Medicare Reimbursement Policies

The Medicare Payment Advisory Commission (MedPAC), an independent agency that advises Congress on Medicare issues, recently voted to recommend to Congress that reimbursement for non-emergent, outpatient hospital visits be equalized with the reimbursement for the same service physician's office.
  

Lyle Swenson, M.D.,
2011-2012 MMA President

The MedPAC Trustees acknowledged that Medicare pays about 80 percent more for an outpatient visit at a hospital than for the same type of visit at a physician’s office.  With the increased hiring of physicians by hospitals, this is thought to be costing Medicare a significant amount of money.  MedPAC Chairman Glenn Hackbarth says that “Medicare needs to move, over time, to paying the same amount for the same service, regardless of the provider type”.

For both Medicare and commercial insurers, the reimbursement disparities between hospital based and office based outpatient services has been apparent for many years.  Despite previous efforts to bring the light of day to this issue, it is not well known in the medical community, and is not understood at all by the public.  The MMA House of Delegates has addressed this topic, but there has not been a clear consensus on how to address these disparities.

This should be an issue where physicians come together to promote clarity, honesty, and fairness.  It seems now that MedPAC, through their recommendations, may promote a wider understanding of these disparities, and possibly foster a broader discussion of reimbursement policies and a more logical, equitable approach to reimbursement for outpatient services in the future.

The New Language of Medicine

In the October 13, 2011 New England Journal of Medicine there is a Perspective article entitled “The New Language of Medicine.” The authors assess the recent use of the terms “consumer”, “customer,” and “provider.” I urge all physicians to read this very well done essay that we are republishing in the print edition of the December issue of Minnesota Medicine.

Lyle Swenson, M.D.,
2011-2012 MMA President

The article states the importance of the words we use to explain our roles, and how they “set expectations and shape behavior.” While many in the health care industry may try to justify the use of the term provider, this is an all-purpose term that is “deliberately and strikingly generic, designating no specific role or level of expertise.”  It does not begin to capture the complex, and tremendously important role physicians have, and carries no implication of professionalism.

The generic term “provider” suggests that doctors and other health care professionals are interchangeable. The authors state that use of the term “provider” signals that care is a prepackaged commodity that is “provided” to the “consumer,” rather than a personalized service delivered by skilled professionals, tailored to the needs of the individual patient. They conclude that reducing the relationship between physicians and patients to a commercial transaction of buyer and seller ignores the essential psychological, spiritual, and humanistic dimensions of the relationship, which are essential to our profession.

We must take on the responsibility for how our profession is defined. This is a beautiful, clear, and concise discussion of why physicians must reject use of the term provider for our own profession.

Our core principles

Lyle Swenson, M.D.,
2011-2012 MMA President

It was a great honor to be inaugurated MMA President on September 15. Afterwards, I even had a few requests for the text of my speech. So though it is long for a blog post, I wanted to include it here, since it addresses some of the key issues I hope to focus on as MMA President. 

Inaugural Address

 Our profession has its origins in antiquity.  The earliest known written records of mankind are found on Sumerian clay tablets from Mesopotamia, which are over 4000 years old.  These tablets contain the oldest medical manuscripts, and they give us some insight into the role of the asu, the physician, in this ancient society.

     From the Code of King Hammurabi, 1700 years before the birth of Christ, we find a detailed description of the rewards due to the surgeon for surgical procedures prevalent during that time.

     The foundations of our profession were most firmly established by Hippocrates, the Greek physician we call the Father of Medicine.  In his oath, we find the enduring principles that have guided us as physicians for over 2000 years. In the Hippocratic oath, and in the oaths now taken by all those who become physicians, we find the basis for the relationship that we have with our patients.  This commitment is a covenant, which is an agreement based on trust.  In our oath we also pledge to hold the health, well-being, and best interests of our patients above all else, and above our own interests.  We pledge to do no harm to our patients, and to hold all that passes between our patients and ourselves in confidence, in order to protect our patients, and to maintain their trust.

