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Legislative: Healthcare reform: 2009 may be a critical year for Medicare programs


Not long ago, a dermatologist from the southwestern United States who works in a busy six-physician practice received a check in the mail from the Center for Medicare and Medicaid Services (CMS). It was his share of more than $36 million in bonus payments made by CMS for satisfactorily reporting quality information under the 2007 Physician Quality Reporting Initiative (PQRI).

Key Points

There was excitement in the air as he checked out the envelope. How much would it be? He had heard that some of his colleagues had received checks for several hundred dollars. Certainly, that would be worth the effort.

He ripped open the envelope. His check was for $85.21.

"I filled out all of the appropriate forms, codes, office notes, etc., for all patients that had a melanoma or a history of prior melanoma.

"I guess I didn't read the line that said we may earn an incentive of 1.5 percent of total allowed charges. Don't think I will volunteer anymore," he says.

Worth more

Now, the doctor says it wasn't all that burdensome providing CMS with the data, but it was certainly worth more than $85.21.

Medicare patients constitute more than 50 percent of his practice, the doctor says.

"It's a big deal. If they start this pay for performance or mandate electronic medical records like they're talking about, it could be expensive.

"As far as I'm concerned, when they keep putting in these new regulations, it just gets between us and our patients, and adds a new layer of cost," he says. "But what can you do? They're going to do what they want to do."

Health reform

With a new Congress and a new president coming into office, sweeping actions affecting healthcare policy and particularly Medicare can be expected, and dermatologists need to pay attention.

"The Finance Committee will move forward on comprehensive health reform early next year," says committee chairman Sen. Max Baucus (D-Mont.). Indeed, Sen. Edward M. Kennedy (D-Mass.), chairman of the Senate Committee on Health, Education, Labor and Pensions, reportedly plans to move healthcare reform immediately after the new Congress and new president take office in January.

Sen. Baucus' Republican counterpart on the committee, Sen. Charles Grassley (R-Iowa), says healthcare reform must be a priority. There is also strong support among leaders in the House of Representatives for reform.

As this occurs, it is clear that major changes in Medicare are in the offing - both in the way physicians are paid and through new policies that will impact their practices.

Previous legislation advanced by Sen. Baucus, as well as recommendations from the Medicare Payment Advisory Commission (MedPAC), may offer insight into the changes to come.

'Medical home' concept

For example, the "medical home" concept, which would establish a system of coordinated care for patients, appears to be gaining momentum.

There are currently several medical home pilot projects under way, such as one sponsored by United Health Group in Florida, and MedPAC, in a Sept. 16 report to Congress, recommended that Medicare establish a pilot program for beneficiaries with chronic conditions. Sen. Baucus supports funding.

Under the Florida plan, a patient selects a personal physician, or "medical home," who knows his or her medical and family history and coordinates medical care. The physician is responsible for treating specific ailments or conditions and for managing the patient's healthcare needs and arranging needed care with other professionals.

Qualifying 'homes'

Under MedPAC's proposal, qualifying medical homes could be primary care practices, multispecialty practices or specialty practices that focus on care for chronic conditions, such endocrinology for people with diabetes.

"Geriatric practices would be ideal candidates for Medicare medical homes," according to Mark E. Miller, Ph.D., executive director of MedPAC, who presented the commission's report to the Senate Finance Committee.

In addition to receiving payments for fee-schedule services, qualifying medical homes would receive monthly per-beneficiary payments that could be used to support infrastructure and activities that promote ongoing comprehensive care management, Dr. Miller says.

For dermatologists, the medical home concept could mean that they would need to find a way to participate in such an entity or risk losing Medicare patients.

Former congressional aide Bob Gatty covers Washington for businesses specializing in healthcare and related issues. He has written Dermatology Times' Washington Report for more than 20 years, and welcomes comments and suggestions. Mr. Gatty is available at: bob@gattyedits.com

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