Thursday, January 21, 2010

"Dazed and Confused"

... is how Chris Frate aptly characterizes the Democrats' state of mind on how to proceed with health care reform. It doesn't help that President Obama and his White House staff are sending mixed signals.

It seems as if there are only a few options left:

- The House passes the Senate bill "as is" but with a commitment to modify parts of it through a separate budget reconciliation bill. This has the advantage of not requiring 60 votes because a filibuster is not in order in the Senate for a bill that has already passed and is awaiting action by the other chamber. Any changes made through budget reconciliation can also be passed by a simple majority. But as the Washington Post reports today Speaker Pelosi has rejected this option, at least for now.

- The House and Senate could drop the current bills and start anew with drafting a new bill to be passed strictly through budget reconciliation on a strict majority vote. This though creates all kinds of political and procedural hurdles - including the need for the committees of authorization to have to "mark up" a new bill. The reconciliation bill could only include provisions with a direct effect on federal spending and revenue, so popular regulatory provisions, like banning pre-existing conditions exclusions, likely would have to be left out. And, with the Democrats eager to get health reform behind them, I don't see them wanting to start anew.

- Reid and the White House could reach out to a small handful of Republicans, like Olympia Snowe (R-ME) and Susan Collins (R-ME), to get them to support a compromise that gets them to 60 votes. Not impossible, but difficult, because the Democratic leadership may have burned bridges with them, and the few Republicans who might be "in play" will be under tremendous pressure from their party not to play ball. Compromises to get GOP votes will run the risk of losing votes from Democrats, and I would not be surprised to see some of the Senators who voted for the current bill having second thoughts. The back-and-forth negotiations that would be required would drag the process out longer and lead to more deal-making, the last thing the Democrats want.

- Or the Democrats could themselves break the bills up into individual parts and force Republicans to vote for or against provisions that may be popular. The likely result would be a far less expensive bill that would make modest changes (like banning pre-existing conditions and voluntary pooling arrangements, maybe with Medicaid expansion and some limited subsidies targeted to the poor). This too, though, would require new committee "mark up" and drag the process out for months, with no certainty of success. And disaggregating the bills could lead to an unworkable result: for instance, requiring that insurance companies accept people with pre-existing conditions (popular with voters) likely will require a mandate that individuals buy insurance (less popular) and subsidies (very expensive) to make coverage affordable.

- The White House and Congressional leadership could just walk away from the process of trying to get health reform passed and try to blame it on Republican obstructionism, making the midterms a referendum where both sides would point figures on why health reform failed.

Where does this leave ACP and its public policy agenda? We don't control the politics, process or procedures of health care reform. Our agenda is determined by our own policies - not the politics of the moment. As such, we will continue to advocate that Congress enact legislation to advance our four priority areas: coverage for all, workforce and primary care, payment and delivery system reform, and medical liability reform. We have been pushing this agenda long before the latest political developments, and will continue to do so until progress is achieved.

There is no easy way forward. But if health reform fails, the best opportunity we've had to advance fundamental reforms to achieve key policy objectives - like reforming Medicare payments to support primary care, training more primary care internists, funding research on comparative effectiveness, and of course, affordable coverage for all - will be set back. And if health reform fails, health care spending will rise at a rate that that the country simply can't afford.

Kevin Pho, MD, may have said it best, in his admonition to his colleagues on the Right:

"With the potential defeat of ObamaCare, you may have won the battle, but will lose the war. The current health reform efforts, in the grand scheme of things, were very incremental in nature. Without it, the number of uninsured will rise, and health costs will continue to spiral upwards. That will eventually bring America's economy to its knees, and, as I said a few months ago, 'once that happens, more draconian measures will be forced upon us. Measures that assuredly will not be friendly to doctors.'"

Today's question: Do you agree with Kevin Pho that defeat of Obama's health care reform will lead to more draconian measures being forced upon physicians?

P.S. - The ACP Advocate Blog with Bob Doherty has been nominated for consideration in the Best Health Policy/Ethics category in the 2009 Medical Webblogs Award Program sponsored by epocrates. (It may not yet show up yet in the list of nominees, since it usually takes a day or so for the latest nominees to show up.) If you would like to support the nomination, you can do so by following the instructions "to place a nomination." The editors ask that when nominating, you indicate the blog's name and URL, as well as your thoughts why this particular blog deserves recognition.


