Health care reformers test 'medical home' service model


With a new Congress powered by Democrats and a new Democratic president, sweeping actions affecting health care policy and, particularly, Medicare can be expected in 2009.

"The Finance Committee will move forward on comprehensive health reform early next year," said committee chairman Sen. Max Baucus (D-MT). "While some suggest that the current economic situation might thwart efforts to overhaul America's health care system, I believe the state of the U.S. economy makes the need for health care reform even more urgent."

"It is not a question of arithmetic or accounting; it's a question of priorities," an aide to Sen. Edward M. Kennedy (D-MA), told the Associated Press in late October. "When AIG needs the money, somehow the money is found. When Freddie and Fannie [the Federal Home Mortgage Corp. and Federal National Mortgage Association, respectively] need it, somehow the money is found. The theory is, they're too big to fail. It can certainly be argued that the health care system is too big to fail, but it's failing for millions of people every day."

Baucus' Republican counterpart on the committee, Sen. Charles Grassley (R-IA), also says health care reform must be a priority, as did Obama and John McCain (R-AZ) during the presidential campaign. There is also strong support for reform among leaders in the House of Representatives. The question is, what will shape that reform?

Regardless, it is clear that major changes in Medicare are in the offing, both in the way physicians are paid and in the new policies that will affect their practices.

"This will be a dramatic change," predicted Priscilla Chatman, director of government relations and advocacy for AUA. "The larger goals will be to cover the 47 million people who are uninsured and to regulate insurance companies to cover pre-existing conditions.

"The other piece, the one that will directly affect urologists, is the Medicare reform that will take place. Part A will be insolvent by 2019 and Part B is unsustainable at the current rate of growth."

How will care change?

Medicare reform means significant changes must be made in the physician fee schedule, which, under the current system, annually calls for increasingly large payment cuts that are eventually rolled back by Congress. Chatman expects an effort to establish separate fee "buckets" for specific categories of service, possibly resulting in a generally more equitable fee structure.

Previous legislation advanced by Baucus and others, as well as recommendations from the Medicare Payment Advisory Commission (MedPAC) can be expected to shape those reforms, which may do far more than simply address physician payments.

For example, the medical home concept, which would establish a system of coordinated care for patients, appears to be gaining momentum and may emerge as a cornerstone of Medicare reform. Several medical home pilot projects are under way, such as one sponsored by United Health Group in Florida. In a Sept. 16 report to Congress, MedPAC recommended that Medicare establish such a pilot program for beneficiaries with chronic conditions, and Baucus supports funding the program.

Under the Florida plan, patients would select a personal physician, or "medical home," who knows their medical and family history and coordinates their medical care. The physician is responsible not only for treating a specific ailment or condition, but also for working with the patient to better manage health care needs and arrange appropriate care with other professionals. The patient-centered medical home model emphasizes preventing disease and improving the care of chronic conditions and provides behavioral health support and patient education.

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

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

In addition, 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 said. To be eligible for these payments, medical homes would be required to:

"These stringent criteria are necessary to ensure that the pilot evaluates outcomes for the kind of coordinated, timely, high-quality care that has the highest probability to improve cost, quality, and access," Dr. Miller said. "The pilot must assess a true intervention, rather than care that is essentially business as usual."

AUA: Consider data carefully

Chatman said that "thoughtful consideration" should be given to the data and outcomes that are derived from the pilot and that funding should not be provided at the expense of surgical specialty fees. She cited concerns about how savings would result without the medical home acting as gatekeeper to regulate patient services.

Chatman also said that officials at the Centers for Medicare & Medicaid Services have taken great pains to assure specialists that the medical home concept would not be implementation of the managed care gatekeeper concept.

"We recognize that this is just a demonstration project at this point," she said. "After the data is in, let's consider and discuss and determine the next steps that should be taken."

Meanwhile, MedPAC's report emphasized the need to prevent "price distortion" that the agency said results from underpayments for primary care services and overpayments for specialty care and procedures.

Stay tuned. 2009 may well be a critical year for health care reform.

Bob Gatty, a former congressional aide, covers news from Washington for Urology Times.

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