Barbara McAneny, MD, founding partner of New Mexico Oncology Hematology Consultants, discusses why putting risk on oncologists is not the way to fix cost issues in cancer care.
Barbara McAneny, MD, founding partner of New Mexico Oncology Hematology Consultants and former American Medical Association president, discusses why putting risk on oncologists is not the way to fix cost issues in cancer care and how she would amend the ongoing cost issues in care delivery.
As you look ahead, what is your biggest concern about the future of payment reform?
They are so stuck on this idea of risk, which is if you're a bad doctor and you cost too much money, we will punish you.
Let me talk for a minute about some of the hospital plans. We have seen 170 small community hospitals close in the last 10 years, and they close because they're not paid their cost of doing business. I think they also close because many of them are very badly managed—but that's a different topic. But if they're being paid Medicare and Medicaid rates, critical access rates, etc. and they cannot make it, and they're taking care of a poor population with adverse social determinants and poor health literacy who come in with a hemoglobin A1C of 14, and they get it down to 9, they still do terrible on their quality measures, because the quality measure of nine for hemoglobin A1C is terrible. So they take away more money.
So every time they take away more money, how is the hospital supposed to invest in making its processes better? If they penalize physician practices—the ones that take care of people with poor social determinants—and they penalize you and take away the money, then guess what? You will just gradually dwindle away until you're not solvent and and you close shop or sell to a hospital where the price will double. So my fear for for the future of payment reform is that we will stay so stuck on making physicians take actuarial risk that we will stop looking for other solutions. And we need those other solutions.
The Part A trust fund hits zero in 2024. We are on track to spend 6 trillion—with a T—dollars by 2026. We don't have that kind of money. We're going to have more COVIDs, we're going to have fewer employer insured patients to fill in the hole of inadequate cost payment from Medicare and Medicaid. But we're going to have more Medicare and Medicaid because of the change in demographics with the job losses we're seeing.
So if I were running Medicare, I would look very hard at the site of service differential. I would look very hard at using data science to come up with actual pricing for optimal care. Then I would recognize that every business needs a margin, and I would have each of the various plans —Medicare, Medicaid, etc.—pay that optimal rate. Gradually, the hospitals would have to come down to that and the physician practices would have to come up to that so that we can shift more of the patients out of the hospital setting and into the community practice setting.
Your hospital-based members will not like hearing that, but I think it's what has to happen, because right now we pay double when we get the same service from Hospital Outpatient Prospective Payment System as when we get it from Physician Fee Schedule, and the country is going broke. We have to figure out what we want hospitals to do, what we want practices to do, and how to pay them appropriately and transparently.