Monday, November 9, 2009

Tap-dancing through a minefield

I write today's blog from the back row of the American Medical Association's House of Delegates meeting, where the main topic of debate is whether the House will back its own elected Board of Trustees' decision to support H.R. 3962, the Affordable Health Care for America Act of 2009. The House of Delegates is considering resolutions that would either force the AMA to withdraw support for the bill and/or set a list of non-negotiable set of pre-conditions for the AMA to continue to support health reform. Yesterday, I sat through over eight hours of debate in front of a "reference committee" of House of Delegates members charged with hearing testimony and then drafting recommendations on the resolutions introduced by state and national medical specialty societies. The vote on the reference committee recommendations will take place this afternoon or evening.

As I've listened to the debate here, and also Saturday's debate in the U.S. House of Representatives, the image of tap-dancing through a minefield keeps popping into my head. To get a narrow majority to vote to pass H.R. 3962, Speaker Nancy Pelosi had to step around a series of political minefields, any one of which could have blown the bill apart. As reported in the Washington Post, the decision by Pelosi to allow a vote on an amendment to preclude federally-subsidized health plans from offering coverage of abortion was necessary to win the support of "pro-life" Democrats, but "pro-choice" advocates in both the House and Senate are vowing to block a final bill if it includes the same prohibition. Abortion, like it so often is in American politics, may end up being the single biggest minefield, because it is not suitable for "split the differences" compromises used to overcome other divisions.

The AMA is tap-dancing through its own minefields. If the delegates vote to overturn the organization's support for H.R. 3962, it could well paralyze the ability of its own Board of Trustees to continue to negotiate for its members, since the administration and Congress will lose confidence in the AMA's leadership to deliver. Yet there is a very vocal group of conservatives within the AMA House of Delegates who oppose H.R. 3962 on deeply held philosophical, political and ideological grounds, and they argue that the AMA will lose members if it does not change course.

There are many other delegates who believe with equal fervor that the AMA Board of Trustees did the right thing, and that the AMA stands to lose members if it reverses course. There are delegates who believe it is unwise for the AMA to reconsider its support for H.R. 3962, even if some of them have their own misgivings about the bill. They want the House of Delegates to set pre-conditions, or at the very least a list of top priorities and concerns, to guide future decisions by the Board of Trustees. The reference committee attempts to tip-toe through the minefield by affirming the House of Delegate's support for health reform in accord with established policies, even as it expresses "strong concerns about inclusion of" several provisions in health care reform legislation that would reduce payments to physicians who do not report on quality measures, reduce payments to higher resource use physicians, redistribute Medicare payments among physicians based on outcomes, quality, and risk-adjustment factors "that currently do not exist," and Medicare payment cuts for all physician services to partially offset bonuses for primary care services. (Interestingly, these provisions come from the Senate Finance Committee's version of the bill, not H.R. 3962.) I expect though, that efforts will be made today by conservative members of the House to turn these concerns and other issues into non-negotiable pre-conditions for continued support by the AMA and/or to substitute the original resolutions to reverse support for H.R. 3962.

The ACP, for its part, believes that H.R. 3962 advances important long-held policy objectives. (Our website has just been updated to provide a detailed list of answers to frequent questions about the ACP's views.) Our delegation to the AMA believes it would be a huge mistake for the House of Delegates to force the AMA to either withdraw support for H.R. 3962 or set "my way or the highway" pre-conditions, some of which are neither desirable nor achievable, which effectively would result in the AMA coming out against the current health reform effort.

No matter how the vote goes today in the House of Delegates, the AMA's slogan of "Together, we are stronger" does not reflect today's reality. Organized medicine will continue to be divided on health reform, reflecting the deep divisions among physicians on the role of government in health care, just as the close vote in the House of Representatives reflects the deep divisions on the same among the American people.

Today's question: What would you do if you were the AMA?


Harrison said...

If the AMA House of Delegates undermines the leadership, physicians will have lost an important voice in the most important health care debate in decades.
The AMA will need to regroup. We will do best with a strong unified voice.
It will be unfortunate if we fragment further.

Arvind said...

The AMA is defunct organization trying to regain its legitimacy in American medicine. It does not represent the practicing physician; hence its endorsement does not reflect the will of the community physician.

