Dr. Robert Wergin, president of the American Academy of Family Physicians, made little effort to contain his glee Wednesday over the news that Congress had voted to end a reviled payment system for doctors, simultaneously averting a 21 percent physician pay cut and overhauling the way Medicare will pay doctors in the future.
"I just can't be more positive about it," said Dr. Wergin, who is a family doctor in rural southeast Nebraska. "The one word is yahoo."
Then he added: "Now, what next?"
President Obama has signaled that he will sign the bill, resolving an issue that frustrated lawmakers in both parties for more than a decade because it repeatedly required Congress to step in to avert cuts to doctor fees. Doctors and health policy experts have begun to take stock of the practical implications of the legislation, which seeks to move away from paying doctors solely on the volume of their services and toward reimbursing them based on the quality and value of the care they provide. Many said the legislation was short on details about how such quality will be measured, and others expressed apprehension about whether the system will be fair.
"It's very important legislation in that it aims to support better care and lower costs, but there are a whole lot of details that still need to be filled in," said Dr. Mark McClellan, a senior fellow at the Brookings Institution and a Medicare administrator in the George W. Bush administration.
Under the new legislation, Medicare will increase the amount it reimburses doctors by 0.5 percent for the next five years. Doctors will earn a 5 percent bonus if they participate in newer payment models that seek to better coordinate care. One example is the so-called medical home, in which a medical team coordinates a patient's care. They could also work in groups, called accountable care organizations, that receive a set fee to take care of a patient while still meeting quality standards.
"It's a very big boost to these models," said Paul B. Ginsburg, a health economist at the University of Southern California, although he and others noted that how these payment models will be defined is still not clear.
Mr. Ginsburg and others expressed more skepticism about another component of the legislation: one that, beginning in 2019, would pay doctors based on how they perform on quality and other measures. Ultimately, the Department of Health and Human Services will decide those standards.
Mr. Ginsburg said that doctors did not typically see enough patients to yield reliable data about how well they perform, or to adjust their scores for whether their patients are sicker than average.
Travis Singleton, senior vice president at Merritt Hawkins, a physician consulting firm, said doctors needed more direction and were understandably worried. "What if my patient isn't listening to me? Who is judging this quality?" he said. "I just don't think doctors are there yet. I don't think they're fighting the concept of trying to be more efficient, but I don't think anyone's given them a clear mousetrap or a picture of how they're going to do it."
Some standards are straightforward, such as measuring a patient's blood pressure or a diabetic's blood sugar. But Meredith Rosenthal, a health economist at Harvard University, said there was no clear agreement on how best to measure the quality of other kinds of doctors, like radiologists or a dermatologist in solo practice. "Once we're out of primary care, we're in kind of a neverland of measurement," she said, predicting that there would be significant work to develop new standards because of the legislation.
Some doctors said they feared the new measures would result in a loss of independence. "All of a sudden you have nonmedical entities and people outside of medicine deciding what is value," said Dr. Daniel Craviotto, an orthopedic surgeon in Santa Barbara, Calif., who has spoken out against what he describes as a loss of autonomy as insurers and Medicare have increasingly scrutinized doctors' practices. "It's become so burdensome for some of the silly things we have to do."
Dr. Wergin, of the family practice group, said he sympathized with concerns like those of Dr. Craviotto. "But what do we have now?" he asked, noting that doctors are often held to a variety of standards by different insurers. He said he hoped that the legislation would lead to more standardized quality measures. "Isn't quality quality, no matter which insurance you have?" he asked.
Doctors are also relieved that there is now more certainty over how they will be paid, with both Medicare and private insurers moving toward a system that rewards them for delivering higher-quality care. Doctors had complained of being paid under the old volume-based system even as they were trying to meet the demands of new models. "It allows docs to have a good sense of the next decade and plan for it," said Dr. Lisa Bielamowicz, an expert on physician strategy for The Advisory Board Company.
Even small physician practices are going to have to invest in making sure that they can better keep track of patients, she said, predicting that this would add to the pressure on doctors to join larger groups or work for hospital systems.
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