PCP said...

We were always going to be on the menu rather than at the table.
If the ACP/AMA believed that the 2 month patch on Medicare with the implicit assumption that in March we will SGR reversal and other more physician friendly provisions, then they might as well believe in the tooth fairy and other such myths.
Our leadership is perpetually following the political winds, rather than rally the troops behind common principles that benefit Doctors (yes Doctors!) and by extension our patients, not the other way around, which tends to be the promise of every other special interest group.
Patients trust their doctors, and only when we can speak with a united and loud voice, will the public take notice. Perhaps only then will health care reform pass.

As far as a collapse in Insurance is concerned. The attitude of many PCPs is "bring em on",
The barrier to most of my patients paying me cash for an office visit, is not the prohibitive cost of that visit at $70 (heck the copays are often over half that). With less administrative hassle we could easily split the difference.
What is at real issue is the cost of the other stuff, the tests, medications, referrals and the like. None of which has anything to do with my business. It could if some foolish stark laws were reversed, but does not.
So effectively, I say so what if Insurance collapses, perhaps we would then see the long ballyhoed renaisance of primary care.

The People of Mass. who would know best(as they have been subject to this policy for the last 2 yrs) have spoken. I have always said that if we were as a nation allowed to see the catastrophe unfold in Mass. for another 1-2 yrs we will never see this pass nationally, perhaps I was naive. I believed the overzealous and clearly biased polls suggesting 80% approval of that plan have now been clearly exposed. They must not have been as thrilled with the liberal policies eh.

ray said...

May be they will get a smaller sensible version of reform with bipartisan support and maybe primary care will be part of it as it always had bipartisan support in congress. If they don't correct the proceduralist versus cognitive discrepency, health care in this country will never improve. The incentives will always be to do more procedures and more testing. ACP, AAFP have to stand up strongly for this, for too long specialist societies have played with RUC. How could only 5/23 members be from primary care for RUC board and rest be from specialities? Reform for physicians has to start with RUC reform. Primary care has suffered because of how their own members treated them like second class citizens.

Rich Neubauer MD said...

Predicting the future accurately is of course very difficult.

If the current effort to reform the health care system fails, it will be the second time in two decades. The last failure saw the ascendancy of managed care and various experiments at cost control that arose to fill a vacuum. Basically what emerged from the rubble of the Clinton failure was what we have now. Not good.

The present time is different from the 1990’s in many ways including the emergence of quality and performance measures, electronic medical records, an emerging culture of accountability, and efforts by large employers and even some insurers to take matters into their own hands by supporting innovative models (like the Patient Centered Medical Home) to reduce costs. Even if we don’t get any health reform legislation from the current effort, these innovations will likely continue to evolve but will likely do so in a way that increases the disparities of care within our system, much to the disadvantage of the growing ranks of those without insurance coverage. Furthermore, since government accounts for so much of our aggregate health care spending, they will continue to explore ways to decrease expense, regardless. Perhaps they will even be “forced” to consider workforce planning and the plight of primary care in some way shape or form.

However, it is hard to see a lot of positive in a failure to pass health care reform, both for physicians and for patients. I suspect that Dr. Pho is right. More draconian measures will be forthcoming if current efforts fail.

Don Mitchell said...

I agree with ACP's Top Four Priorities for Health Care Reform with one modification: "Provide ALL Americans with access to affordable health insurance." That it, truly universal access. The current House and Senate bills--and who knows what will happen to them now--would only cover 95% of the population, and only after 10 years. The remaining 5% equals more than 15 million people--unacceptable.

I regret that ACP has not chosen to emphasize this. The two bills are further deficient in not even beginning to extend coverage until 2013 or 2014. At an estimated 45,000 deaths a year of people who lack health insurance, that could amount to perhaps 150,000 deaths.

Don Mitchell, MD
Member, Physicians for a National Health Program

Don Mitchell said...

I strongly recommend that the first of ACP's Top Priorities be amended to: "Provide ALL Americans with acess to affordable health insurance." It is inexcusable that we don't have truly universal--100%--coverage of our population. Even the current House and Senate bills provide for only about 95% coverage in ten years--and who now knows the fates of these bills. The remaining 5% not covered amounts to more than 15 million people.

