January 18, 2008

1. MedPAC Makes Recommendations on 2009 Payment Updates

2. NIH Announces Public Access Policy

1. MedPAC Makes Recommendations on 2009 Payment Updates

During its January 10-11, 2008, meeting, the Medicare Payment Advisory Commission (MedPAC)—an independent agency that advises the US Congress on issues affecting the Medicare program—approved recommendations for Medicare payment updates in 2009, including a 1.1% increase to physician payments and a 20% decrease in indirect graduate medical education (IME) adjustments to payments for hospital care.

MedPAC’s physician payment update recommendation is based on a formula that reflects the projected change in the input of prices for physician services (2.6%) less expected productivity growth (1.5%). According to MedPAC, a 1.1% update would stabilize the physician payment system and provide Medicare a chance to improve the value of the physician services it purchases. The proposed update would increase federal spending by an estimate of more than $2 billion in 2009 and more than $10 billion over the subsequent five-year period. Under the recommendation, Part B insurance and coinsurance rates for physician services would increase for beneficiaries. While MedPAC’s recommendations are only proposals to Congress, the request for a positive increase in physician payment rates, supported by the commission’s analysis, may bolster efforts to reverse the 10% physician pay cut that is scheduled to take effect July 1, 2008.

Within its physician payment update recommendation, MedPAC also recommends Congress enact legislation that would require the Centers for Medicare & Medicaid Services to establish a process for confidentially measuring and reporting physician use of resources. The intention is that MedPAC and Congress would use the data, collected during a two-year period, to inform payment policy.

Regarding hospital payment updates, MedPAC recommends Congress increase payment rates for acute inpatient and outpatient prospective payment systems in 2009 by the projected rate of increase in inflation and also implement a pay-for-performance (P4P) program. The P4P program would operate separately from the update; therefore, the update and the hospital’s quality performance would ultimately determine its net change in payments for the year. MedPAC recommends $1 billion in funding for the P4P program come from reducing the IME adjustments teaching hospitals receive in 2009 by 20%.

According to MedPAC, “using the savings from reducing the IME to help support a pay-for-performance program provides a more focused use of these funds that will benefit both teaching and non-teaching hospitals.” Testimony from the MedPAC meeting indicates that decreasing IME adjustments by 20% would reduce the gap in overall Medicare margins between major teaching and non-teaching hospitals by 2%.

Now that MedPAC has formalized its recommendations, it will present them to Congress. For more information, please visit the MedPAC website.

2. NIH Announces Public Access Policy

The National Institutes of Health (NIH) announced Friday, January 11, 2008, plans to implement a new public access policy, mandated in the Consolidated Appropriations Act of 2007 (PL 110-161). The policy is similar to the agency’s voluntary public access provisions which were implemented in May 2005. However, the new policy requires all peer-reviewed articles—accepted on or after April 7, 2008, and stemming from NIH-funded research—to be submitted to NIH’s PubMed Central within one year of journal acceptance.

According to the NIH announcement, the public access policy “applies to all peer-reviewed articles that arise, in whole or in part, from direct costs funded by NIH.” If a journal restricts public access via PubMed, an investigator is prohibited from publishing in that journal. The onus is placed on the investigator and applicant institution to ensure that journal copyright agreements conform to the public access policy.

NIH plans to enforce the policy by incorporating public access compliance in grant submission. Investigators are required to submit the PubMed Central or NIH submission numbers for all pertinent articles referenced in NIH grant applications and progress reports. According to NIH Office of Extramural Research Director Norka Ruiz Bravo, PhD, other potential methods of enforcement include reprimands from an NIH program director and suspension of grant support, though she cautioned that “we hope we’re not going to get there.” According to the National Library of Medicine, under the voluntary policy only 12% of authors submit their articles to PubMed.

Opinions on the new policy appear mixed. According to a January 11, 2008, article in Science, some researchers are concerned about confusion over having two different publicly-available versions of an article; the PubMed version would be the author’s non-copyedited manuscript rather than the published journal article. The publishing community has also raised concerns about a loss of income due to fewer journal subscriptions, which could lead to a decrease in funding for educational activities and peer review. In addition, some publishers have argued the policy might violate copyright law. Allan R. Adler, Vice President for Legal and Governmental Affairs at the Association of American Publishers announced, “the issue isn't finished yet,’ suggesting they may pursue a legal remedy.

Proponents of the policy argue that federally-funded, tax-supported research should be made available to the public. According to Harold Varmus, MD, former NIH Director and current President of Memorial Sloan-Kettering Cancer Center, “facilitated access to new knowledge is key to the rapid advancement of science.” Vice President for Academic Affairs at the National Association of State Universities and Land-Grant Colleges David Shulenburger argues that, “improved access will enable universities to maximize their own investment in research, and widen the potential for discovery as the results are more readily available for others to build upon.”

The Alliance for Academic Internal Medicine—the nation’s largest academically focused specialty organization—consists of the Association of Professors of Medicine, the Association of Program Directors in Internal Medicine, the Association of Subspecialty Professors, the Clerkship Directors in Internal Medicine, and the Administrators of Internal Medicine.

Please contact AAIM Vice President for Policy Charles P. Clayton (cclayton@im.org), AAIM Policy Associate Nicole V. Baptista (nbaptista@im.org), or AAIM Policy Assistant Allison L. Haupt (ahaupt@im.org) at (202) 861-9351 with questions or comments about this week’s Merlin.