Senate Vote Paves the way to SGR Reform

From AMA Advocacy Update:

On January 28, the Senate passed H.J. Res. 45, a resolution to raise the federal debt limit along with several limited exemptions to the PAYGO rule. This includes exception for addressing the Medicare physician payment cuts about to be produced by the sustainable growth rate (SGR) formula.

This action means that up to $82 billion spent for an SGR fix would not have to be offset by other revenue or cuts. This amount could fund a five-year freeze. Thus, some have characterized the SGR exemption as a five-year freeze.

The House is expected to take up and pass H.J. Res. 45 this week. Congress must still enact separate legislation to stop the SGR cuts prior to March 1.

To obtain permanent repeal of the flawed payment formula, the PAYGO exception must be accompanied by an additional $130 billion in budget offsets.

AMA position: The AMA continues to insist that Congress pass legislation to permanently repeal the SGR.

Health Care: Too Big To Fail?

Paul Volker wrote in the New York Times today of 'the implication that really large, complex and highly interconnected .... institutions can count on public support at critical times'. He refers, of course, to the financial sector.

Are there parallel lessons that apply to the health care sector (and to health system reform)? Certainly the health care sector, as well, is 'too big to fail.'

Leadership? MIA for Now

President Obama indicated that he might be willing to scale back his proposed health care overhaul to a version without provision for near-universal insurance coverage. Speaker Pelosi says the House wants 'comprehensive reform' and (thankfully) won't pass the flawed Senate bill.

While Massachusetts enjoys the lowest percent of population without coverage (about 5%) and Texas enjoys the highest (about 25%), Californians now talk of reintroducing universal single payer legislation in order to eventually save money.

While White House officials and Democratic Congressional leaders still struggle to find a viable way forward for the health care bill, your blog-masters ask, "Where is the national leadership here"?

Everyone seems to agree that some reform is needed. But nobody needs a compromise for sellouts and lobbyists. What about true leadership, and what about a physician voice?

Assumptions and Guesswork

A New York Times editorial outlines and opines on the differences between the House and Senate HSR legislation. Their opinion is wrong on two provisions that affect physicians:

• They note that the House bill relies heavily on Medicare pilot projects to determine which approaches to restraining medical costs might work best. The Senate bill would, instead, empower an independent board to carry out 'successful reforms broadly within Medicare and recommend changes in private programs'.

The Times prefers the Senate bill because the House bill lacks a strong mechanism, like an independent board, to drive successful reforms into widespread use.

The Times incorrectly characterizes this board as a 'crucial cost-control mechanism'. This opinion is misguided because we've essentially been doing this for the past 30 years - only we've called it managed care.

Simply granting an 'independent board' authority is insufficient. After all, Medicare pilot projects have been ongoing for more than ten years! Sustainable, effective cost control will require integrative strategies and they'll need to be physician based. Physicians are truly the only entity, once empowered, that can initiate and sustain cost containing/integrative reforms.

• The House Bill provides for the paying of primary-care doctors the same (amount) that Medicare pays.

The assertion that this would make it more likely that poor patients could find a doctor is spurious - inadequate reimbursement, albeit more generous, would still be inadequate. Just look at the access problems faced by (and those that threaten) the Medicare population currently.

Journalists and elected officials could better serve their clients were they to consider the vast experience of the provider community when they prepare their opinions. Some folks would refer to that as 'evidence based.' As in industry, a quality health care initiative (like the principles of six sigma) , ought to be driven by a commitment to making decisions on the basis of verifiable data rather than mere assumptions and guesswork.

AMA and House-Senate Conference Committee

SP wrote that he had been ambivalent and confused about recent ama performance. But upon reading the ama hsr bulletin, he has decided to remit his ama dues. Below is an excerpt from that bulletin that clarifies ama position on the upcoming House-Senate Conference Committee, the committee that will craft the final hsr bill for the president to enact.

"The AMA has made it clear to senior White House staff, the Senate leadership and the House leadership that its support for a House-Senate conference agreement is contingent upon:

• Movement on a clear pathway for passage of legislation to permanently repeal the SGR by the end of February
• Modifications of the proposed Independent Payment Advisory Board
• Refinements of the quality improvement and Medicare data release provisions
• No new major problematic provisions surfacing in conference

While there were some earlier reports about efforts to circumvent the House-Senate conference committee process, recent statements from the House leadership indicate that the House will not take the Senate bill as is or with minor changes. As noted earlier, the House bill does not include an Independent Payment Advisory Board, and 53 House members signed a letter objecting to that concept.

The AMA's strategy of constructively working for changes at each stage of the process has put it in a position to have significant influence in the House-Senate conference committee negotiations. The AMA retains the ability to withhold support for a conference committee agreement if it fails to achieve our priority objectives.

We still have not seen the final bill that the president hopes to sign into law. The AMA will be actively engaged throughout the conference committee negotiations to positively influence the key issues for medicine."

No Caps Because 'The Lawyer Has to be Paid'

Last summer, Tom Baker, professor of law and health sciences at the University of Pennsylvania School of Law and author of “The Medical Malpractice Myth,” was interviewed by a free lance author for a piece (published in the new york times blog) on medical liability.

He believes that making the legal system less receptive to medical malpractice lawsuits will not significantly affect the costs of medical care (because he measures the cost of liability as a percent of total health spending, yet he ignores that the burden falls disproportionately upon physicians). He acknowledges that:

• "The medical malpractice system only works for serious injuries...
• Lawyers discourage people from bringing suits if their injuries are not serious in monetary terms — a poor person or an older person who can’t claim a lot in lost wages ...
• Gerontologists’ premiums are exceedingly low."

Still, he opposes caps on pain and suffering because (in states with caps) a plaintiff gets reimbursement of medical costs in principle... "(but) in fact, they don’t, because the lawyer has to be paid. These cases can cost $100,000 to $150,000 to bring, so the patient has to deduct that amount from any award. I’ve had lawyers tell me they would not take a case ... even if it’s a slam-dunk. The damages wouldn’t be enough."

So why is congress afraid to remove the lawyers from the equation - and allow a reliable system of justice that compensates victims better and at less cost to the health care system?

Senators to be Pilloried

In the NY Times are two columns (link to a, link to b) suggesting that passing the Senate Health care Bill is worthwhile, despite its shortcomings. The shortcomings of the bill highlight the shortcomings of our political process.

In 'column a' David Brooks asks if the bill will "put us on a path toward the real reform, or does it head us down a valley in which real reform will be less likely"? He worries that "it will slow innovation. (Because) Government regulators don’t do well with disruptive new technologies ... (and) We’ll shovel more money into insurance companies". Yet his worries about the costs could easily be addressed (and the cost curve bent) if only the reformers would shovel less money to the insurance industry and instead give doctors the incentive to innovate - remember Gawande's accountable care organizations.

And we don't need new demonstration projects. Here in the downstate New York region, a hospital network clinically integrated (a huge hurdle were it a physician network) then emerged, to the consternation of the payers, as the low cost health care provider in its region!

In 'column b", Paul Krugman describes some Senators as "motivated largely by a desire to protect the interests of insurance companies."

Protection of the insurance companies is anti consumer - it is the enemy of physicians, patient interests and meaningful health care reform. Those Senators, and their bill should be pilloried.