     In the second century after Christ, scientific medical investigation by Galen led to the realization that   anatomic accuracy and physiology are the basis for the understanding of disease. 1000 years later, the scholar, philosopher, scientist, and physician Maimonides further defined and shaped our profession.  In his physician’s prayer, Maimonides writes “Inspire me with love for my art and for Thy creatures.  Do not allow thirst for profit, nor ambition for renown, to interfere with my profession”.  As Dr. Carmel has so eloquently stated, this is what we call integrity. He has also reminded us that in the care of our patients, we must have compassion, we must have empathy.  The traditions of using scientific knowledge for the benefit of our patients, with integrity and empathy, have been growing for thousands of years.

     From the earliest efforts of the asu, to the scientific investigations of Galen, to the discovery of the double helix by Watson and Crick, our profession has seen profound changes in our ability to understand, diagnose, treat, and cure disease. With the tremendous growth in scientific knowledge and our improved understanding of disease, there have been great opportunities to improve the health of our patients.  With these opportunities have come great challenges, and the challenges of our time now threaten the very foundation and time-honored principles of our profession.
    
 With greater scientific knowledge has come the need and the desire for specialization, and the development of medical subspecialties has given us the potential for better care for our patients, but it has also led to disagreements between specialty societies and a lack of unity  within our profession.

     With the commercialization of health care, the potential for financial gain has led to worrisome conflicts with the principles of our profession. The business of health care has become politicized, and now political posturing and ideology threaten to drive us apart as physicians.

     Fundamental changes in the delivery and financing of health care have resulted in the rewards to our profession being doled out by large payers who are influenced primarily by economics and politics, with those rewards having little relationship to the value we bring to our patients and our communities.  Many physicians have understandably responded to these realities by changing their medical practice, and some of these changes have resulted in alliances and relationships which challenge, and threaten to alter, the covenant we have with our patients.  The conflict between economic survival and prosperity on the one hand, and the best interest of our patients on the other, is certainly not new, but our current conflict is unprecedented in its magnitude, and how we, as a profession, respond to this conflict will have profound effects lasting many, many years.

     As we recall the history of medicine, we recognize and cherish the abiding principles that give us hope and guidance in our professional lives today.  The supreme importance of our patients’ health and wellbeing; the covenant we have with each patient we care for; the continual quest to bring new scientific knowledge into our practice for the benefit of our patients, brought with integrity, trust, empathy, and compassion; these principles we must hold sacred.

     All challenges to our profession, whether great or small, must be faced openly and honestly, with courage, without restraint or hesitation, and without deference to politics, ideology, or commercial interest. We must renew our commitment to our profession.  We must renew our commitment to the principles of our profession.  We must be unwavering in their support, and we must resist the forces that threaten to drive us apart.

     It is now our time to do our part, as physicians have done for thousands of years, so that in the years to come, physicians will be free to practice the science and the art of medicine, with knowledge, integrity, empathy, and compassion, for the benefit of their patients.

To Err is Human



Patricia Lindholm, MD,
2010-2011 MMA President



I believe that we all recognize the above title as a timeless adage, but also the title of the Institute of Medicine report that brought to public scrutiny the problem of medical errors in hospitals and the prevalence of harm that patients experience during their hospitalizations.  The report jump-started a nascent patient safety movement that now appropriately applies to outpatient care as well. 

An excellent article appeared this week in AMA News about physicians who have publicly acknowledged their medical errors.  They are using such disclosure as teaching opportunities for themselves and other health care professionals, and to highlight that systems improvement is the key to preventing errors.  The “I’m Sorry” legislation that has been discussed in various states reflects the need to provide transparency to patients and to make amends when they are harmed by medical procedures and decisions. 

