The fight against ObamaCare not only has activated and mobilized average people at the grass-roots to become politically active for the first time in their lives, it also has created an efficient information-sharing network through Google Groups and other networking devices that allows experts to disseminate information, discuss and debate issues among themselves and interact with non-specialists in real time. 

It is a kind of spontaneous Wikimedia.  It is fabulous, and it means the doors to the Washington backrooms have been blown off the hinges, sunshine now penetrates to the deepest recesses of Capitol Hill, if not in real time, with minimum delay.  That doesn’t mean these jokers don’t bear constant watching because no matter how quickly we expose their nefarious schemes, they still are able to cut deals and jam legislation through in the dead of night and under extraordinary parliamentary procedures.

The most recent example of the Wikimedia phenomenon is an email sent out last night by Dr. David McKalip, a St. Petersburg, Fl Neurological Surgeon.  Here is his take on the Baucus Bill (Finance Committee Chairman’s mark):

I am reading through the Baucus Bill and what I see is disturbing assault on the profession of medicine. I see a process that will lead to the near extinction of small group  and solo medical practices.  A system where docs who still want to practice will be forced into hospital employment or large groups.  A system in which docs are coerced into primary care or into various geographic areas.

It will be a system where docs are forced into capitated payment models whether they like it or not – or even know it.

A system where docs will be more beholden to a committee’s perception of “efficiency” than the needs of patients.

A system where medical costs will escalate for insurance and medical care and doctors will be further penalized for prescribing anything that is too “expensive”.

This will be the death of our Profession as Dr. Plested warned us in 2006 at I-06. 

Once again, our AMA and the profession of medicine are being held hostage to the SGR fix -  some things never change.  No doubt, many of these onerous provisions I describe below will be decreased or dropped as bargaining chips to get AMA endorsement of very bad Medicare and health system reform in exchange for avoiding the SGR cut.  As has been said many times – the SGR cut should be allowed to pass.  Call the bluff of Congress and watch the senior citizens rise up against Congress when docs no longer are seeing Medicare patients. In this case we are being held hostage because we have loaded the gun and put it in the hands of congress and showed them how to hold it to our heads – over and over.

What is most sad is that Congress is openly embracing a centrally planned medical economy – we all know such central planning fails every time.

Here is how I come to these conclusions. (corrections are welcome if I misinterpreted or missed something).
 

            1.            A centerpiece of the bill will be Pay for Performance.  Doctors will be penalized 2% if they don’t report data to the “Physician Quality Reporting Initiative”. Doctors will receive a bonus if they send data to the government, but a penalty if they don’t.  (p 78) To be a “meaningful user” of HER’S (under recovery act), the EHR will have to include PQRI reporting!  “Efficiency” of physician care would be based on “episode groupers” which were the source of the NY state lawsuit against United Health care and is a clear rationing model (a budget is given for care – and doctor is penalized if he/she goes over budget) (p 80).There is no requirement that valid sample sized per physicians are used. Docs will receive a 5% cut in payment if their care costs into the “90th percentile of national utilization” which would grow more onerous with time. More on “efficiency” on p 85.  $500 million to finance quality measure development and implementation with $200 million out of Hospital insurance trust fund (HUGE PAYOFF TO AMA PCPI). Hospital readmissions and “hospital acquired conditions” won’t be paid for “never events”.  P92: “Vary payment to physicians ordering advanced diagnostice imaging accorting to adherence to “appropriateness” criteria” (pilot).
 

            2.            Capitation will be the predominant model of payment for most patient care - Accountable Care Organizations (ACO’s) (p 88) will be favored for payment with bonuses. This will drive docs to bigger practices.  The docs will ONLY get a bonus if they have cut spending.  Medicare patients will be “Assigned” to ACO’s based on their use of Medicare items and services in preceding periods” (p 90). Doc’s will be basically given a set budget (capitated amount) and rewarded for spending less on their patient.

 

            3.            Bundled hospital/physician fees in Medicaid and Medicare – Under a pilot program, hospitals will receive all money for hospital and physician services and docs will have to go to the hospital to get paid.  This is a dangerous approach that will force doctors out of independent practices. (p 60, p 95). If the program fails (p 97) there is no option for scrapping it – only for addressing “shortcomings”  to look for “improvements”.

 

            4.            There is redistribution of Medicare funds to primary care – at the expense of specialty care. P 101.  Encourages docs to go to rural areas and “underserved areas” by preferentially giving them a bonus (which denies it to others).

