Lessons From 1986 Tax Reform

"The bipartisan trade-off in a viable health care bill is obvious: Combine universal coverage with malpractice tort reform in health care ... let us hope, may be that Congress will surprise everyone this fall."

Bill Bradley, a former Democratic senator from New Jersey

A version of this article appeared in print on August 30, 2009, on page WK9 of the New York edition.

Political Affiliation and Health Reform

According to a Rasmussen Reports poll:

• 78 percent of conservatives opposed the reform plan.
• 73 percent said that they would still oppose it even if the controversial public option was removed
• By contrast, liberal support for the plan sans public option dropped by a third
• A majority of unaffiliated voters are opposed to passing health care reform legislation with or without (regard to) the public option.

link to image

'They Are Not Evil' -He’s (Just) Embarrassed

'Mr. Potter says he liked his colleagues and bosses in the insurance industry, and respected them. They are not evil...'

Yet, his colleagues and bosses:

• deny requests for expensive procedures
• seizing upon a technicality to cancel the policy of someone
• raise premiums for a small business astronomically after an employee is found to have an illness that will be very expensive to treat

The insurers are open to one kind of reform — so as to give them more customers and more profits. But they don’t want the reforms that will most help patients...(instead they embrace a strategy to negate) the entire point of insurance, which is to spread risk.

Link to NYTimes Column

Link to Senate Testimony

Public Option - Employers Dump Benefits?

'Indeed there are even some very serious concerns that with a public option, most employers will dump employee benefits. (This will leave) people no choice but a government plan with no clear cut selection of plan benefits as many private insurers (currently) offer'.

Kira A. Geraci-Ciardullo M.D. MPH

H. R. 3459 - Comprehensive Med Mal Reform

HR 3459 IH

111th CONGRESS

1st Session

H. R. 3459

To provide comprehensive reform regarding medical malpractice.

IN THE HOUSE OF REPRESENTATIVES

July 31, 2009

Mr. BAIRD introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned

---

A BILL

To provide comprehensive reform regarding medical malpractice.

Link to HR 3459

Texas Liability Reforms

• protected the patient,
• shielded doctors and hospitals from unscrupulous trial lawyers eager to make a quick buck at the system's expense.
• capped non-economic damages at $250,000 per defendant, or up to $750,000 per incident,
• no cap on more easily determined economic damages, such as lost wages or cost of medical care due to injury.
• ended the practice of allowing baseless, but expensive, lawsuits to drag on indefinitely, requiring plaintiffs to provide expert witness reports to support their claims within four months of filing suit or drop the case.

And what about the money that used to go to defending all those frivolous lawsuits? You can find it in budgets for upgraded equipment, expanded emergency rooms, patient safety programs and improved primary and charity care.

Link to Gov Perry's Op-Ed piece

'PBM Premium' - The Broken Drug Payment System

"It's a scam of major proportions. When we're trying to find billions of dollars to fund health care reform, this is an area that absolutely has to be cleaned up."—Rep. Stephen Lynch (D-Mass.), June 24, Dow Jones Newswires

The sale of prescription drugs is tightly controlled by an ever-consolidating number of pharmacy benefit managers. They determine which drugs a plan covers and what the co-payments will be. These companies were originally hired by large employers and other health plan sponsors to rein in soaring drug costs. Instead, they have concocted a complex system that places their robust fees and profits above their clients' interests, not to mention the patient's.

(PBMs are middlemen who are unregulated by federal or state law. They are neither insurers nor providers of services)

(This is) costing employers, unions, the government and patients billions of dollars in higher insurance premiums. Quantifying exactly how high this "PBM premium" is can be difficult.

From Article in Rollcall.com

Managed Care, the Only Survivor?

Unlike individual workers or even corporations, managed care companies can increase revenue by simply raising premiums, which uniquely situates them as survivors in this landscape.

The graph of health care costs, below, indicates that the slope of the rise in costs is untenable. It will bankrupt the country, its populace and physicians. The only survivor will be managed care.

This is a horrid view of the future which we as physicians must attenuate even at some cost to ourselves. You can't just sit there and say to heck with reform, as physician disinterest in a plausible solution will be tantamount to a death warrant to a great portion of the population.

This chart, below, shows the rise in workers' wages, corporate profits, and insurance company premiums adjusted for inflation over a 20 year time span ending in the present day.

As we can see here, the American worker has received only a one percent increase in wages over this time period, effectively paying for the rise in his or her health care costs. This also demonstrates the ease with which the managed care company will be able to weather the storm.

