Progress creates pushback as ACP moves ahead on reform

In last month's column, I wrote that by aligning ourselves with like-minded employers and consumers, ACP was “on the verge of transforming health care policy to support and restore the value of primary care.”

Recent events show how much progress we are making, and the growing level of controversy that has resulted.

Who should pay for primary care?

In April, the Medicare Payment Advisory Commission, a blue-ribbon commission of experts that advises Congress on payment policies, adopted two ground-breaking proposals to help internal medicine and other primary care specialties.

The commissioners agreed that primary care-focused practitioners should be allowed to use a special billing modifier to get bonus payments for each of their primary care services. The bonus would be applied in a budget neutral manner, so that the added expense would be paid for by making across-the-board reductions in total payments to physicians. The budget neutrality offset needed to pay for the primary care adjustment depends on the size of the adjustment and which doctors would be eligible to claim it.

One alternative suggested by MedPAC would pay eligible primary care doctors 10% more for office visits and other primary care services, which would require slightly more than a 1% budget neutrality reduction in total physician payments.

The Commission also voted to recommend that Medicare implement a national pilot of the medical home model. As the Commission envisions it, this pilot would be a larger and better funded national evaluation of the medical home than a more limited demonstration project that will be implemented by Medicare in up to eight states.

Medical homes would receive a monthly care coordination payment in addition to the usual office visit fees for each eligible Medicare patient who selected the practice. The care coordination fee would cover services that are not part of the usual office visit, as well as some of the costs to the practice of acquiring health information systems.

Following these recommendations, Sen. Max Baucus (D-MT), chair of the Senate Finance Committee, told ACP and specialty society representatives that he'd hoped to include a primary care bonus and a medical home pilot in a bill he'd planned to bring to the Senate floor in mid-May. In addition to helping primary care, his bill would replace a 10.6% Medicare physician payment cut on July 1 and a 5% cut on Jan. 1, 2009 with positive updates for all physicians.

ACP joined with the American Academy of Family Physicians and the American Osteopathic Association to strongly support Mr. Baucus's efforts. In an April 17 joint letter, the organizations noted that targeted increases in primary care payments would be an important first step toward addressing the broader Medicare payment problems. These issues have contributed to a sharp decline in the numbers of new physicians choosing primary care and the exodus of many established primary care physicians from practice.

The letter also acknowledged that although such increases will initially comply with current Medicare fee schedule budget-neutrality rules, new ways are needed over the longer-term to fund primary care. Alternatives include applying anticipated savings in other parts of Medicare, such as reductions in preventable hospital admissions when care is coordinated by a primary care physician.

Pushback and progress

Several other specialty societies stated that they will oppose any primary care increases that are paid for by lowering payments to other physicians. They closed the door even to small increases in payments for primary care financed by even small pay cuts to their own members, even as part of a bill that would benefit all of medicine by stopping the much larger 10.6% SGR cut.

Major factions within the medical profession will fight against taking money from specialists unless a new way is found to finance primary care, such as using the anticipated savings from primary care coordination. Even within ACP's own ranks, some subspecialists may object if their pay is cut to give more to general internists. Such objections may lead Congress to lower its sights as to what can be accomplished now.

So far, the medical home has not generated the same level of opposition as the primary care payment bonus. Some specialty societies, including the American College of Cardiology, have embraced the model. Others have adopted a wait-and-see perspective. But controversy will come if some of the money needed to pay primary care physicians in a medical home comes from cutting pay to other doctors, or if the medical home gives primary care physicians more control over referrals and other resources for patients in a way that threatens other specialists' interests.

Transformational change is extraordinarily hard to achieve. Just when change is most likely to happen, opposition to it becomes the most intense. The renewed discord within organized medicine is a direct result of ACP's progress in building a powerful consumer-employer-physician coalition to transform health care policy to support and restore the value of primary care.