Friday, June 26, 2009

House proposal moves policies in the right direction

Yesterday, the House Committee on Energy and Commerce wrapped up three days of hearings on a draft bill to provide health coverage to all Americans, to establish policies to ensure an adequate physician workforce, and to revamp payment and delivery systems to get more value for each dollar of health care spending.

In a statement submitted for the hearing record ACP expressed broad support for the goals of many of the specific policies proposed in the bill. Like ACP's own plan, the bill expands Medicaid to cover everyone at or modestly above the Federal Poverty Level; provides individuals and small businesses a choice of health plans offered through an exchange (similar to that offered to federal employees); provides sliding scale subsidies for individuals to purchase coverage through such an exchange; requires that that all health plans, both within and outside the exchange, abide by rules relating to acceptance of all individuals without regard to pre-existing conditions or health status, guaranteed renewability, modified community rating; and requires that they offer essential benefits, including preventive and primary care services, as recommended by an expert commission. Employers would have to contribute to coverage or face a penalty and individuals would be required to obtain coverage once it is available and affordable, with appropriate hardship exemptions.

On workforce, the bill would create a national advisory group to recommend national health workforce goals, greatly expand funding for primary care training programs and create new ones to provide scholarships and loan forgiveness to primary care physicians who serve in areas of need, allocate more graduate medical education slots to general internal medicine and family medicine residency programs, allow residents to defer their debt through completion of their residencies, provide grants for primary care training and enhancement, eliminate barriers to teaching in non-hospital based primary care practices, and provide grants to address health care disparities and education on team-based models of care. Many of these provisions were taken directly from the bipartisan Preserving Patient Access to Primary Care Act, introduced by Representative Allyson Schwartz (D-PA) and Senator Maria Cantwell (D-WA), which is based principally on ACP policies and has received the College's strong endorsement.

The legislation also advances payment and delivery reforms aligned with patient-centered primary care. It would eliminate the pending 21 percent Medicare payment cut from the Sustainable Growth Rate and completely wipe out all of the accumulated costs resulting from the failure of past Congresses to enact a long-term SGR solution. (This accumulated cost -- running running into hundreds of billions of dollars -- has been a principal barrier to getting rid of the annual cycle of Medicare doctor pay cuts). The current SGR formula would be replaced with two separate spending targets for physician services, one for primary care and prevention (GDP plus 2 percent) and the other for all other physician services (GDP plus 1 percent). ACP has expressed concern, though, that continuing to benchmark physician updates on growth in the U.S economy, as measured by GDP (even with the additional percentage allowances for each category), could result in future payment cuts to physicians.

The draft bill provides more than $1 billion to fund two national Medicare pilots of the patient-centered medical home, one of which would pay qualified practices directly for prevention and care coordination of high risk patients and another that would pay community-based organizations for providing care coordination services to physician practices and provide payment to the practices themselves that use such services.

Primary care physicians would also receive a bonus payment for designated services. The amount of the bonus, 5 percent for most primary care physicians and 10 percent for those who practice in health professional shortage areas, is considerably less than ACP has requested. The College will continue to press for a more substantial primary care bonus. Primary care physicians would also see their Medicaid payments increased in every state until they are equal to Medicare.

Finally, the bill proposes new rules to streamline and standardize the administrative costs of health plan interactions, which impose a disproportionate burden on primary care physicians.
Although it is certainly true that "You can't always get what you want" from legislation (although I don't think Mick Jagger was thinking about health reform when he coined this refrain), the House proposal goes a long way toward advancing our goals on coverage, workforce, payment and delivery reform and administrative simplification.

Today's question: what do you think about the House proposal, and particularly, its impact on health coverage and primary care?

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