Trendspotter: Healthcare Reform Is First Step To Shore Up Deteriorating System

Many pundits have weighed in on the likely consequences of not passing healthcare reform, which is expected to come to a head within the next few days. But a recent blog post by Matthew Mintz, MD, an internist in Washington, DC, puts things in perspective for physicians.

Judging by his essay, Mintz is neither a Tea Partier nor a single payer advocate like those who belong to Physicians for National Health Program (PNHP). Both the Tea Party and PNHP oppose the reform bill-the former because it would expand government intervention in healthcare, and the latter because it fails to put government in charge of healthcare. Mintz is not concerned that the proposed legislation would give the government too much power; rather, he worries that, in the absence of reform, the healthcare system will continue to deteriorate. In fact, he believes that while the reform bill deserves to pass because it expands insurance coverage, healthcare will decline even if it's adopted. What’s missing, he says, are more stringent cost control measures and a plan to increase the supply of primary care.

Writes Mintz: “Though our dysfunctional system and plans for reform may not affect you now, things will get worse. Without addressing costs, premiums will continue to go up and even more patients will lack the ability to afford health care coverage. Without addressing the bureaucracy of insurance paperwork and the pay disparity between specialists and primary care physicians, students will continue to go into non-primary care fields and current primary care doctors will retire. In addition, our nation is only getting older and fatter, and thus sicker and more expensive.”

Despite the shortcomings of the reform bill, Mintz views it as an essential step toward providing everyone with high-quality care at an affordable cost. If the legislation is voted down, he points out, Congress will probably not revisit the issue for a long time to come. By then, he says, things will be so bad that everyone will be demanding reform.

I agree with Mintz on the politics of reform, and I also concur that the system’s decline will accelerate unless the federal government takes decisive action. But several elements in the bill could help slow cost growth. One is the proposed Independent Medicare Advisory Board, which would theoretically have more power than the current Medicare Payment Advisory Commission (MedPAC) to make changes in Medicare reimbursement. While the proposal has elicited strong opposition from the healthcare industry, including medical societies, it's needed because Congress is too political to make the required cost-cutting decisions. The problem with the proposal in its current form is that it takes hospitals, physicians, and drug companies off the table for the next decade. So it would not have much practical effect unless later legislation gave the independent board real authority.

Another provision in the bill would encourage the formation of accountable care organizations – combinations of hospitals and physicians that would share in whatever savings they produced for Medicare by improving coordination of care. Most likely, big healthcare systems would take advantage of that opportunity. There are also demonstration projects for payment bundling and enhanced home care for chronically ill seniors. Many hospitals are already preparing for payment bundling-which would provide a single payment for multiple kinds of services, such as acute and post-acute care-by employing more physicians.

Last but not least, the Senate bill that forms the backbone of the final reform legislation places 1 to 2 percent of hospitals’ Medicare reimbursement at risk for meeting quality and efficiency targets. While the bill is not specific about physician incentives, it proposes studying physician utilization patterns before deciding how much of your reimbursement to put at risk.

As for increasing the attractiveness of primary care to young doctors, the bill would shift some Medicare funds from specialists to primary-care physicians-a direction in which CMS has already started moving.

Needless to say, the AMA and many specialty societies oppose most of these initiatives. So if Washington is really interested in cost control, it’s unlikely to get much help from physicians. And yet, if both public and private health spending growth is not restrained, an increasing percentage of patients will no longer be able to afford your services.