-Bob

Democratic Support for Tort Reform?

When President Obama addressed the American Medical Association earlier this year, many in attendance criticized the fact that he brought up many of the issues facing physicians but didn't say much about what he would do to make sure they would be addressed as we move forward with health care reform. The one thing he made clear was that he would not support a cap on non-economic damages, something physicians have advocated for years. Naturally, the audience responded by voicing their disagreement with his stance on the issue. With so much uncertainty about what comprehensive health reform would look like, the only clear detail was that a top priority for many physicians was a non-starter.

In 1975, California passed the Medical Injury Compensation Reform Act (MICRA), which imposed a $250,000 cap on non-economic damages in medical malpractice suits. This legislation was adopted as a result of a medical liability crisis in California in the early 1970s. Not unlike today, many physicians then saw a rapid increase in their liability premiums due to rising frequency and payouts from malpractice suits. The result was that many physicians stopped providing high-risk procedures, left the state or stopped practicing altogether, leading to a physician shortage in many areas of the state. Anyone familiar with the liability crisis looming in states like New York, Illinois and Florida know this is a natural progression of medical liability that is left unchecked. Thirty-four years after MICRA and the resulting caps, California has some of the lowest liability premiums in the country. Texas followed suit in 2003. After it's implementation, Texas found they couldn't keep up with licensure applications for all the new physicians who elected to move to a state with a more favorable liability climate.

President Obama has, on several occasions, made reference to physician utilization and the suggestion that many patients receive "unnecessary care" based on increased reimbursements for services rendered. There is no denying that the provision of medical care in this country presents a perverse incentive: the ones who decide how much medical care patients need are the same ones who reap the benefits from providing more medical care under a fee-for-service model. The president and Congress are right in their attempts to identify instances where funds are utilized unnecessarily and remedy these. Their support for improved communication via health information technology and coordination of care through the medical home are examples of their commitment to improve utilization. Taking any discussion of caps on non-economic damages, however, is not. Accusing physicians of spending money that doesn't improve patient care while letting trial lawyers off the hook for their role in compromising patient care is just plain irresponsible.

Physicians are charged with providing necessary medical care. Similarly, lawyers are charged with protecting patients from gross negligence. Taking care of patients is both a privilege and a tremendous responsibility. The purpose of medical liability is to keep gross negligence in check, punish inappropriate physicians and, when necessary, remove them from practice. Not only does the current liability system fail to protect patients from gross negligence, it also fails to protect physicians who practice appropriately but whose patients suffer bad outcomes. Trial lawyers cream-skim cases where both potential payouts and likelihood of settling before trial are high, irrespective of whether inappropriate care was provided. Additionally, lawyers often promise to not charge a fee unless the patient is compensated as a result of the suit. With nothing to keep frivolous lawsuits in check and an incentive to select high-paying cases over ones where patients have experienced gross negligence leaves neither physicians nor patients protected. Only trial lawyers stand to benefit from this system.

Acknowledging that physicians have a perverse incentive to provide more care is important. Where President Obama and Congress have failed patients all across this country is their failure to acknowledge the perverse incentive the Democrats have to support trial lawyers. For years, trial lawyers have supported Democratic candidates in exchange for their obstruction in any attempts to achieve meaningful liability reform. In many states where liability crises loom large, Democrats have told physicians for years that caps on non-economic damages were off the table. Caps are certainly not a perfect solution: opponents rightly argue that limiting non-economic damages prevents some patients from seeking retribution in cases of gross negligence. But perpetuating a system that fails to protect physicians or patients while compromising access to care and wasting funds only calls the credibility of its Democratic supporters into question.

We as physicians are the guardians of the health and well-being of our patients. We are charged with ensuring that they get all necessary care but have the responsibility of preventing wasteful spending. As health care spending grows to nearly 20 percent of the GDP and the number of uninsured people in this country approaches 50 million, we cannot afford a system that wastes as much money as our current one. President Obama was right to recognize this and advocate for change to remedy what ails us. But holding physicians accountable while giving the trial lawyers a pass is not only irresponsible, it is nothing more than politics that compromises the health of our nation.

Employer Mandates

As we focus in on a plan to reform healthcare, we must ensure that we learn valuable lessons from what works and what doesn't work in other health system. Cross national models of healthcare delivery provide valuable insight into the likelihood that reforms will have meaningful impact. We know that most of the developed world has managed to provide universal coverage for its citizens, but how did they accomplish that? In Brittain and Canada, they turned to a single-payer system managed by the government to provide healthcare to all citizens. As a result, they have faced shortages and rationing as government budgets dictate health delivery with all the incumbent political pressures. But the rest of the developed world has avoided this pitfall. How have they done it? Employer mandates.

