The following is part of a series of original guest columns by the American Medical Association.
by J. James Rohack, M.D.
As the year winds down, health system reform continues to move forward. The Senate bill currently under debate includes a number of provisions that are consistent with the AMA’s reform priorities, some provisions we oppose and others that need to be improved to better benefit patients and physicians. As part of its continued commitment to health system reform, the AMA sent a letter to the Senate outlining the provisions in the bill we support and those we oppose. An abbreviated version of the AMA’s likes and dislikes is below:
What the AMA likes
The Senate bill includes a number of key benefits for meaningful reform. It will improve choice and access to affordable health insurance coverage and will do away with denials based on pre-existing conditions. It will enhance Medicaid coverage so it can continue to be a viable safety net for those in need. It will increase coverage for preventive and wellness care that can lead to better disease prevention and management, and it will further the development of comparative effectiveness research that can help patients and physicians make informed treatment decisions.
What can be improved
Medicare Physician Payment Formula
With the baby boomers aging into Medicare in just over a year, more must be done to protect the security and stability of the program and seniors’ access to care. For example, the Senate bill would avoid a 21 percent cut to physicians in January but does not include permanent repeal of the broken Medicare physician payment formula. A permanent solution to this flawed payment formula is necessary to ensure current and future Medicare and TRICARE patients have access to the physician of their choice.
Medicare Buy-in
With all the fiscal problems the Medicare program has, the proposal being discussed in the Senate that would allow those ages 55-64 to buy into the Medicare program early cannot be supported. The AMA is committed to legislation to expand affordable health insurance coverage to all Americans, but we believe a health insurance exchange without an expansion of Medicare will provide more affordable choices and better access to care for Americans ages 55-64.
Value Based Payment Modifier
While the AMA strongly supports efforts to develop quality improvement programs, we don’t think redistributing Medicare payments among health care providers based on measurements that are not scientifically valid, verifiable, and accurate is the way to go. Section 3007 of the bill requires the development and application of a cost/quality index modifier based on the availability of policy tools and a level of precision that does not currently exist. Core components needed to develop the cost/quality index are in their infancy, and CMS lacks the resources to develop and implement them. In addition, there are fundamental, technical problems with the basic concept of adjusting payments at the individual physician level, as well as with adjusting payments based on outcomes for the previous year’s patient case mix.
Primary Care and General Surgery Bonus
Few would dispute that a physician shortage does exist in the U.S. and that this is an area that needs to be addressed so physicians can remain in practice, and we can attract the best and the brightest to all areas of medicine. We support primary care and general surgery bonus payments funded as a workforce investment with new money, but they cannot be offset through a reduction in payments to other physicians. We strongly encourage the identification of other financing mechanisms to avoid across-the-board payment cuts for other physician services.
Tax on Cosmetic Surgical and Medical Procedures
The bill imposes a five percent excise tax on elective cosmetic surgical and medical procedures performed by a licensed medical professional collected at the point of service. The AMA strongly opposes taxes on physician services to fund health care programs or to accomplish health system reform. We believe that additional revenues generated to help finance health system reform should come from broad-based taxes.
Physician Quality Reporting Initiative
We do not support mandatory physician participation in the Physician Quality Reporting Initiative (PQRI) or the imposition of penalties on physicians who do not successfully participate. Based on physicians’ experience with the PQRI to date, this program is fraught with administrative problems that have made it extremely difficult to assess whether a physician has successfully participated. Further, not all physicians are currently eligible to participate in the PQRI with endorsed measures that are relevant to their service mix.
Physician-Owned Hospitals
While the AMA supports the disclosure of physician hospital ownership and investment information, we oppose the proposal to eliminate the whole hospital exception to the Stark self-referral law. Physician-owned hospitals have achieved the highest quality scores in some markets and have been shown to provide more community benefits through uncompensated care and taxes than not-for-profit competitors. Limiting the viability of physician-owned hospitals will reduce access to high-quality health care and have a destructive effect on the economy in communities these hospitals serve. The provision in H.R. 3590 would also effectively shut down many physician-owned hospitals currently under development.
Provider Enrollment Fees
The AMA opposes the imposition of Medicare provider enrollment fees on physicians. Given the multiple screening procedures that already apply to physicians in various licensing and credentialing processes, we believe this is an unnecessary duplication of review processes and another administrative burden that can further discourage physicians from participating in the Medicare and Medicaid programs.
We anticipate a lengthy debate, multiple amendments, and modifications of the Senate bill in the weeks to come. The AMA will stay involved every step of the way to advocate for reforms on behalf of patients and physicians.
J. James Rohack is President of the American Medical Association.
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