The most interesting part of the article for me is a discussion of how to support physicians who have harmed patients through diagnostic or treatment errors.  I trained in the era of “shame and blame” when one person was assigned total responsibility for an error.  This led to a tendency to hide our errors from patients, hospitals and our colleagues.  Physicians judge themselves quite harshly and question their general competence or even their personal worth when faced with an error. 

In Boston at the Brigham and Women’s Hospital, a Center for Professionalism and Peer Support was created to reach out to physicians who are in the painful and lonely position of having acknowledged a medical error.  A number of physician peer advisors are available to reach out to their colleagues and ask about their wellbeing and offer support.  Similar programs have developed at medical centers around the country.  A compassionate and human approach to such colleagues can save careers as well as the lives of the physicians who are supported. 

Several years ago when I served on the board of MMIC (the professional liability company started by MMA some years back) we started the Physician Litigation Support Program.   Each physician facing a claim is personally contacted by a psychiatrist whose only purpose is to provide support and education to the insured.  We have received many thanks from recipients of this caring program.

If your training program or health care organization does not have a mechanism to support colleagues who have made errors or who face litigation, what can you do to get such a program started?  I suggest that the first step is speaking up and insisting that collegial support programs be proactive, supported and expected.  You should expect to hear from colleagues who want to work with you to make good work happen.  I suspect you will have richer friendships and happier patients as a result.   

A Common Ethical Dilemma

Patricia Lindholm, MD,
2010-2011 MMA President

Forgive my absence from the blog for the last few weeks.  I have good excuses.  (1) It’s summer in Minnesota.  (2) With all the rain I am mowing the lawn in my free time.  (3) My clinic went live with electronic health records this summer.  (4)  I adopted two dogs from the Humane Society and they need a bit of training.  I am sure I can find more if need be.

I have also been following some of the blogs and social networking sites as I troll for more information and resources on physician wellbeing.  On a bittersweet note, I recently read in the Huffington Post that Dr. Lee Lipsenthal (of whom I have written earlier in this blog) has a recurrence of his cancer and has been told that is the last season of his life.  His interview is a demonstration of a remarkable ability to be fully present in life as well as fully present to others as he anticipates their grief.  His work has enriched us and will continue to do so for many years to come. 

Dr. Lipsenthal was a presenter at the inaugural program of the Osler Institute’s conference on physician wellbeing last fall in Albuquerque.  I am happy to report that the conference will be offered again in the coming year, possibly twice.  You can follow the Osler Institute on Facebook. 

Of course I am also following Dr. Kevin Pho on his site KevinMD.com.  There are many posts of interest by physicians from around the country.  One that caught my eye this week was posted by Michael Kirsch, MD and titled, “Medical ethics in the office should not be a private matter.”  It appeared the day after I attended an ethics committee meeting in our newly integrated hospital and clinic.  We discussed bringing up examples of daily ethical dilemmas faced in outpatient medicine.  Dr. Kirsch lists several such outpatient dilemmas which resonate with me.  The problem is that no sooner is the issue behind me than I forget about it and lose the opportunity to fully discuss and analyze it with colleagues.  (I suspect it is a function of middle age.)

Here is an example of an ethical dilemma I have faced many times in my practice (I paraphrase):  A patient’s family member sends a note or calls to report some private information shortly before my patient’s appointment, with instructions “not to tell” the patient about who divulged the information, but hoping I can somehow dig into the matter.  Do you tell the patient about the conversation?  I have reacted differently on different occasions.  How about you?

How Minnesota Repealed Its Provider Tax

Patricia Lindholm, MD,
2010-2011 MMA President

An unexpected but satisfying item was tucked in the final Health and Human Services Budget Bill passed by the Legislature and signed by Gov. Mark Dayton this week.

Lawmakers have agreed to phase out the 2 percent provider tax and repeal it altogether in 2019.

I am relieved by this unexpectedly positive development not because it is a pocketbook issue – though it should help reduce health care costs – but because lawmakers are redressing a breach of trust with Minnesota’s medical community that has soured the relationship between physicians and state government, since this law was passed in 1992.