Our country already functions largely upon employer provided healthcare. About 60% of Americans receive their healthcare through their employers. When combined with those covered under Medicare and Medicaid, we find that 15% of Americans remain uninsured in the current system. Who are these people? As Medicaid covers the unemployed, most of the uninsured are either at small businesses that cannot afford to provide health coverage for their employees, or they are freelance workers who either choose to go without health coverage or cannot afford the premiums. This number is growing in the economic downturn as more employers drop coverage when the cost becomes untenable.

Looking at other countries can allow us to determine what to do about this 15%. Most of Europe, Japan, Israel, and a host of other countries have utilized employer mandates to cover every citizen. Under these systems, every employer is required to provide healthcare for all workers. Small businesses receive assistance from the government to ensure their ability to pay for health coverage. Freelance workers enroll in insurance pools that greatly reduce the cost of health insurance. Most of these countries require that all citizens carry some type of health insurance either through their employer, through the freelance clearinghouse, or under the government's indigent program (much like Medicaid). To ensure that insurers treat consumers fairly, most of these countries also develop the "benefits basket" which are mandatory services that all insurers must provide. To compete in the marketplace, many insurers will provide additional services not included in the "basket."

So, why can't we do this in America? The simple answer is - we can. In the 90s, the Clinton healthcare plan actually approximated an employer mandate system, but was so complex and unwieldy and designed without stakeholder influence, so it was easily decimated by industries that would have suffered under it (e.g. health insurers who would face greater market competition that would cut into profits). According to a recent survey conducted by the Employee Benefits Research Institute (EBRI), 3 out of 4 Americans support an employer mandate for health care coverage. Clearly there is much interest in such a system, both from the perspective of policymakers and from the public.

What stands in the way of an employer mandate? Business, of course. The U.S. Chamber of Commerce and the National Retail Federation, amongst others, have been very outspoken on this issue which they feel will put an undue burden on business, especially small businesses. The Health Insurance Industry has been straddling this issue, fearful for the increased competition that might drive down profits while excited about the prospect of having an additional 15% of the population as members of an insurance plan.

Looking at so-called "ObamaCare," there are overtures toward an employer mandate system. There are incentives in the various bills for employers to cover their workers, especially for the small businesses that currently opt out of such a system. The President and many of his Democratic colleagues feel that a public option is also necessary, not only to plug the gap which may still remain between Medicaid and the employer system, but also to create even more competition on the insurance market. The fear that the public option would eliminate the private insurers due to better rates and services is largely grandstanding - this would only happen if insurers choose to NOT be competitive in order to maintain high profit margins or do not find internal ways to reduce their administrative costs which are currently well above those required for Medicare.

So, Obama's plan, while not an employer mandate and relying more heavily on government programs, does accomplish many of the goals of the employer based systems of the other developed nation. With an increased buzz about employer mandates and support from big businesses like Walmart and Target, later versions of the bill may find it useful to increase subsidies to small businesses for providing insurance and create insurance pools for freelance workers. Time will tell whether our great nation can learn from the experiences of others.

Anniversaries Are a Time to Remember: A Cautionary Tale

Just ask any husband who has ever forgotten one, and he'll tell you, anniversaries are a time to remember. This past weekend marked the eighth anniversary of the announcement of a class action lawsuit brought against managed care companies by the Medical Society of the State of New York (MSSNY). In a coordinated effort, suits were launched at that time not only by MSSNY, but also by 17 other states and counties against six major insurers including Excellus, Aetna, Cigna and United.

“We just got tired of all the improper business practices of all the different insurance companies and a lot of states were getting like this, and we all knew we needed to do what we could to fight back against them,” says Dr. William Dolan, one of the primary plaintiff's in the MSSNY suit, former MSSNY President and current trustee of the American Medical Association (AMA).

Some of the improper practices outlined in the suit include: arbitrarily reducing a physician's payment for medically necessary care by "downcoding," or changing claims and billing codes to indicate a doctor should be paid less; bundling claims, or issuing a single payment for a group of related medical services; failing to pay physicians in a timely fashion; forcing physicians and their staffs to expend an unreasonable amount of time and resources attempting to obtain reimbursement to which they are entitled; exploiting the doctors' unequal bargaining power to force physicians to enter into one-sided HMO contracts.