 

            5.            DOCTORS WILL BE ESSENTIALLY FORCED To PARTICIPATE IN MEDICARE.  – THIS IS CRITICAL GIVEN THE ONEROUS PROVISIONS ON MEDICARE DOCS WILL SEEK TO DRIVE THEM OUT – yet they will have nowhere to go if they want to provide for Medicare patients.  P 185.  “All Providers, including physician who order items or services, would be REQUIRED to be a Medicare enrolled physician or eligible professionals before they would be allowed to ORDER OR PRESCRIBE services that would incur ANY cost to the Medicare program”.  Okay, so if I choose to leave medicare due to the medical police state and unethical pay for performance programs and a Medicare patient wants to see me – THEY CAN’T!  If they do, nothing I order or do for them will be paid for by Medicare!  No matter if I offer an 80% discount to get them in the door or am the best neurosurgeon in town, they can’t get the MRI I order paid for or the hospital bill for the surgery I do.  This is a backdoor avenue to mandated physician participation in Medicare.

 

            6.            Medicare devices and drugs will be taxed – increased costs will be attributed to doctors who will be PENALIZED!  Under the PFP models, docs will be penalized if care is too costly (see above).  However, care costs will be driven UP as drug costs and device costs are taxes  $2.3 billion for drugs (payable to Medicare Trust Fund) and $4 billion for devices, $750 million on lab services.  Any doc who orders these will be ordering test, drugs, devices that will be higher priced. This will increase the cost of medical care.  Docs who have “utilization patterns” that are too high will be penalized. They will thus avoid ordering test, drugs and devices.

 

            7.            Doctors will be subject to overly aggressive “fraud and abuse” investigations and be made to pay for it.  - (p 185) Doctors will be made to pay $350 each into a fund to pay for a “screening” program to reduce waste which would include unannounced and random site visits.  If the Secretary (HHS) determines there is a “risk” of fraud in some area of service covered by Medicare, then NO NEW DOCTORS may be able to enroll in that sector (e.g., if “spine surgery” had too much “fraud” then no new spine surgeons could be enrolled by Medicare).  ALSO, doctors can be required to put up a $500,000 surety bond to protect the government from “fraud”.  Same will apply to Medicaid (why would docs stay in Medicaid then).  The NPDB will be unified with other “centralized sanctions” and a new “patient-abuse/neglect” registry data systems to  “assist” licensing boards with granting licensure (p 188).  Docs will be “required” to implement compliance programs to be in Medicare that will document referrals to “programs” at “high risk” of “fraud” and be dis-enrolled for up to a year if they don’t or is “not able” to do so (p 190).  Docs will repay “overpayments” within 60 days after date of the overpayment based on an “internal compliance audit” they must institute (p 191).   Penalties for all of this activity will be increased. This includes for “False claims”, which in Florida recently has included “incorrect coding” based on a very zealous federal prosecutor.

 

            8.            Scope of Practice will expand to nurse practitioners and physicians assistants. (P.A.’s can manage patient in hospice as an “attending physician” p 115).

 

            9.            Medicare Advantage plans will be invented to cut spending for services to 85% of Congressional fee schedules.  This will lead to decreased physician compensation and less access to care for patients.(p 137)

 

            10.            Committees and unelected officials will artificially drive down Medicare spending and have power to drive down physician compensation.  – The IMAC will be told to cut Medicare spending if it doesn’t’ meet certain thresholds for decelerating cost growth. (p 156) . The 
”CMS INNOVATION CENTER” (p 90) will look for further cuts in Medicare spending.  Secretary of HHS can cut rate of physician reimbursement artificially (p 112).

 

            11.            Doctor-owned hospitals will be allowed to wither on the vine. (p175) Can’t add new OR’s, angio suites or procedure rooms (e.g. endoscopies) unless it meets stringent government requirements meant to serve their needs, not patient needs.

After reading through this bill, it is a wonder doctors will want to practice medicine any more – precisely the result desired by many central planners since it will reduce utilization.  The only docs left will be those who dutifully comply with regulations and don’t mind rationing and practicing from a cookbook.  As was stated by “Dr. Hendricks in Atlas Shrugged (paraphrasing) ‘ Doctors will have a gun held to their head and the patients will be working under the hands of a doc whose life has been throttled.  The doctor who resents this will be dangerous, but not as dangerous as the ones who don’t resent it’.