Who makes the decisions on Medicare reimbursements

On problem with outcome based reimbursements, and that is….Many patients do not want to be healed! Let’s face it…People like to complain (so there is no way a treatment will help), Americans have become so fat that the obese do not seek to recover from an illness or injury, and finally there is disability payments that the government will pay out (SSI). And….that’s the bottom line!

GAO: Medicare-Paid Physicians Decide How Much Money They Make

A committee of Medicare physicians controls how much doctors providing services to the government health care program’s patients are reimbursed for their services, but don’t ask to see the reasoning behind their decisions.

Physicians received more than $70 billion in such payments from the government in 2013.

The reimbursement panel withholds information about its members and voting records from taxpayers even though conflicts of interests are all but certain. The panel is comprised of doctors who benefit from its decisions, according to the Government Accountability Office.

The American Medical Association formed the Specialty Society Relative Value Scale Update Committee in 1991 to help the Centers for Medicare and Medicaid determine how much to pay physicians for each service. CMS relies heavily on the committee’s recommendations following nearly seven out of 10 of its recommendations.

“Although the [committee] is currently the only comprehensive source of information regarding physician work, its recommendations may be undermined by … potential conflicts of interest,” GAO said.

Eliminating the conflicts of interest, however, is difficult since Medicare-paid physicians are among the few experts on how much their services are worth.

“This has got to have a lot of subjectivity to it,” said John O’Shea, a senior fellow at the Heritage Foundation and a practicing surgeon. He noted that a cardiologist and a primary care physician would disagree over how much each of their services were worth.

Instead, O’Shea suggested that Medicare switch to a system that pays for a patient’s outcome, rather than a physician’s service. In other words, doctors are paid for the quality and efficiency of their patients’ recovery.

“I think the system is starting to move toward that, but it’s a fairly slow process,” O’Shea said. “The fee-for-service system is going to be around in some shape or form for a while.”

However, O’Shea admitted that a system based on care would also be flawed, since patient outcomes are often beyond a doctor’s control. Two patients could receive the same treatment for the same illness, but could see opposite results.

If a patient-outcome system can’t be developed, there could at least be improvements to the current method.

“This system can be made better, realizing this system has some inherent flaws,” O’Shea said. He agreed with the accountability office’s finding that the relative value committee lacks transparency.

For example, the committee requires certain panels to “include a mix of physician and non-physician experts” to decrease conflicts of interest, but investigators found “detailed information on composition was frequently missing,” GAO said.

The committee argued that it doesn’t disclose voting records “to protect members’ independence through the deliberation process from, for example, outside lobbying and potential negative feedback from colleagues.”

Further, the relative value committee’s votes are usually unanimous, GAO said. “This unanimity typically results from members resolving disagreements about services during deliberation.”

O’Shea believes more transparency is needed. “They say the meetings are open and that the public can go to them, but if you go, you have to sign sort of a nondisclosure form,” he said.

Consequently, CMS can’t be transparent about the panel’s work, since it heavily relies on the opaque committee. A lack of transparency and data sources “may undermine payment rate accuracy,” GAO said.

Inaccurate payment values could incentivize physicians to provide services that would give them a bigger payday from Medicare, “which affects patient care … Mis-valuation can also lead to unwise spending of taxpayers’ and beneficiaries’ money.”

Bean Counters and Office Managers cause Physicians to limit time with patients!

It’s not that Physicians do not want to spend time with Patients…Physicians would like to spend time with those they care for. Problem is the “Bean Counters” have taken control of medicine, and force physicians to treat patients as a source of revenue! That’s just the half of it…the other half are office managers that are assigned (by the Hospital/Health system) to manage the office’s operation. Most (not all…I know several good ones) of these managers are incompetent (and are only taking orders from the Bean Counters & HR)!

Why it’s hell to be a doctor in America today

By Susannah Cahalan

August 23, 2014 | 3:00pm

NY POST

Dr. Sandeep Jauhar is mad as hell.

American health care is in upheaval. On one side, overhead and malpractice insurance costs keep increasing, while salaries stagnate. On the other, patients believe that expensive drugs are better, more people are on government-run insurance that pays less, while private insurance fights every claim.

