a birth date. Giving him every benefit of the doubt, he will have his 75th birthday no later than December 31, 2032. Including May 1, 2015, this leaves 6,455 days to his goal of not living beyond his 75th birthday.