Excellus was the first company to settle, and in the end, all but United Health followed suit. The settlements included both monetary payment and agreement to improve practices. For example, the Excellus $60 million settlement included a payment of $1500 to all of the physicians in the involved upstate NY counties as well as agreement to completely adhere to the CPT4 Codes, Guidelines and Conventions, which they had not previously been following.

In recounting the day the suit against Excellus was announced eight years ago, Dr. Dolan recalled the beautiful view of the New York cityscape, including the then still standing Twin Towers. And while the skyline of the city, and indeed our nation have undoubtedly changed since then, the battle between physicians and the bad practices of insurers has remained constant.

Just this past spring New York Attorney General Andrew Cuomo filed suit against United Health and Ingenix Inc., for allegedly altering data so insurers paid less and patients more for out-of-network services. “It's fraud. They deliberately cut the numbers so the consumer pays more of the cost,” Senator Jay Rockefeller, chairman of the Senate Commerce, Science and Transportation Committee told The Associated Press of the practice.

“There's a lot of excess money being spent on the part of practitioners on billing the insurance companies,” Dolan says. In 2008, the AMA launched the National Health Insurers Report Card (NHIRC), which evaluates major insurers on 13 metrics regarding the timeliness, transparency and accuracy of claims processing. With physicians spending close to 14 percent of their income on billing, it's clear that steps such as this and more are still necessary. A PNC bank study estimated that $200 billion are spent each year on billing.

“We're going to have to continue stridently, and to do battle if necessary or come to some negotiation with AHIP [America's Health Insurance Plans] and the various insurance companies with all our information, and they know, in the past, we've won these battles,” Dolan said.

As we move forward in the healthcare debate, it is important to remember and remain mindful of these past, present and future battles between physicians and insurers, as we won't be able to make up for forgetting them with flowers or expensive jewelry.

Obama, 'Four main ways (to) Provide Stability and Security to Every American'

"No one in America should go broke because they get sick."

Link To Obama Op-Ed Piece

A Position on HR 3200 - Not Our Local Job?

A growing disillusionment of the membership is leading the county medical societies to define a position on hr 3200. Several county and state medical societies have adopted a position to oppose the ama hr 3200 strategy.

But more than one county has positioned itself neither embracing nor condemning one side of the issue or the other.

One such county president, when asked how this position was developed, said,” I realized that solving national health reform was not our local job! We’re ... preparing to help our members deal with the fallout. “

Instead, their role is to keep the membership informed. This mission is vital and distinct from the national and state omnibus societies. This position avoids the alienation of an entire sector of the membership.

Link to County Society Alert

Malpractice Reform is Healthcare Reform

In order to get physicians onboard with healthcare reform, the administration should push to reform the practice environment. Polling many physicians of disparate backgrounds and political persuasions, we find one area of unanimity. The present system of adjudicating claims of malpractice must be changed.

Duke University’s Donald H. Taylor, Jr. writes in the North Carolina News&Observer:

…A successful malpractice system would protect patients from harm via a deterrent effect of lawsuits, compensate patients for harm and exact justice. In addition, a good system would protect physicians from frivolous suits, identify substandard physicians so that medical licensure boards could remediate them or remove their licenses and provide a clear signal to insurers regarding the risk of insuring a physician.

Our malpractice system does none of these well.

http://www.newsobserver.com/opinion/columns/v-print/story/1638305.html

A large number of lawsuits are filed when no malpractice has occurred. Conversely, many cases of real negligence do not result in a lawsuit. Not only is compensation inequitable, but the system itself is ponderously slow. It takes about five years from summons & complaint until trial or resolution. Moreover the costs involved with filing, answering, expert opinions, depositions and the cost of trial are such that for every dollar paid a successful claimant, half again as much goes to administer this system. While the costs of malpractice may only amount to 2% of healthcare costs, this still amounts to over twenty billion dollars which is not a trifling sum, even when a budget of trillions is being considered.

And then there’s the cost of defensive medicine, which has been estimated to cost $100 billion annually. It appears that as the administration scrambles to answer concerns of runaway cost estimates, they are avoiding an obvious chance to bend the cost curve favorably – reform the US medical malpractice system. Professor Taylor lists several suggested modifications to the current system. Suffice it to say our medmal system can be reformed so that it is efficient, equitable and evidence-based. Reform medmal and achieve both cost-savings and physician support. Win – Win.

