Hi Tobin:

Great blog - you're off to a wonderful start. I can tell you in pediatrics, salaries seem to increase quickly early on then hit a wall. You basically camp out at the same salary forever. In fact, I have not seen the base salary for board-certified pediatricians increase much over the 10+years I've been boarded despite changes in cost of living,etc. So, essentially, I'm losing money!

Best,
Dr. Gwenn

Hey Tobin,
I'm sure this hits a nerve for most physicians. Obviously, a multifactorial problem without simple solutions. Not as easy anymore just to "see more patients." Part of the problem is that we, as physicians, continue to give away our services for free. It is not as simple as seeing 20-25 patients and giving quality care. We also must deal with the multiple phone calls (my average is in the 40-60 range daily) asking for advice, refills, treatment over the phone, etc. For those of us that do this, we are practicing for free. But, I just can't see 40-50 patients a day and give quality care. What to do? Another huge issue is the insurance companies. They continue to hold the bulk of the power in the medical world. They are allowed to make the rules and enforce the rules. A deadly combination. In addition, they make and enforce these rules according to the financial bottom line as they have stockholders and wall street to answer to. Not sure our individual voices are heard, and there seems to be no significant avenue for our collective voices to be heard. Some will say the AMA or our respective specialty academies re the way to be heard, but those groups pale in comparison to the insurance companies lobbies and financial backing. So we beat on...
jeff

I was recently at a meeting for Oncology Medicare Carrier Advisory Representatives. The theme of the meeting was trying to figure out what Medicare wants. We say "Insurance," but at least in oncology, Insurers follow Medicare. I wrote up a letter for oncologists. It may have parts that are greek to the reso of you, but I would be interested in the thoughts of others specialties about the points that are common to us all.

The point that it makes regards physician salaries is that the rules are going to be changing faster than medicine does. That pay for performance will be the name of the change, and that it will be designed to spend less on healthcare, not more on performing docs. So getting ahead of the curve is, as noted above, really is going to take more than hard work, it's going to take whole lot of clairvoyance instead.

Here is the letter:

What Does Medicare Want?
Reflections on ASCO’s 9th Annual CAC Networking Meeting

I’ve been to enough CAC meetings now to be able to categorize them. My first CAC meeting was well before MMA. It was the “What are we supposed to be doing meeting?” Then there were the “Lets bash the carrier medical directors” and “How to make up with you carrier medical directors” meetings; they were held successive years. Then there were the meetings on either side of MMA, “Don’t worry the sky isn’t falling” and “Okay so it fell, but we can still fix it.” CAC meetings have felt increasingly serious and desperate since then. But this year was different. Instead of talking about Medicare, it seemed like Medicare did the talking.

The keynote speaker was Mark McClellan, recently the top dog at CMS (he had the unenviable task of implementing MMA after Scully left to cash in his chips) and before that the top dog at the FDA. Also on the agenda were 5 other CMS physicians and 3 carrier directors, though we missed two of the CMS speakers. One of them had her car (my dog) stolen (ate my homework) on the morning of the CAC meeting and was too busy filling out a police report. The other was scheduled to address the proposed national coverage decision on ESAs. He called ASCO a week before the meeting to announce that regrettably neither he nor anyone else familiar with the proposed would be unable to attend.

Even with the no shows, the theme of the meeting was Medicare, but this meeting was not about what Medicare has done or is doing, or even about what it will do. It was about what they would like to do. What does Medicare want?

Per Mark McClellan, and he should know, Medicare has 3 wishes: 1) Medicare wants to be able to measure the quality of healthcare. 2) Medicare wants to use the quality measurements to be able to assess the quality/cost of therapies in order to transform from a passive payer to an active and discriminating purchaser of value based healthcare; call it pay for performance (P4P) if you prefer. 3) Ultimately, Medicare wants an evidenced based reimbursement system. Of course the devil is in the details: define quality, when does discriminating purchasing devolve into rationing care, and how does evidence based medicine differ from evidence based reimbursement.

Quality is one of those “in the eye of the beholder” kind of words. To use a less subjective terms, Medicare will measure processes and outcomes. Outcomes include measures that we are used to seeing in our literature, such as mortality/survival data. Other outcomes that CMS will measure include patient satisfaction, utilization, and data generated from what they are calling “coverage with evidence development (think PET registry). Examples of process measurements would be clinical guidelines and pathways. Medicare could ask, “Do you have them, do you use them, and do you follow them.” More specifically, processes that are designed to allow quality measurement are ASCO’s Quality Oncology Performance Initiative (QOPI) and Medicare’s newly christened Physician Quality Reporting Initiative (PQRI).

