Dr. Atul Gawande’s new article called Overkill is a great asset for all of us change agents. The tagline is: “An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it?” It appeared in the May 4 issue of the New Yorker magazine. The topic is “no value” healthcare, and he describes both over-diagnosis and over-treatment. Me and my gang know that those things also create over-impairment and over-disabling — and ruined lives!
Recommendation: Use this article as a tool to educate yourself – and others! It is much better than most of the stuff on this general topic in medical journals and august scientific publications – because he explains things so clearly and in such simple yet vivid language. There’s a powerful vignette of a guy with two prior spine surgeries whose local doctor recommends a third one – and how the story turns out. A happy aspect of the Overkill article is that Gawande also describes how the dark forces that are driving these things are being countered by more positive ones. Things are slowly and spottily changing FOR THE BETTER!
I am ashamed at my petty jealous hatred for this man — because he is handsome, brilliant, insightful, incredibly talented, articulate, frank, and a fabulous writer. He has been a columnist for the New Yorker since 1998. Based on his photograph, he must have been a baby then. I’ve read several of his articles and books, and recommend them to you. In particular, if you want to be sickened at how the constant emphasis on money has corrupted the physician culture, read his earlier article entitled The Cost Conundrum – like the White House did. I’ve just finished his latest book Being Mortal. It is wonderful — richly informative yet with a very positive tone and personal feeling. See more about Gawande on the New Yorker’s Contributors webpage or on Gawande’s own website.
Jenny Weast’s predicament appears to be a perfect example of how today’s “system” encourages dependency instead of independence among people with disabilities — and increases the barriers to work rather than reducing them! Jenny is a popular and energetic high school teacher in California who is quadriplegic. She needs personal care attendants to help her with her activities of daily living, but Medicaid has decided she doesn’t qualify for coverage — because she earns too much money. According to Jenny’s Facebook page, Medicaid says her “fair share” of these services would be $2400+ dollars per month, which would leave her with 26% of her paycheck to live on. There is NO CHARITY and NO FOUNDATION in this country (as far as I know – and I have searched) who sees it as their mission to help people with disabilities STAY EMPLOYED. Karen Cage who has taken up Jenny’s cause has created a crowd-funding opportunity to help defray the expenses of Jenny’s personal care attendants. I did make a contribution to help Jenny stay employed – because if the government and existing charities won’t help people in her situation – who will? It’s NOW that her job is in jeopardy. Jenny will be on SSDI by the time that Congress acts and/or a foundation’s new initiative gets funded and underway.
Many people with disabilities don’t need personal care attendants – they have much more modest expenses, but can’t afford to pay for them because they earn an even-more-modest-than-that salary. Small things often make ALL of the difference. As the centuries old proverb says:
For want of a nail the shoe was lost. For want of a shoe the horse was lost. For want of a horse the rider was lost. For want of a rider the message was lost. For want of a message the battle was lost. For want of a battle the kingdom was lost. And all for the want of a horseshoe nail.
Perhaps the charity of individuals will support Jenny’s caregivers while we encourage Congress to figure out a way to help ALL people who ARE EARNING A LIVING despite significant disabilities to get help with the EXTRA EXPENSES that make it possible for them to work! Or maybe, one of the big foundations will notice this opportunity to make a big positive difference and step in. Obviously, the kinds of impairments that warrant extra services and the definition of services that are covered have to be precise enough to actually accomplish the purpose while avoiding wholesale abuse, but …… doesn’t this just plain old make sense?
You’ll be pleased to hear about two developments that are good signs for the transition away from the fee for service payment model in healthcare and towards payment for outcomes. Buy-in among healthcare CEOs is clearly growing, and Congress just passed MACRA — a new law will increase the mechanisms available to support value-based healthcare reimbursement, particularly for physicians. See below for more details on these two developments.
But first: If you believe that a FUNDAMENTAL purpose of healthcare services is to enable people to participate as fully as possible in life –which for most working age people includes earning a living — then ability to function & work should be on the list of accountable health outcomes. Thus, it is CRITICAL to ensure that SOMEONE is sitting at the table advocating for those outcomes — when the nitty-gritty details of the new mechanisms called for in MACRA are worked out! As you read on, consider what you can do to increase the likelihood that someone IS sitting there.
First, a recent survey of healthcare CEO’s revealed that the VAST majority of them LIKE the idea of value-based payment – even though a substantial fraction of them predict difficulties and revenue reductions as a result. Almost 8/10 of them said this statement best reflected their attitude: “Value-based reimbursement models should play the dominant role in healthcare reimbursement with fee-for-service medicine playing a declining and minor role.” The CEO’s also predict that value-based reimbursement will improve quality of care (93% agree). Overwhelmingly, they think the pace of change is NOT going too fast (91% agree). NOTE: Almost all of the CEO’s think we can’t throw away the existing CPT-based payment system entirely – because physicians need an incentive to work hard, and because the metrics that underlie value-based payment don’t work well when there are statistical challenges (unusual conditions, rare events, low practice volumes, and other reasons for small numbers and high variability).
In another development, while repealing the dreaded Medicare fee cuts called for under the SGR legislation (Sustainable Growth Rate), Congress opened the door to some (potentially) HUGE changes in physician payment. MACRA – the Medicare Access and CHIP Reauthorization Act of 2015 – lays out a general plan for changes in CMS’ physician reimbursement methods. MACRA replaces the uncertainty about SGR and its draconian 21 percent cut to physician fees this year with tiny but predictable payment increases for the next four-and-a-half years. Then, starting in
2019, MACRA removes some irritating and burdensome penalties and gives physicians two ways to earn performance based incentive payments, either by participating in a new Merit-based Incentive Payment System or an Alternative Payment Model, like a Patient-Centered Medical Home.
Here’s how the White House blog portrayed this legislative achievement. And here is a brief summary of the key features from the point of view of the American College of Physicians (the ACP) which also provided a more detailed discussion of the law’s provisions concerning physician payment And here is a one page handout summarizing these provisions of MACRA prepared by ACP for its member physicians.