Furthermore, these bills will not begin to extend coverage until 2013 or 2014. At an estimated 45,000 preventable deaths per year attributed to lack of health insurance, this means perhaps another 150,000 preventable deaths before coverage is extended.

True reform is "Expanded and Improved Medicare for All," as advocated by the organization to which I belong--Physicians for a National Health Program.

Don Mitchell, MD

Arvind said...

Agree with PCP. Kevin Pho is wrong this time. Interestingly the health care cost curve may already be bent as this blog points out

The hysteria that doing nothing will mean doomsday, has been echoed too many times. Why should the government be a solution to this problem, when they (and the AMA) have really caused it? Why are we depending on those that dragged us down this path for the past 16 years to lead us to a better future?

Let's open up the process; allow direct dealing between physicians and their patients; allow tax incentives for people to buy whatever coverage they seem appropriate and affordable. Agree that pre-existing condition clause must be eliminated and tort laws have to be remedied. Other than these, the government has no constructive role in health care. MA sent the message after experiencing Romneycare for 3 years. They don't need Obamacare in addition. Let us learn from that message and be wiser.

Steve Lucas said...

As a business person I have always been surprised that doctors do not change their business model to cash or retainer. The cash model works well for a young transient population. Even an older population can purchase the time and services they want, all with up front pricing. Many labs now offer cash discounts. Many retailers offer $10 90 day supplies of generics and pharma is lamenting the number of drugs going off patient in the next couple of years.

The retainer model offers a steady income and the type of medical home touted as a cure for our current system. While I would limit practice size, doctors could band together to cut down on office expense. Seeing fewer patients per day doctors would have a personal relationship with their patients. Under both of these models the fees charged are often less than insurance premiums.

There would be changes needed to the tax laws to allow for medical payments to be deductable. The insurance market would need to be deregulated to allow broader competition for policies that better suit a person’s insurance needs and financial situation.

Add tort reform and you will change the way medical services are delivered in this country while maintaining choice. Doctors get out of the business of being a business and back into the business of treating patients.

Steve Lucas

Robert J. Sobel, M.D. said...

The rationale for restructuring the health system finance remains, as huge inequities in profitability exist. These will presumably get worse in the absence of effective reform. On the other hand, the introduction of new bureaucracies, as the House and Senate Bills would do, has always concerned me. The desire to refocus on the essentials, brought upon by the super-majority evaporation, is music to my ears. I always felt key incremental reforms were a lot more important than introducing untested concepts such as the accountable care organizations, the medical home, or mandated and integrated electronic medical records. I am struck by not only the cost implications of the latter, but the reintroduction of elitism that integrated medical records represents (for instance, the current treatment of hospitalized patients as if no PCP exists if the hospital-associated system is not being used). The interoperability dream of the programmers still strikes me as Orwellian.

When it comes to accountability, let's really straighten out the rhetoric. I am accountable and I am liable and a healthy tort system is totally appropriate. If the Illinois Supreme Court wants to uphold our current law, I am satisfied we could continue to make inroads on tort reform. What is absolutely untenable, unethical, and a cost before patient debacle, is the third party commandeering of my prescription authority and direct interference with patient pharmaceutical regimens. There must be cost regulation of drugs that does not restrict our rights in absurd, confusing, and ever-changing ways, as the brand-generic landscape evolves. Why I need a bunch of third party software to send me unsolicited commentary on my patients' medication routines is beyond me. The current quality games are both wasteful and dangerous.

When the Cozaar Paragraph IV litigation is through, and generic losartan is available, how should we proceed? Flip-floping of drugs introduced by third parties because of profit differentials is currently ongoing. It is cost-shifting and not cost-saving. The marketing excesses of Big Pharma versus the refined strategies of for-profit insurance puts us in the middle of a true perfect storm. I would ask organized medicine to begin advocating for coherent reform of the Hatch-Waxman Act. Drug importation won't get the job done. PBC's are hardly the answer.

Control drug costs. Respect physician independence and autonomy. Regulate hospital infrastructure wisely. Let private insurance exist in a state-based, federally- standardized, non-profit, need- subsidized system where marketing is severely limited.

If the debate has taught us anything, it is the danger of over-complicating the complex. We need to reward not only the cognitive but the conservative. Tried and true should be protected from the hype machine; innovation will not be stymied by a long-term perspective.