Tuesday, March 3, 2009

Obama and the health care NIMBYs

Just about everyone has had experience with the "Not in My Backyard" (NIMBY) crowd. NIMBYs inevitably show up at community forums to object to proposals to build schools or add new retail or residential development, just about anything that they decide might adversely affect their property values and quality of life, no matter how meritorious.

Health care has its version of NIMBY-ism. Every health care interest group in Washington is for health care reform - until, that is, someone asks them to help pay for it.

In which case, the health care NIMBYs (call them lobbyists, if you like) come with a refrain that sounds something like this:

"Not in my backyard, they say,
We all want health reform ... some day
Just as long as we don't have to pay!"

President Obama's speech to Congress, and release of his budget outline, brought the health care NIMBYs out in force. He proposes to create a $634 billion fund for health care reform that would be paid for by raising taxes on persons earning more than $250,000 per year. He also proposes to reduce payments to Medicare Advantage insurers ($174 billion saved over 10 years), reduce drug prices ($29 billion saved), lower payments to hospitals with high rates of readmissions ($26 billion saved), and reduce home health expenditures ($37 billion saved).

Karen Ignagni, CEO of America's Health Insurance Plan, a health insurer trade group, says the Medicare Advantage cuts "would jeopardize the health security of more than 10 million seniors enrolled in Medicare Advantage and would turn back the clock on innovative payment incentives to improve the quality of care that patients receive," reports Julie Rovner and April Fulton in a National Public Radio story. (To be sure, AHIP has proposed its own plan for universal coverage, which does not include cuts to Medicare Advantage plans).

The Pharmaceuticals and Research Manufacturers of America issued a guarded statement congratulating President Obama for his commitment to funding health reform but warning "against the adoption of policies that could undermine innovation and disrupt patient access to life-saving medicines."

Even with President Obama's proposed savings, Robert Leszewski argues in his Health Affairs blog post that "President Obama hasn't made anywhere near the hard decisions that need to be made." Leszewski argues that "we need to reduce what we pay physicians" to get real savings but that "it is also the most politically problematic for all the clout the physician lobby has."

I think the reaction to the budget shows the challenge President Obama will face in getting health care reform enacted. The health care NIMBYs will try to block any reforms that will affect their own backyards.

To be fair, I am not pointing the finger at other interest groups - ACP would almost certainly object to "savings" that come at internists' expense.

President Obama knows he is in for a fight. The Huffington Post has a video that quotes President Obama as saying "I know these steps won't sit well with the special interests and lobbyists who are invested in the old way of doing business, and I know they're gearing up for a fight. My message to them is this: So am I."

This is a message he likely will repeat to ACP and the key stakeholders invited to Thursday's White House summit on health care reform.

Today's questions: Do you think health care NIMBY-ism will kill health care reform? What would you advise President Obama do to overcome it?


Steve Lucas said...

Nicholas D. Kristof writing in the NYT's Even Cypriots live longer than Americans has a very good diagnosis of the problem. We have groups so invested in the current system they cannot see any advantage to changing to a simpler or less costly method of delivering medical care.

From my prospective the issue is not getting a piece of the medical pie, but of expanding that pie with never ending "reforms." This will never happen as long as those chosen for positions in the administration have themselves conflicts, with past and current financial ties to existing medical providers or insurance companies.

Again, from my perspective, I see a bubble, similar to the tech and now financial bubble, driving medical expenditures that will at some future day break, leaving us with a still broken system and a pile of debt.

Steve Lucas

Jay Larson MD said...

There is the real world and the political world. NIMBY-ism may make health care more challenging, but will not kill the process. There is too much grassroot support for health care reform from patients. My patients can't wait to get health care reform moving.

Michael D. Miller, MD said...

Medical Homes, if properly structured and compensated, could reduce the growth in costs and improve quality. The Medicare demonstration scheduled to start next year has been delayed a bit - but hopefully will still start next January. I've written about this a bit at http://www.healthpolcom.com/blog/2009/02/16/controlling-health-care-costs-and-improving-quality-with-effective-care-coordination/

Feel free to comment or rebut. Michael D. Miller, MD

PCP said...

Not all NIMBYs are created equal. Sadly none will admit to it either.
Unless we start to look at value in health care and put that ahead of all else in reform, we will not see the "right" NIMBYs rewarded and the others cut to size.
What we have are distortions in the health care system for a variety of reasons. Unless we can set them apart, we will not get the kind of reform that will benefit our country.
For example, we need to determine whether we want more than 2% of our medical students going into General IM outpatient. If the answer is no, we need do nothing else, we are going there. If the answer is yes, then we must act, not by force but by realligning incentives. Whatever the RUC committee reccomendations. Likewise we need to stop undermining PCPs and develop models of care where they lead teams and feel valued and respected.
If we take such an approach to every NIMBY, then we stand a chance. In an era of limited resources, we quite simply cannot continue to waste resources. PCPs have little left to give in the current system, which has failed us while simultaneously failing our patients. Might these two be related?

Jay Larson MD said...

PCP is right, not all NIMBY's are equal. The general internist's backyard is in the undesirable part of town. The only plants left in the backyard are very hardy but are wilting from all the herbacide dumped on them.

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