AAN President Bruce Sigsbee, MD, Speaks Out About Health Care Reform and the Implications for Neurology

September 2, 2010

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By Bruce Sigsbee, MD, AAN President

As the Academy's president elect, I have had the privilege of attending many of the AAN committee meetings. These committees do great work that is often not fully reported to the membership. As the major organization representing neurologists and the expertise we bring to the care of our patients, the AAN must be proactive and effective in the rapidly changing environment of health care.

In mid-August, two major committees for the AAN, the Governmental Affairs Committee and the Medical Economics and Management Committee, met to discuss the impact of the health care reform bill on the practice of neurology.

A great deal has been said about the Patient Protection and Affordable Care Act (H.R. 3590) signed into law in March. On review of the huge bill, there are four major initiatives that can be identified: cost of care, uneven quality, access, and support for certain specialties identified as being in short supply.

The AAN Board adopted key principles as reform moved forward. One of those principles included coverage for the insured. We all have the experience of patients struggling to pay for medications or needed diagnostic tests. The provisions intended to address the lack of coverage include tax credits for individuals and small business to help pay for the insurance, high risk pools, among others. Perhaps the most controversial aspect of the changes to health insurance for individuals is the requirement that everyone has insurance or pays a penalty.

Currently, the federal government pays for 40 to 50 percent of health care already through the Medicaid and Medicare programs. In 2009, these programs represented 21 percent of federal expenditures. The rise in cost of health care far exceeds the inflation rate and continues to consume a greater share of the GDP, about 18 percent now. To state the obvious, the trend in cost escalation for the federal government and the private sector is unsustainable. No clear consensus was reached on techniques to control costs. A number of new payment models and demonstration projects were funded with the intent of identifying a payment mechanism for the future such as accountable health care organizations (ACOs). These organizations will receive bundled payments or a share of savings for the services provided. In effect, the decisions as to what to pay for services will be pushed to these organizations.

One of the most controversial provisions in the entire bill facing physicians is the formation of the Independent Payment Advisory Board. If the growth in payments for Medicare exceeds certain targets, the board will make mandatory recommendations for changes in payments unless specifically reversed by Congress. In fact, the Congressional Budget Office predicts that this provision alone will save more than $15 billion over 10 years once the recommendations go into effect in 2015.

A number of studies document the uneven quality of health care currently delivered in the United States. Congress elected to expand the current PQRI (Physician Quality Reporting Initiative) as a start to answer this problem. As a quality program, the initiative is burdened with an unworkable infrastructure and administrative burden. However, to receive the bonus now offered and avoid the future penalty, physicians must participate. This program is likely to be an interim initiative. Your practice should be thinking about tracking quality if you are not already.

Bonus payments are directed at primary care and general surgery if they meet certain criteria. These specialties are viewed as being in shortage and in need of support. One can reasonably argue the initiative misses the mark in that other specialties such as neurology are experiencing the same problems. That is a topic for another blog.

Currently, the AAN is active in all of these areas representing the interests of our specialty and neurologic patients.

On the legislative front, we are lobbying Congress to include neurology in the same bonus program as primary care—not because neurology is a primary care specialty but because neurologists care for many patients with chronic disease requiring time and expertise not currently recognized.

The Academy also is working to repeal the Independent Payment Advisory Board. Many of the details of implementation of the bill are left to the secretary of Health and Human Services. These details will be forthcoming as regulations from the Centers for Medicare and Medicaid Services. The AAN also is working to influence the regulatory process.

Health care reform is a significant issue in the debate between the view that government should provide services to the citizens, including universal health care, and the concern about a large federal government that inappropriately intrudes into personal freedoms. The AAN will not take a side in this argument but will work hard to assure that neurologists are recognized for the effort, expertise, and innovation that they bring to the care of patients with neurologic disease.