NEJM: Healthcare reform needs work before 2014
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Jim McDermott, MD, U.S. representative (D-Wash.) stated in the article that although he supported the PPACA, there remain areas of concerns that must be addressed well before 2014, when 32 million newly insured Americans will join the healthcare system.
“Our foremost task this year must be to develop a strategy to ensure the sustainability of our primary care system,” the representative asserted. “Any strategy for meeting the objective of primary care sustainability must address Medicare’s sustainable growth rate (SGR) formula for determining physicians’ reimbursement levels, and given Congress’s tendency to address problems only when they reach crisis proportions, the SGR is ready for action.”
December’s last-minute vote to delay for a year the scheduled 25 percent reduction in the SGR marked the fifth time that Congress intervened in 2010 to forestall a critical problem related to Medicare access—this time at a cost of $19 billion, according to McDermott.
McDermott offered a multitude of possible trouble-shootings to assist the situation, from eliminating the SGR altogether with no replacement, while encouraging the development of payment reforms such as those in the PPACA (for example, bundling of payments for episodes of care and the creation of accountable care organizations), to modest improvements such as using the Medicare Economic Index minus certain productivity adjustments to more closely align reimbursement changes with medical inflation.
“Congress should consider separating and shielding preventive services from SGR cuts because primary care is not responsible for overutilization and because the economic effect on primary care practices could be devastating,” iterated McDermott.
One approach might include federal scholarships that cover a significant amount of the cost of medical education if the candidate selects a primary care path, suggested McDermott. “Such a program could be especially useful in conjunction with innovative curricula that defy the current pedagogical trend toward producing superspecialized physicians and researchers.”
Graduate medical education (GME) also presents an opportunity to improve the sustainability of the primary care system, according to the representative. “If the ultimate goal is for patients to avoid the highly specialized tertiary care inpatient setting, then it makes sense to have residency opportunities in less-intensive settings in which primary care physicians would actually practice.”
McDermott stated that the Center for Medicare and Medicaid Innovation (CMI) under the Centers for Medicare and Medicaid Services (CMS) is the most overlooked important advancement in the PPACA and needs to be promoted more. “It is the nexus from which our delivery system may transform into an integrated and sustainable network that can harness and scale up many of the innovations that are already in place but are scattered around the country.”
While admittedly not an all-encompassing game plan, McDermott concluded that “[m]y greatest fear is that what may get lost amid the angry threats of ‘repeal and replace’ and endless oversight hearings is our best chance to improve on the historic opportunities afforded us by the PPACA.”