I personally much prefer QOPI to PQRI. We were one of the beta groups. Joseph Simone’s goals of meaningful and efficiently extractable yes or no measurements have largely been achieved in this self evaluation program that allows comparison within a practice and to a national norm. Perhaps its incorporation into the ABIM board certification process will allow it to succeed, but participation in the first two years that it has been open to all of ASCO has been disappointing. CMS, for their part doesn’t think that a voluntary program will succeed.

That is why PQRI, if the democrats don’t disappear this republican brain child first, will eventually have enough teeth that it cannot be ignored. Strictly speaking, PQRI is not P4P, but P4Reporting. Founded on measures developed by professional societies, Medicare would like us to think that PQRI was our idea. For the most part it works this way. Medicare asks us if we did something. For each patient who qualifies, you then respond with “yes I did it,” “no I didn’t and I documented why”, or “no I did not and neither did I document why.”

There are 4 heme and 4 onc measures. If you see enough melanoma there are three more derm measures you might be interested in. The eight hem/onc measures are: 1) Baseline bone marrow cytogenetics in MDS and acute leukemia, 2) Iron store evaluation prior to initiating ESAs in MDS (assumes you will be able to use ESAs in MDS of course), 3) IV bisphosphonate therapy in multiple myeloma, 4) Baseline flow cytometry in CLL, 5) Tamoxifen or aromatase inhibitor therapy in ER/PR+ breast cancer, 6) XRT recommendations in breast cancer treated with breast conserving surgery, 7) Adjuvant chemotherapy in stage III colon cancer, and 8) Documentation of a treatment plan prior to starting chemotherapy.

If you successfully respond, your answers don’t matter, just your response, at least 80% of the time, the denominator being based on CPT and ICD9 codes for the disease in question, you will be eligible for a bonus, essentially 1.5% of E&M charges. The bonus and a confidential report on your performance in 2007 will be delivered in mid 2008. You can get much more confusing detail about PQRI from a variety of sources. I would refer you to ASCO. CMS admits to having done a terrible job of getting the word out in an understandable form.

P4R not withstanding, P4P is still something that CMS and Congress are very serious about. Of course there is no consensus on what P4P really means. Rest assured we are not talking about a lot of new money into the system. Pete Stark, Chair of House Ways and Means is fond of saying something to the effect of, “I’ve been paying for performance that I haven’t gotten. P4P simply means that from now on you have to perform to get paid.” Mark McClellan was a little more specific in an ambiguous way, speaking of “value based provider payments that reward personalized care plans, IT systems, screening programs, and one stop disease care centers,” and then gave a number of examples of CMS demo projects by way of clarification.

The list of P4P demo and pilot programs is impressive in its breadth, targeting hospitals, large physician group practices, small group practices, nursing homes, HMOs, home health, ESRD, other disease specific programs, and even individual high-cost beneficiaries. More impressive is the hundreds of millions of dollars that they are paying into them. In our state the Everett Clinic and its more than 250 multispecialty physicians are in a gain sharing Physician Group Practice Demo. The clinics brainchild is to place a hospice nurse within internal medicine pods of 4 docs. By identifying patients likely to be within the last two years of life, they intensify communication with the patient, emphasizing and enabling good medical care as well as end of life discussions, palliative care, and hospice. As long as certain quality measures are maintained, every dollar of decreased utilization that results from the project puts eighty cents into the coffers of the Everett Clinic. It wasn’t very long ago that the OIG looked askance at such gain sharing arrangements, but that position has been rethought.

At the heart of Dr. McClellan’s comments, and it appears to be a deeply ingrained bias in Congress and at CMS as well, is a belief that our country spends way too much on health care simply because physicians are financially incentivized to do so and that if we changed the incentives and let patients choose, they wouldn’t want to pursue the expensive and life extending therapies that our current system foists upon them.

Can’t say that I share the perspective, but they seem to be holding all the cards right now, and if the carrot of P4P can’t do it evidence based reimbursement is the big stick. When we practiced evidenced based medicine, we mean to take all of the evidence available to us and use it to make the absolute best decision possible. In the absence of absolute evidence we use what we have. Cost is not a factor that we consider in EBM. Evidence based reimbursement is different. The evidence is the same, but cost is central, and EBR says that in the absence of absolute evidence, said another way, in the presence of incomplete evidence, you don’t get paid for doing something if it is deemed expensive.

The terminology of EBR currently includes: least costly alternative, comparative effectiveness, step therapy, and coverage with evidence development. Least costly alternative emerged in the DME world and nebulizer treatments. We know it by way of LHRH agonist payment policy that says Zolodex and Lupron are equivalent and we will pay the lowest ASP+6%, regardless of which drug is used. Least costly alternative is on shaky legal ground. Nothing in Medicare statutes allows for using price to determine coverage, but no one in Congress is going to complain.