 

Now doctors spend most of their time trying to game the system, requiring endless paperwork, protracted bureaucratic battles and “treadmill medicine,” seeing as many patients as possible in as little time. This problem will only intensify as millions join the ranks of the insured under the Affordable Care Act.

 

In this self-perpetuating cycle, doctors spend most of their time as businessmen — and care suffers.

 

It’s no wonder then that doctors no longer enjoy their jobs, explains Jauhar, director of the Heart Failure Program at Long Island Jewish Medical Center and author of “Doctored: The Disillusionment of an American Physician” (Farrar, Straus and Giroux), out now.

 

“This book is meant to be like the scene in ‘Network’ when [Howard Beale] opens the window and yells, ‘We’re not going to take it anymore,’ ” Jauhar says in an interview with The Post.

 

“I see an emotional emptiness created by the relentless consideration of money. Most of us went into medicine for intellectual stimulation or the desire to develop relationships with patients, not to maximize income,” he writes.

In a 2008 study of 12,000 physicians, only 6% described their morale as positive. Even insurance claim clerks polled in a different study were happier.

As managed care has grown (by the 2000s, 95% of insured workers were in some kind of managed care plans), so has physicians’ discontent. In 1973, fewer than 15% of physicians reported any doubts about career choices. Today nearly 40% say that they would not choose to enter the medical profession if given the opportunity to do it all over.

 

If things continue as they are, the US can expect a shortage of 150,000 doctors by 2025, according to the American Medical College. Jauhar says that doctors on the online community SERMO are threatening to leave the country or scrap their private practices.

 

The serious downside here is obvious: Unhappy doctors make for unhappier patients.

“The physician-patient relationship is the worst it ever was,” he says.

 

To hammer in this point, Jauhar quotes facts from the Commonwealth Fund: The US ranks 45th in life expectancy (“behind Bosnia and Jordan,” he adds) and compared to other developed countries near last in infant mortality and health-care quality, access and efficiency. We also have fewer physicians and hospital beds than average.

 

This “mid-life crisis in medicine” is reflected in Jauhar’s own writing.

Readers can follow his skepticism in “Intern,” his first book about his internship year at New York Presybterian, harden into disillusionment in “Doctored,” which chronicles his time at LIJ as he enters his middle age (he’s now 44).

 

“Doctored” opens with: “When I look at my career in midlife, I realize that in many ways I have become the kind of doctor I never thought I’d be: impatient, occasionally indifferent, at times dismissive or paternalistic.”

This “kind of doctor,” once so idealistic, now takes morally ambiguous speaking gigs with pharmaceutical companies and side-jobs at “sketchy” cardiologist private practices who push for expensive and often unnecessary tests for the reimbursements.

And this is where the book gets really bleak. Doctors — like his own brother, also a cardiologist — refer to patients as “commodities.” One physician at LIJ admitted that “sometimes you have to drag out” a hospital stay for a patient if you want to get paid.

He writes about one of his patients, a 50-something man who complained of shortness of breath. Fourteen doctors, 12 procedures, and hundreds of thousands of dollars later, he was released with minimal improvement.

 

This is a problem not only of milking income, which of course happens, but because doctors just don’t have the time to do their jobs. Primary care physicians (doctors who Jauhar believes are most unhappy) spend an average of eight to 10 minutes per patient.

It’s a self-fulfilling prophecy. With less time for each patient—studies show (no surprise here) that rushed doctors listen less — relying on expensive tests, which don’t necessarily lead to more accurate diagnoses. Med school advises doctors-in-training that you should be able to diagnose 80% of cases with a health history and an exam alone.

 

No further tests required.

 

But in this exam on-the-run environment, doctors are more likely to practice “defensive medicine,” or “cover your ass” medicine — costing us about $750 billion a year (of the $3.8 trillion we spend a year) in wasteful procedures that lead nowhere.

“After so many years in medicine, I am convinced of one thing: The vast majority of doctors aren’t bad. It is the system that makes us bad, makes us make mistakes,” he writes. “There is a palpable sense of grieving. The job for many has become just that — a job.”