Unsettling Times

November 30, 2011

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Dr. Bruce Sigsbee

As I write this column, there is a great deal of uncertainty in Washington surrounding funding for medical services and research. Can you imagine how devastating a 30-percent reduction in payment would be to neurologists? This is what we are facing. Unless corrected, the sustainable growth rate formula (or SGR) dictates a cut of almost 30 percent in payment to physicians on January 1. To permanently correct the flawed formula will cost $347 billion. Why so much? Since 2003, temporary fixes have pushed the issue down the road with ever increasing cost to correct this problem—a problem that was created by Congress in the first place.

At the same time, Congress has created the Joint Select Committee on Deficit Reduction, known as the "Super Committee," which is tasked with identifying in a very short time at least $1.2 trillion in savings. Given that Medicare and Medicaid together represent 25 percent of the federal budget, it is highly unlikely that these programs will not be impacted. The Congressional Budget Office estimates conclude that future additions to the deficit will arise almost exclusively by rapid increases in Medicare and Medicaid costs. At risk are payments such as the facilities fees paid to hospitals or graduate education payments that support training programs. If the Joint Committee cannot convince Congress to support its efforts, whatever they may be, there will be an automatic 2- to 3-percent reduction in payments to all health care programs.

The increasing federal deficit is a fundamental national issue. Over the past three years, about 42 percent of federal expenditures represented deficit spending. In other words, the federal government has relied on borrowed money for 42 percent of its expenditures. The president's own deficit reduction commission projected that in 2020, the debt service alone would be $1 trillion dollars, about one-half of revenues. The continual rapid addition to the deficit in the long run will place a major economic burden on the country resulting in suppressed innovation, diminishing the safety net for the vulnerable, and certainly trashing the jobs sector.

Adding to the uncertainty are the programs of the Centers for Medicare and Medicaid Services targeting quality measurement and "meaningful use" of electronic health records. The Physician Quality Reporting System (PQRS) will shortly penalize physicians who do not participate. To be meaningful, quality programs must identify meaningful measures and give frequent feedback. So far, PQRS has not met either of these basic requirements. Meaningful use of EHRs currently applies to electronic prescribing. The bar will be increased over time. Unfortunately, the requirements seem to change with each new legislative effort. The costs for many practices are prohibitive.

How are we to respond? These trends transcend not only neurologic issues, they transcend medicine. The SGR fix is tied into the current talks surrounding the deficit. The deficit problem is real and continues to grow. Congress appears completely dysfunctional and unable to effectively address these problems in a meaningful way. The short time frame for the "Super Committee" precludes the development of a sophisticated, coordinated approach that the problem requires. The federal government in its infinite wisdom has concluded that measuring quality as it is doing will improve the quality of health care and that EHRs will improve the delivery of medicine. That decision will not change.

As neurologists, we cannot forget the importance of patient care. I know physicians who now make practice decisions purely based on revenue, not the needs of the patients. These behaviors will disenfranchise physicians if they become widespread. Our credibility comes from our care of patients. We need to stay informed. As the payments for health care and the delivery system evolve, we need to be certain that patients continue to have access to the knowledge and skills we bring to the care of neurologic disease. Could even a great internist adequately care for an MS patient? Finally, we need to remain flexible. Change will come. If we adopt a head-in-the-sand approach and resort to constant, ineffective griping, we individually and as a specialty will be left behind.

As president of the American Academy of Neurology, I am asking you to become a leader in these efforts. Stay informed. Support the AAN's efforts to represent your interests. Respond to requests to contact your legislators. Numbers and intensity matter! Educate your representatives as to the consequences of actions in Washington. Encourage your colleagues to get involved. As much as possible, develop a relationship with your legislative delegation. Increasingly, medicine is impacted by legislative and regulatory decisions locally and in Washington. Engagement in the political process is critical to protect adequate funding for training, research, and practice. It is easy given this environment to become discouraged, if not despondent. Remember that one individual can make a difference and your participation is important. Neurology has a great deal to offer our patients. Our responsibility is to assure that patients retain appropriate access including access to new treatments.

Bruce Sigsbee, MD, FAAN
President, AAN