To doctors, it has always felt particularly unfair that the state decided to make those who must seek medical services – which is already a hardship – also pay a selective tax. Then when lawmakers rolled out the tax, they weren’t transparent about it. They explicitly prevented providers from telling patients about the tax by itemizing it on bills.

The courts ultimately overturned this provision, but the feeling of distrust toward lawmakers remained. Finally, after saying the funds would only go to MinnesotaCare, lawmakers broke that promise time and time again by using hundreds of millions of these dollars to balance the general budget. Once again doctors were left feeling distrust and disillusionment.

So I want to thank lawmakers for taking this step to repeal this law and repair the relationship. I must admit that after many years of the MMA working to repeal this regressive, selective tax, this victory seemed to come out of nowhere.

The person who deserves the most credit for this is probably House Majority Leader Matt Dean (R-Dellwood).  Rep. Dean saw early on that as the Affordable Care Act is fully implemented, there will no longer be a need for MinnesotaCare and the provider tax. The MMA worked with Rep. Dean early in the 2011 Session to help him draft a bill that would reduce the size of the provider tax as the need for it went down.  This bill passed a few House committees but did not move in the Senate. Then during the final budget negotiations Rep. Dean, with the support of Senate leadership and Gov. Dayton saw an opportunity to replace the provider tax with the new federal subsidies that will come online in 2014 for Minnesotans earning up to 400 percent of the federal poverty level.

I am convinced that the MMA helped lay the ground work for this breakthrough by working hard since the tax was adopted’s adoption to remind law makers that it is regressive, hits sick people harder than healthy, and adds to the overall cost of health care. Many legislators over the years, both Republicans and Democrats, agreed with us that this was a bad tax, yet there was never enough support to find the $450-$500 million it raises each year to replace it.
 
Now, our challenge over the next eight years will be to continuously remind legislators of their commitment to repeal the “sick tax” and ensure that this unfair tax eventually goes away.

A Generous Listener is a Healer

Patricia Lindholm, MD,
2010-2011 MMA President

Recently I had the opportunity to attend a seminar by Rachel Naomi Remen, M.D., in California.  It was called “The Healing Power of Story:  Toward a Closer Human Connection.”  Many of us are familiar with Dr. Remen through her books Kitchen Table Wisdom and Blessings From My Grandfather.  In her books she tells stories that indeed are healing to the teller and to the reader/listener. 

In attendance were physicians from various specialties, chaplains, social workers, nurses, psychologists and others in the healing professions.  There were people from the US, Canada, Australia, Britain and Germany.  There was no formal syllabus for this course. 

Each day of the three day course was divided into two parts.  Most of the time we were doing guided small group activities with groups of 2 to 7 people.  Each half-day session had a theme and we had the opportunity to delve within ourselves and tell our stories to each other.  We were taught the technique of “generous listening.”  We were to listen completely and mindfully to each person without interjecting any comments or questions.  I found myself having to consciously restrain my impulse to ask follow-up questions which I so often use in my practice.  Likewise as a story-teller I felt completely supported and heard by my story-listeners.  The results of generous listening were profound.

I was privileged to be a listener to a story by a physician who had been carrying a load of pain and shame since her residency days.  She had not felt safe in telling her story before.  She clearly was relieved to tell her story to a generous listener and felt healed by the experience.  I also felt healed by sharing a story with her about a loss in my life. 

It occurred to me that patients come to us so that they can tell their stories and be heard.  They are looking for the healing that we can provide simply by being generous listeners and confidants.  This is true of procedural as well as cognitive specialists.  Sometimes a patient has a distressing and perplexing story to tell and we squirm because we do not have “answers.”  What Rachel Remen taught us was that we are “enough.”  We do not need special knowledge or wisdom to be healers.  A story listener is a healer.  That is enough.  We are enough.