Art Fougner

The New Doorknob Question, And the Need for a United Answer

The doorknob question, that important or embarrassing question our patients traditionally ask at the "close" of an encounter is a long-standing and common phenomenon. The chorus of this phenomenon, however, is changing from, "Oh, Doc, I've got this rash..." to "But Doc, I don't have the cash..." All too often prescriptions go unfilled and followups unscheduled because patients simply can't afford them. Physicians find themselves scouring the $4 prescription lists for a suitable alternative, which may or may not exist, or seeing if the local supermarket is still offering free antibiotics. Cost has become the rate-limiting step in our ability to treat, and is as paramount to our patients as their illnesses.

Years of school and training, constant review of emerging research, we as physicians spend much of our time and lives becoming expert in medicine. But along the way we also become expert in patient care. Medical students are taught how to communicate complicated medical pathology and treatment to patients in "layman's" terms because if they don't understand what we feel is necessary, they won't be able to carry out our prescribed course of treatment. So too, is it vital for us to communicate the complicated healthcare delivery issues we see every day to our representatives in "layman's" terms. If they don't understand what we feel is necessary, they won't be able to carry it out, and our patients and our ability to care for them will lay casualty.

There are many clamoring voices in the ongoing healthcare debate, but of all of these, ours is the one that is expert in patient care. The potential power of the physician voice is strengthened when we speak together. Just as a multidiciplinary care team needs to be on the same page when advising a care plan to a patient, we must harness the power of unity and clarity when offering our prescription to the ailing healthcare system.

The "doorknob questions" of comprehensive healthcare reform aren't just being asked in our offices, they're being asked on Main St, Wall St, Pennsylvania Ave and just about every other street in the country. And we as physicians need to come to a consensus on our answer. Failure to do so may not only compromise our ability to care for patients, but may prove far more dangerous and deadly than not taking a second look at that rash.

Expanding Access and Controlling Costs

In his article today, Samuelson challenges President Obama's statement that "The status quo is unsustainable for families, business and government." He brings up the point that we, as a society, value expanding access because people tend to think of health care as a right (or at the very least, something that we should be able to provide our citizens as one of the richest countries in the world). At the same time, what makes our system unsustainable is not the number of people we cover, but the amount of money that we spend providing care for each person. Many uninsured currently seek primary care in the emergency room, one of the most expensive places to deliver care. Providing coverage for many of the currently uninsured and shifting their care to primary care settings will help to cut costs, but not enough to offset the cost of expanding coverage.

Our challenge now is to figure out how we can take the money we currently spend on health care and cover the uninsured, eliminate waste in the current system and provide better and more coordinated care for patients. There is no easy solution to this problem, but this must be part of any meaningful health care reform in order to create a more sustainable system.

Link to Article

Disinformation?

The President gives great insight into the main street debate surrounding healthcare reform. (this link for example)

No longer just healthcare professionals talking about reform, it is now that much more important that we (physicians) stay present to the debate occurring at the American dinner table.

(Still, it is) disturbing that the White House asks the American public to report any dissenting opinions about health care reform that may be construed as "misinformed."

Robert A. Dugger II MPH

MS II - Stony Brook School of Medicine

http://www.whitehouse.gov/blog/Facts-Are-Stubborn-Things/

Insurance Reforms & New Yorkers.

What would the insurance reforms in the federal healthcare bill mean to us New Yorkers. An insurance consultant responded thusly:

He stated that the ‘system’ wouldn’t change much in New York because the bill proposes extending the New York ‘system’ to the rest of the country. For example:

• In New York a policy is guaranteed issue - a company can't decline you due to your health,
• In most cases pre-existing conditions are already covered - in most areas of the country a health insurer requires a medical exam, and an insurance company can decline you for coverage

I asked about HSA’s and why they are not more popular. I learned that HSAs are both good and bad. They are advantageous because the premium is less expensive then most other options (HMO, EPOs, PPOs). But, the premium savings often isn't enough to justify the purchase of an HSA.

He stressed that insurance reforms alone are merely a component of HCR. He stated that needed reform also included tort reform, obesity issues, etc

link to health insurance protections

The Polls

An article in the Wall Street Journal today by Scott Rasmussen (link below)

discusses the fact that 68 percent of voters have health insurance that they rate as good or excellent. He argues that this will be an obstacle to achieving health care reform, and I agree. Americans want to see everyone have access to high-quality, affordable health care, but not if it means their own health care or access will be worse than it is now. It seems reasonable enough; nobody wants reform that is going to make them worse off. To these people, health reform is a gamble. We won't know if reform makes each of us personally better or worse off until it actually gets implemented. So why take a gamble on health reform if you're happy with what you have and it might make you worse off. Essentially, if it ain't broke, don't fix it.

