How should plans pay doctors?

By National Underwriter

National Underwriter


By Allison Bell

Figuring out a better way to pay doctors might cut the cost and improve the quality of health care, but using bad quality measures could make matters worse, according to Dr. Frank Opelka.

Opelka, a medical education policy specialist who is active at the National Quality Forum, warned Congress against relying on low-quality care quality measures Tuesday, at a Medicare reimbursement strategy hearing organized by the House Ways and Means health subcommittee.

Policymakers who want to get providers to deliver care more efficiently need to use quality measures, to keep the providers from cutting costs by providing bad care or by providing too little care, witnesses said.

But "linking payment to poor quality measures will not drive the system to be more patient-centered or higher-performing," Opelka said.

Linking payments to low-quality quality measures "will add cost and burden," Opelka said.

Rep. Kevin Brady, R-Texas, the subcommitte chairman, organized the hearing because of worrries about rising Medicare costs; concerns that the traditional Medicare program "fee for service" payment system encourages providers to jack up revenue by providing too much care; and physicians' anger about a proposed "sustainable growth rate" (SGR) Medicare physician pay rate cut that could slash reimbursement rates by more than 20 percent.

For years, almost every federal budget proposal has started out including SGR cut required by federal statutes. Congress has always responded to physician outrage by finding ways to postpone making any SGR cuts.

"My hope is that we can put the days of kicking the SGR can down the road behind us," Brady said in a statement.
Private plans can use provider contract negotiations to do more to manage care than the traditional Medicare program can, but traditional Medicare program rules can have a big influence on the private health insurance market, because private plans often base their provider reimbursement schedules on the Medicare reimbursement schedule.

Dr. David Hoyt, executive director of the American College of Surgeons, testified in support of a proposal to replace the perennial SGR rate cut proposal with some new type of payment system that would give physicians an incentive to provide high-quality, efficient care.

The college believes in the importance of "breaking down the silos" that separate different types of providers and in coordinating care, Hoyt said.

"The college believes it is incumbent upon every physician and health care provider to commit to being a responsible steward of the nation's health care resources," Hoyt said. "Physicians and other providers will need to work together to achieve cost savings."

One of the hearing witnesses, Dr. Patrick Courneya, medical director at HealthPartners Health Plan, said his plan has encouraged provider efficiency by offering bonus payments for providers that improve practice performance; providing grants to help physician groups upgrade their operations; supporting the creation of regional quality and patient satisfcation measures; and supporting the creation of cost measures.

One cost measure, the Total Cost of Care measure, combines a Total Cost Index measure with a measure of the amount of resources used to care for the patient, Courneya said.

Using the Total Cost of Care measure to help employers and consumers compare the value providers provide over time has helped HealthPartners beat state, regional and national cost benchmarks for three straight years, Courneya said.

Opelka, the witness from the National Quality Forum -- a health quality evaluation group that has endorsed the Total Cost of Care measure -- said high-quality quality measures should measure something that's important to measure; be scientifically acceptable; be easy to create and use; and complement existing measures.

The National Quality Forum rejects about 30 percent of the proposed measures, Opelka said.

In other cases, Opelka said, proposed measures may fail to take illness severity or other risk factors into account.

A proposed stroke mortality measure was rejected because of concerns about risk adjustment, Opelka said.

Originally published on LifeHealthPro.com