Comparative effectiveness is least costly alternative on a broader scale and it is all the rage at CMS where they believe that it is a natural application of EBM to EBR. Conceivably it could be used to compare complete chemotherapy regimens, dictating that in the absence of data proving superiority of any particular regimen all first line non-small cell lung cancer patients, barring contraindications, receive cisplatinum/paclitaxel for example. The dangers to being able to access care for patients is obvious given CMS penchant for interpreting underpowered studies that fail to demonstrate superiority as evidence of equivalency. Taken directly from the slide of a CMS speaker is the following statement regards comparative effectiveness. “In Theory, coverage for a product could be limited to the subset of the population for which it is shown to be the most effective treatment option. My interpretation of his statement is that if a trial only enrolled patients up to the age of 75, you cannot use it to treat a patient over 75.

Step therapy could also be called guideline based reimbursement. The FDA has taken a penchant for building in a line of therapy into its drug approvals. For example, Avastin is approved for breast cancer when given with paclitaxel as first line therapy for metastatic disease. Several times a year I get calls from a doctor’s office about Medicare reimbursement for a drug used counter to the approved line of therapy. I am not aware of denials based on line of therapy, but that is what step therapy is all about. Another example would be to say you cannot give treatment B if you haven’t already given treatment A. It becomes evidence based reimbursement when the differentiation between A and B is that A is cheapest.

Oncology is at the forefront of coverage with evidence development. We know it as the PET registry. The idea is to exchange “early coverage,” for an unproven modality in exchange for rigorous data collection that will ultimately demonstrate whether it is effective or not. The biggest problem with this is in who is doing the collection and analysis of the data. CMS is under no obligation to do anything with collected data, and as the recent ESA national coverage decision demonstrates, they are very capable of reaching unsupported sweeping conclusion against reimbursement on the basis of the flimsiest of data. The future of coverage with evidence development could be so far reaching as to tie off-label drug reimbursement to data collecting that would eventually be used to either limit or broaden what is “reasonable and necessary.”

Facilitating CMS in an effort to implement EBR is a new and more sophisticated compendia. The statutes that apply to the use of compendia for CMS drug reimbursement listed three compendia, USP-DI, AHFS, and AMA-DE, or their successor compendia. The latter compendia disappeared some time ago. If you haven’t heard, USP-DI is history too. Thomson-Micromedex, the Canadian publisher that bough it a few years ago has lost its license to use the name and it is being retired. It will be replaced by a new Thomson-Micromedex product, DrugPoints, which will retain its status with Medicare by virtue of being its successor. DrugPoints will no longer give a black or white listing of approval or disapproval. Instead it will be in a summary format and will rate the quality of the evidence used to reach a recommendation.

What Medicare will do with this is unknown. The cynic can certainly see its potential to limit coverage in the name of EBR. Whether Medicare will develop other, more sophisticated compendia, such as NCCN, is also unknown. It seems that there is some reluctance to embrace a compendia generated from within the oncology community.

Ultimately EBR will mean a plethora of National Coverage Decisions (NCD). The recent ESA NCD is just an opening salvo. In 2000, at the Second Annual CAC Networking Meeting, a kid from CMS was the keynote speaker. He announced a changing of the guard and the end of a decentralized and passive CMS. In 2000 there were about 100 NCDs. Today there are over 300, and 150 national coverage analyses are in the hopper as well. And as the ESA NCD indicates, CMS has biases that do not predispose it to bring physicians or their specialty societies to the table in developing policy. In the middle of the State Children’s Health Insurance Program (SCHIP) bill now making its way through Congress is a provision to create a new bureaucracy, the “Center for Comparative Effectiveness.” If CMS is as capable of distorting and stretching the research of others to meet its payer based expectations, wait till it is designing, performing and analyzing the research that they then use to develop policy.

So what does Medicare want? They want to be the prosecutor, judge, and jury of the care that we give our patients. Unfortunately, a clustering of pressures to include the costs of healthcare, particularly the costs of chemotherapy drugs, a war in Iraq, and a Congress that is operating on a budgetary “pay as you go” rule, may well combine to give it to them. The SCHIP bill may be doomed to a president’s veto, but Dr. McClellans’ parting prediction was a Medicare Omnibus Bill late in this session of Congress. It will be purported to fix the unsustainable Sustainable Growth Rate calculation that has become every physician’s annual heartburn, but as every oncologist learned during the Medicare Modernization Act, the devil is truly in the details; details that will include the phrases “value based healthcare,” “pay for performance,” “comparative effectiveness,” and “evidence based reimbursement.” And rest assured that it will be déjà vu, as beleaguered oncologists will once again be in the thick of it.