The problem is that too many people don't see that the system is broken (perhaps "broke" is the better word, since varying estimates show that Medicare will go bankrupt within the next 10 years). The cost of delivering health care continues to rise. Most working-age citizens still get their health insurance from their job, so people lose their coverage when they lose their jobs. More and more employers are shifting more of the costs of health insurance onto employees or are dropping health coverage altogether. Medical bills are the second-most common reason for filing bankruptcy in America. The uninsured are twice as likely to file for bankruptcy than those with health insurance, though nearly a third of all Americans who file bankruptcy for medical reasons have health insurance. In essence, the insured pay for the health care we provide to the uninsured, and at a greater cost. Those without coverage are more likely to seek care in the emergency room, the most expensive place to get care. Meanwhile, the uninsured are charged more for the care they get, since they don't have insurance companies to negotiate the discounted care those with insurance receive. And to top it off, having health insurance doesn't even guarantee that you won't need to file bankruptcy because of medical debt.

Clearly, Congress, the Administration and the key players advocating for health care reform aren't getting this message across. Though 68 percent of Americans may rate their current insurance as good or excellent, our current health care system isn't sustainable. It's broke, and now is the time to fix it. Health care reform is not a gamble; it's the only chance we have to come out ahead.

WSJ Article

Demonstrations or Demons?

At town hall meetings, congressmen are shouted down, hanged in effigy, surrounded and followed by taunting crowds. Key organizers include two Astroturf (fake grass-roots) organizations: FreedomWorks and Conservatives for Patients’ Rights (itself with ties to the Columbia/HCA hospital chain).

Are cynical political operators exploiting public anxiety just to further the economic interests of their backers?

see Congressman Bishop video

Politicians Deal on Health Care Reform

this article, in today's ny times, is the acknowledgement that everyone has been asking for - that the administration made 'deals' with health care stakeholders.

can anyone still doubt the assertion that the administration lured the other stakeholders (including the doctors) with promises as well - since they were part of the original 'coalition' (along with pharma) of health care stakeholders when it was announced in the spring?

a trustee has reminded society members that we are in the early innings of a planned nine inning game. i say to physicians, lets gather some consensus on what's important - especially if this thing goes into extra innings

see nytimes Article

Make the System Better, Make More Money!

In the oft-cited New Yorker Magazine piece, Atul Gawande proposes Accountable Care Organizations (a gainsharing strategy) as his remedy to the seemingly conflicting goals of controlling health care costs while improving quality and efficiency.

While other savings proposals such as cuts in payment rates, bundled payments, and capitated health plans have faced opposition, “a voluntary payment reform designed around ACOs and shared savings offers an incremental and promising middle ground that could meet the interests of providers, beneficiaries, and taxpayers better than the competing alternatives.”

The ACO shared- savings model supports and rewards those who improve care and lower costs. According to former CMS head, Dr. McClellan, “Linking new investments in health care to demonstrated improvements in health and medical costs creates a win-win: providers and patients can get more support for real improvements in care, and we all benefit from lower costs.”

And most physicians and hospitals could form ACOs by building on their current practice patterns.

The problem, of course, is that gainsharing is illegal within the current antitrust environment.

see HR 2959

see New Yorker Article

Physicians... Unhappy With the Lack of Leadership

'Jefferson wrote "A govenment big enough to give you everything you want is a government big enough to take everything you have". This monstrosity of a bill and the amendments they have just marked up make Gottfried look like a charm school book report. ... only physicians are in a position to advocate for our patients and ourselves, and there is only one MD representative that I know of on Waxman's committee, a Republican, who might as well have tape over his mouth. This legislation will undoubtedly be revised and amended, but even in altered form, will create a new powerful and controlling bureacracy which will change not only the practice of medicine, but the whole relationship of government to the people of this country.

The AMA failed to attack objectionable provisions in the bill and never pushed for tort and insurance reform, and other vital elements of our survival, as the bill was being formulated. It is naive to think they will be able to work with doctor haters like Waxman to alter those pieces of the legislation once they are finalized. Letters of complaint about the actions of the AMA and MSSNY are beginning to be received in numbers at county societies, and I would contend that most physicians in the country are unhappy with the lack of leadership, be it real or perceived. The profession should not be a commodity to be traded, nor a doormat for poorly informed, and agenda-driven politicians. One can only hope the voters are smart enough to vote these marauders out of office, and restore some sanity, before Big Brother says hello in a Big way.'

clyde locke