Saturday, September 24, 2011

Medicare: Access to Mental Health Care in Danger

In many states, Medicare fees are at the bottom of the barrel, prompting physicians and other health care providers to stop accepting new patients or even to opt out of Medicare completely. A recent proposal from MedPAC (Medicare Payment Advisory Commission, which makes recommendations to Congress) would further reduce rates by up to 38% over the next 10 years.

I wrote an article yesterday in Clinical Psychiatry News explaining this critical danger to the health care safety net for seniors, baby boomers, and people on disability.

I think Medicare needs to reinvent its game by moving away from per-visit payments -- which reward volumes -- toward payments based on severity-adjusted episodes of care combined with quality and outcomes multipliers -- which rewards quality and efficiency.

By re-inventing the way Medicare pays all providers, not by quantity but by quality and efficiency, it has a chance to bend the cost curve without making it harder for beneficiaries to find a doctor who will accept Medicare. Medicare enrollees deserve to be treated better. If Congress messes this up, there will be hell to pay at the ballot box.
         Dinah added a post explaining what this might mean for patients at :


Dinah said...

I will put up a sister post to this called What This Means for Patients at some point soon.

It's a really important issue and I'm glad you wrote about it, but I disagree about changing to a method that calls for "Quality and Efficiency" then requires an entire bureaucracy to determine quality and means more forms for the doctor, more bureaucrats to administer/reject claims, more time and money funneled away from patient care.

SteveBMD said...

But if they get rid of per-visit payments, then I'll never be able to spend my work days seeing 40-50 patients per day, receiving $30-35 per patient, and getting filthy rich!

You mean I might actually have to spend more time with my patients? Especially the challenging ones?

/sarcasm (<-- just in case)

jesse said...

As usual, I agree with Dinah on this one (I'm starting o see it as my default position). I opted out of Medicare because it was vastly too complex and risky for my solo outpatient practice sans office manager or secretary. I just adjust fees as I think reasonable.

Carrie said...

Glad to see Dinah wrote some of what I'd planned to say as well! I have been very active in the quality role for my hospital for a few years now. There are two things that I hate more than anything - and that's when people cut corners on quality or efficiency. I almost view it as a puzzle - how can I do the task I must do, as well as I expect it to be done (flawless) and by doing so in the most efficient route possible. I leave work late many times because quality wins over efficiency every time.

What I mean to say is - you can't measure this stuff. If they try to, I see it being nothing more than an absolute disaster. What does Medicare view as high quality? 0 patient falls, no hospital acquired infections, and so on. Good luck getting paid when those are the standards. I'm not saying they shouldn't aim for that height - they totally should - but, it's gonna make things one heck of a lot tougher to be reimbursed if they make changes into the quality and efficiency model on the bureaucratic level.

What we view as quality and efficiency (or what we think we view) is a lot different than the standards they will set...I guarantee it!

WV = "sweartre" = three times the swearing - what we're all going to be doing if they make this change. :-P

jesse said...

Right on, Carrie. I've been thinking bout this puzzle, and while doing so read about the No Child Left Behind problem. There are a lot of similarities. Medicine can easily become Teaching To The Test, and no specialty more so than ours.

Andrea said...

I am a patient on Medicare and I couldn't find a good psychiatrist who takes Medicare, so instead I pay $85 per 15 minute visit--my psychiatrist runs over if necessary. Because of this, I go to the psychiatrist less often and spend much more time focusing on preventing relapse than I used to. I haven't heard any other patients talk about that--it may be a positive result of the situation. I can only afford to take generic medications, so that is what I do. Sometimes I wonder if that is best.

PDFdoc said...

The Canadian system also works on a per visit basis. There is a detailed billing schedule, and in Ontario a consultation is $200, and psychotherapy etc $80 per 30 min or less. I'm not sure how this compares to medicare or private billings for you. Overhead is probably comparable, although malpractice insurance costs less in Canada, and we have less of a problem with non-payment.

A quality/efficiency approach is a great idea, but is probably to cumbersome to implement.

Roy said...

I didn't say it would be easy to reward on quality and efficiency, but these need to come into the picture, because the pay-for-volume thing is breaking our healthcare back.

moviedoc said...

I have already stopped accepting new Medicare patients. Now I worry that people who are unable to find a physician who does will claim they do not have Medicare so someone will take them on. The new proposal doesn't change my attitude.

Rairy said...

Question: How is quality and efficiency currently measured in the chronic mental health setting?

Even a patient who is a tightly controlled will still need to be seen ongoingly for the rest of their life and despite best effort care may still relapse.

How can quality measures differentiate between best effort treatment for a life long very ill patient and halfbaked/doesnt care treatment that doesnt pay attention or quickly dumps very sick patients?

Sideways Shrink said...

I once asked asked a friend of mine who is a hospitalist when in a moment of low self esteem: why do they pay us so little in psychiatry? Is it because they think what we do is so easy? No, she said, because there are too many chronically mentally ill and they don't want to pay. This coming from an MD, the daughter of an orthopedist, who's mother I later found found out, had suicided after a lot of treatment. She is the most dedicated physician I know, but she can see the forest for the trees.
I do not accept Medicare because with the "psychiatric adjustment" requiring patient to pay 50% of the cost as passed by Congress in 1996, Medicare is a goat rope at best, unless the patient has Medigap. If the patient has Medigap, it is a goat rope for us all, as all Americans overpay for that person's health insurance coverage.
Now I have a sliding scale fee that bottoms out at $100.00 cash or check for psychotherapy but the no show fee remains the blistering same as ever because I treat a fair amount of ADD patients. This is my solution to people running out of insurance but me having to pay my student loans and still being able to assess them safely once a month to continue prescribing for them. My experience is that unless people have their own psychotherapists to alert me of problems, seeing patients less than once a month it is best to follow up once a month to maintain a relationship. It is old school. But I like my patients and the mutual attachment seems to be
"prophylactic". I don't want to run a volume crisis business of strangers called "health care".
Finally, I/we may have,through my Board, gotten funding for the start up funds for the sliding scale psychiatric center for uninsured patients who don't qualify for Medicaid or Medicaid.
There is a huge need for this now. This is the new reality of the new America. In my state, a prosperous state, the estimate is that there are 1 million uninsured working adults, many of whom just at or above poverty levls and countless more who can not afford to use their insurance due to the high deductibles.
Trotsky said to build parallel structures to the ones that exist in the capitalist structure to win the people's hearts. Well, we are way out ahead on this one. But don't tell anyone....because I pay my taxes--hell, tell anyone you want 'cause I am just a side ways shrink and who is going to listen?

Alaska Medicare said...

Nice article Dinah. I'll be looking forward to the sister article.

The proposed 30% cut in provider fee which is to take effect this year would just make many psychiatrists who practice psychotherapy to opt out.By doing so, they can charge what they like and they don't have to deal with the hassles of filing any paperwork. Sad :(