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Health Care Reform: The Carrot, the Stick and the Hippocratic Oath

One interpretation of the Hippocratic Oath states “Into whatever homes I go, I will enter them for the benefit of the sick, avoiding any voluntary act of impropriety or corruption....”. It seems that part of the physicians pledge might be in need of a modern re-interpretation such as: “I will enter them for the benefit of the sick and my e-prescribe incentive, avoiding any act of impropriety or corruption that will lead to a payment penalty next year”.

The Federal government, the major payer of medical services in the US, is increasing its control of the heath care system. Improved quality and cost containment are the stated and admirable goals.
The federally mandated rush to reform health care is often times being enacted with a “carrot and stick” approach of incentives and penalties. While the focus is on President Obama’s Patient Protection and Affordable Care Act (PPACA), most of what health care providers are facing today in terms of new regulations, rewards and penalties antedate this legislation. If you thought that e-prescribe began with the PPACA, you would be wrong. How about PQRI and meaningful use? You would be wrong again. These rewards and penalties as tools of health care reform started with three other bills passed in 2006, 2008 and 2009, all before the 2010 PPACA. These first three bills laid the groundwork for how providers will be directed to follow these government health care mandates by initially rewarding (the carrot) and then punishing (the stick) for failure to comply.

The e-prescribing incentive and penalties were included in the 2008 Medicare Improvements for Patients and Providers Act (MIPPA) legislation. An initial incentive was provided to doctors who e-prescribe 10 times for Medicare patients in 2011. Using e-prescribe at least 25 times by the end of 2012 will qualify for a 1% percent bonus on Medicare payments in 2012 and decreasing to 0.5% in 2013. Failure to comply will result in increasing penalties each year through 2014 whether or not a physician received any program incentives. Providers are required to comply with the MIPPA “G-coding” documentation for e-prescribing to avoid future MIPPA penalties.

The American Recovery and Reinvestment Act (ARRA) of 2009 was part of President Obama’s economic stimulus. Sub section XIII of ARRA, the “Health Information Technology for Economic and Clinical Health Act” (HITECH), set aside $19 billion in incentives to encourage providers to adopt and “meaningfully use” electronic health records (EHR). The goal is to improve the quality and efficiency of health care, reduce disparities, and improve coordination of care. To obtain the incentives, the government requires providers meet defined criteria. Incentives decrease each year with the total potential incentive pool of up to $44,000 over 5 years. The aggressive time-line to qualify for these “meaningful use” incentives has caused many to rush into the unsettled and highly competitive world of EHR vendors and systems. A recent article in Forbes magazine noted that government incentives will not even begin to cover the staggering costs of many EHR systems required by HITECH. The forthcoming PPACA mandates will further increase spending on EHR systems. The long term carrot is that the EHR will also decrease health care costs. With all of the regulations and legislated mandates in these costly programs, the government may be flying in the face of history. Failing to implement an EHR will ultimately result in monetary penalties to providers and hospitals. Regrettably, these initial incentives only cover part of the expenses related to the implementation and ongoing maintenance of the EHR. Who will bear the EHR costs in the future when the incentives end in a few short years?

Thousands of physicians will see their Medicare payments reduced 1.5% in 2015 if they do not participate in the Medicare Physician Quality Reporting Initiative (PQRI) requirements next year. The 2006 Tax Relief and Health Care Act established this physician quality reporting system with only an incentive payment component. The PPACA has now added a penalty provision with the AMA advocating removal of these new penalties. This trend towards reward and penalty programs is concerning to many physicians who strive each day to deliver the best health care possible. Arguably, rewarding providers for a job well done has some appeal, but a system that relies on penalties where no direct patient care or cost saving benefits have yet to be convincingly demonstrated is unsettling.

Another part of the Hippocratic Oath states: “I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug”. These new carrot and stick programs can easily count things like procedure codes for a surgeon’s knife and chemist’s drug through e-prescribe. I am searching for the ‘warmth, sympathy and understanding’ G-code box to check on my meaningful use super bill. Somehow, I cannot find it.

Leonard G. Gomella, MD

Thomas Jefferson University, Philadelphia, PA

© The Canadian Journal of Urology™; 19(4); August 2012


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