Its endorsement of this bill was a premature capitulation. It would have been far better if it laid out its agreements and/or disagreements about specific proposals in this Bill. But that would just be asking too much from the AMA. As far as I am concerned, I have no organization that appropriately represents my views/ideas or lends support to my profession.

As far as the "conservative" idea of keeping government out of my practice is concerned, it is obvious that you Bob, have never had to deal with the government to get get paid; so you would not know. When I was a young Resident in NYC in the early 90s, someone once told me - you become a conservative once you have been mugged in the subway. I hope the analogy is pertinent here!

DrJHO7 said...

I think the AMA has more to lose than to gain by rescinding its support of HR3962. If they (I am no longer a member) lose their credibility with congress by ostensibly pulling "physician support" for health care reform, it could conceivably cripple the momentum of the process which is at best, tenuous, and they may do irreparable harm to their effectiveness as a stakeholder, going forward.

On the other hand, although the bill as passed by the House has positive aspects that are congruent with ACP's mission and vision, it doesn't address spiraling costs/overutilization in the fee-for-service environment, and profiteering by health insurance companies and pharmaceutical companies that incessantly increase costs for employers/purchasers and patients, and suck huge amounts of money out of the system for the sake of profit. These three factors are going to put our medical system out of reach for more and more of the "victims", until the system is bankrupt and collapses. We do not need a crystal ball or a flux capacitor to fore-tell this; It will occur within the next decade, unless WE do something about it.

Arnold Relman has had the considerable cajones to identify these glaring destabilizers of our medical system, and to suggest some eye-opening remedies in his recent publications. I don't know if his will be the solution, or if something better will spring from the necessity of the crisis as it develops, but the bills that come out of this year's reform efforts in congress, "historic" as they may be, will only be a first stepping stone to the work and reorganization that will be needed to bring our health care system out of the icu, alive.

Jay Larson MD said...

Fortunately, I am not the AMA. There is no way that any organization can represent all the needs and wants of so many people involved in health care reform.

Watching politcal commentary on the House bill was disappointing. Representatives holding Health reform "hostage" for one ideological belief or another... Abortion, public option, gads.

Like Arvind, no one organization represents all my views and beliefs as a physician. I am cut from old cloth, believing that the patient I care for is most important. Not political points scored.

Front line physicians understand the uniqueness of each patient we take care of. No "organization" can manage the health care of individuals like a caring physician.

Whether health care reform legislation is passed or not passed, endorsed or not endorsed.
We will move on dealing with the issues in front of us.

PCP said...

Harrison is correct in his assessment that the AMA is disjointed and needs to become a strong unified voice. However two points on that. Firstly AMA can NEVER unite the house of medicine until it does away with or significantly changes the constitution of the discriminatory RUC and the RBRVU system. Absent that no cognitive physician will consider them their representative. Their policies and priorities over the years have been very lop sided.
Next the AMA needs to learn how to leverage its grass roots strength which is unrivaled amongst DC interest groups. However to do this they must do the first item.
Once that is done, the political impact of hundreds of thousands of respected physicians telling their patients about this issue will be fearsome to most politicians. That will bring about the leverage needed in negotiations(which based on the senate vote not to repeal the SGR last week we clearly have lost). At this time, the AMA focuses its efforts inside the beltway and and is doing nothing to get its grass roots going. Therefore it is weak. Whatever the promises made internally to them to gain their support, I can virtually guarantee that they will not be kept. As I said previously, we will be used and abused.
Sadly, when you get in bed with a politician get ready to be screwed.
That is the route the AMA has taken. That is why so many physicians have reservations about what they are doing.

ryanjo said...

Let's not excuse the foolish endorsements that the ACP's own directors have given the prior & present House bills. Despite admitting to the membership on this website that these bills fail to include many of ACP's essential principles of health care reform, the bills were supported, so ACP can have a "seat at the table" for future negotiations. In the meantime, the SGR repeal is voted down in the Senate and carved out for later consideration in the House.
My patients are astounded that two major physician organizations would give blanket support to this canard.
To the ACP board, I hope that "seat at the table" includes lunch, because that's all that's left after squandering our organization's principles and influence.