Managed Care - February 2009 - (Page 34) Health plans can have a real effect on the pay levels of specialists and primary care doctors by getting involved in the public process of determining the relative value scale, according to Robert Berenson, MD, of the Urban Institute. The Bush administration wanted to eliminate the federal Medicaid match for graduate medical education (GME), but Congress passed a moratorium on that cut. The bleak picture of graduate medical education GME funding is supported by an article in the April 17, 2008 issue of the New England Journal of Medicine. That article said that while there was some concern in Washington, D.C., about the supply of doctors, it was not a high priority for Congress or the Bush administration. So, where will those new U.S. medical and osteopathic graduates go? In 2007 there were 23,759 first-year residents and 6,795 of these slots were filled by international medical graduates, according to the AAMC. If the Medicare cap on residency slots is not lifted, in the immediate future it is conceivable that the additional MD and DO graduates with United States citizenship will supplant some of the foreign graduates. Researchers and physician executives say there are two ways to promote interest in primary care. “Many leaders say that changes in payment policy are the quickest and simplest way to generate interest in primary care,” says Berenson. “The Medi- care fee schedule is the benchmark and basis for the fee schedules used by many health plans, and the solution for them is to become involved in the public rulemaking process for how relative values are determined. Right now the Medicare fee schedule is largely controlled by the specialties.” Each specialty provides information on practice expenses and the physician work component that determine the value of services to the AMA’s Relative Value Scale Update Committee that updates Medicare services. “CMS does not have a basis to reject or modify the recommendations of the self-interested specialty societies,” says Berenson. The Medicare fee schedule is criticized for overvaluing many procedures. “If the chief medical officers of health plans were involved in the Medicare fee schedule, it could look vastly different,” says Berenson. Annual updates to the fee schedule follow public notice and rulemaking procedures, and Berenson says health plans should voice their opinion on payment rates. MedPAC’s 2008 annual report recommended budget-neutral payment changes to support primary care. Budget neutrality could only be achieved 34 MANAGED CARE / FEBRUARY 2009
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