Psychiatry Could Benefit From Education, Workforce Changes

Psychiatrists are likely to see benefits accruing from some of the features of the $938 billion reorganization of the nation's health care system enacted in March, including some who will qualify for expanded physician reimbursements. However, other features of the new law were opposed by APA over concerns that they would reduce reimbursements for some psychiatrists.

APA and several other physician groups endorsed the final version of the health care overhaul that passed Congress in March through two separate measures (PL111-148 and PL111-152), because it provides vastly expanded access to private and public health insurance, among other major elements. Receiving less attention during the long and contentious legislative battle, however, were the ways in which some elements of the legislation will impact psychiatrists and other physicians.

Specifically, several changes to Medicare will increase some reimbursements. The measure reestablishes—effective later in 2010—the expired national average “floor” on Medicare's geographic adjustment of physician payments, which is commonly known as the geographic practice cost index. Reestablishing this floor will result in increased reimbursements for many rural physicians. Another Medicare payment increase to adjust for rural physicians' practice expenses for much of 2010 and 2011 also is expected to benefit many physicians. Taken together, the two Medicare changes included in the health care law are expected to benefit physicians who live in or are considering relocating to rural areas in 51 localities in 42 states, Puerto Rico, and the Virgin Islands, according to an APA analysis.

Among new Medicare programs included in the law is a financial-reward initiative for Accountable Care Organizations (ACOs) that take responsibility for the costs and quality of care received by their patients over a set period of time. The measure encourages the creation of such Medicare ACOs, which can include groupings of physicians, hospitals, nurse practitioners, and physician assistants—among other health care providers—with the goal of meeting quality-of-care targets and reducing the costs of their patients' care relative to spending benchmarks. ACOs that succeed in these goals will receive a share of the Medicare savings they achieve.

The establishment of ACOs, which are a newer concept than medical homes, was supported by APA. ACOs were included in only one of the legislative versions of the health reform and so the concept maintained a low profile during the extended congressional wrangling over the complex legislation. It's also a program that APA plans to follow closely, because it is relatively new and has not been widely implemented in large health care systems.

A Medicaid initiative included in the new law would allow states to add so-called health or medical homes to their versions of the joint federal and state insurance program. These health homes will aim to improve patient health and reduce costs by assigning a single physician to coordinate all aspects of a patient's care. The program will be targeted at Medicaid enrollees with chronic conditions, including those with serious and persistent mental illness.

Training in Child MH Issues Addressed

The new law also includes several workforce-development initiatives. It establishes, for example, a loan-repayment program for clinicians who provide mental health services to children and adolescents within a federally designated Health Professional Shortage Area, Medically Underserved Area, or among a Medically Underserved Population.

In addition, the new law authorizes a series of mental health education and training grants to provide incentives for schools to develop, expand, or enhance training programs in social work, graduate psychology, professional training in child and adolescent mental health, and pre-service or in-service training for paraprofessionals in child and adolescent mental health.

“This will allow more students to go into the field,” said Kristin Ptakowski, director of government affairs at the American Academy of Child and Adolescent Psychiatry, which has long urged increased federal funding for programs and training grants in this field as well as loan-forgiveness programs for professionals trained in this area of mental health care.

Potential Cuts Loom

The new law does, however, also contain features that may have a detrimental effect on psychiatrists. For instance it amends the Physician Quality Reporting Initiative (PQRI) to require all physicians participating in Medicare to report performance measures. The law will require penalties of 1.5 percent of Medicare income beginning in 2015 for physicians who fail to report “successfully.”

The penalty provision was opposed by APA, which supports the general goals of the PQRI, because physicians have faced significant delays in obtaining responses from federal regulators in the existing voluntary PQRI program. Such delays in a PQRI program that penalizes physicians could result in payment cuts, but physicians would not know for up to a year that there are problems with their quality-of-care reports.

Another part of the law opposed by APA established the Independent Payment Advisory Board (IPAB) to recommend changes in Medicare's physician-payment policy. The law requires the IPAB to track spending targets preset by the government and recommend payment reductions if costs exceed targets. Congress could stop such future reductions by the IPAB, but only if legislators are able to find other cuts that would provide the same level of savings.

Some of APA's opposition to the IPAB stems from the law's exemption of hospitals and other health-related entities from its recommended cuts until 2014, which would leave any needed spending reductions to come from payments to physicians and other health professionals. This situation is expected to complicate the issue of pending physician reimbursment cuts under a Medicare payment structure that was established long before the new law and left unaddressed by health care reform.

Citing its excessive costs, Democratic leaders in Congress dropped from the final health care legislation a fix to the Medicare physician payment system, which is slated to steeply cut physician reimbursements.

However, APA President Alan Schatzberg, M.D., described the unaddressed Medicare payment formula and the 21 percent cut it is threatening to impose as one of the major outstanding issues in federal health policy for physicians.

(At press time, Congress voted to delay the implementation of the cut until June 1, and later that day President Obama signed into law legislation that contained that postponement.)

More information on the new law's impact on psychiatrists is posted at <http://archive.constantcontact.com/fs091/1101795608829/archive/1103249925487.html>.