Tuesday, March 16, 2010

How should Congress choose?

By this time next week, we will probably know if health care reform will be signed into law. All indications are that the House will vote on the final legislation on Friday or Saturday. The vote will essentially be on the bill that passed the Senate on December 24, with modifications to be made in a side-car "corrections" bill that can be passed by a simple majority using budget reconciliation.

The process and procedures will be messy, but today, I want to talk about substance. Does ACP believe that the Senate bill, as it will be modified by the corrections bill, deserves a "yes" vote in Congress?

ACP has determined that it does, because in most respects, the legislation is closely aligned with ACP policies developed over many years in a series of position papers.

On coverage, we have long advocated for policies to make affordable coverage available to the vast majority of Americans. We support providing sliding-scale tax credits to help businesses and individuals afford coverage. We support creation of health exchanges to offer one-stop-shopping for qualified health plans and to negotiate affordable premiums with participating plans. We support making all persons up to 133 percent of the Federal Poverty Level eligible for Medicaid. We support increased Medicaid "matching funds" to all states to finance most of the cost associated with such expansion. We support requiring all health plans to provide affordable and non-discriminatory coverage to people with pre-existing conditions. We support requiring all health plans to provide essential and evidence-based benefits including preventive services.

On workforce, we advocate for policies to train more primary care physicians and to reform payment policies to support the value of primary care. We support increased funding for the National Health Service Corps and Title VII health professions training programs. We support creation of a national workforce commission. We support providing eligible primary care physicians with a 10% Medicare bonus on all of their office, nursing home, home health care, and emergency room services, as a first step toward addressing payment disparities.

On delivery system reform, we advocate for accelerated pilot-testing of innovative payment and delivery system reforms, including Patient-Centered Medical Homes. We support funding of more research on comparative effectiveness to inform clinical decision-making.

ACP's support is based solely on how closely the legislation aligns with policy, not the process or politics selected to move it across the finish line.

This doesn't mean we like everything in the legislation. It doesn't go far enough on addressing the crisis in primary care, or in reforming the medical liability tort system. It doesn't give Congress enough control over the recommendations of an expert Medicare payment advisory group. Congress still needs to come up with a permanent solution to the Medicare (SGR) physician payment cuts. These, and other needed improvements, can and should be made in subsequent legislation.

But at this, the final stages of the legislative process, the decision is a pretty simple one. Does the legislation advance the policies that ACP has long championed in our own policy papers? We believe that it does, and tomorrow, ACP will be joining with more than 200 national health organizations to urge that Congress vote "yes" on the final health reform bill.

Should Congress fail to pass health reform, ACP believes that we will be looking at a future - as documented in ACP's recent State of the Nation's health care paper -- where health insurance premiums will double, putting health insurance out of reach of most middle class families, where Medicare will go broke, where one out of five us will have no insurance coverage, and where insurance companies will continue to reject people because they change jobs or get sick.

I know that some of you will see the choice differently. But ACP has made its choice: this legislation, although imperfect, will advance ACP's key policies, and is far better than alternative of once again seeing health reform fail.

Today's question: How do you see the choices facing Congress?


Rich Neubauer MD said...

I don't think congress really has a choice. They need to take this first step toward a new future for the health care delivery systems of the country.

I hope we don't have to see the consequences of the opposing choice which is to do nothing and preserve a status quo that is doomed.

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

At this stage, I am hopeful that the final mark-up from the house will come in strong on the corporate enterprises and return some sanity to "the change paradigm" that has fueled most of our unsustainable growth.

I have stated before that the absence of reform of the current third-party managed care entities would be a glaring oversight. The manipulation that goes on for patients with the misfortune of needing chronic meds and not finding or tolerating the favored (by third party bean counters) formulary agents should be eliminated.

Let's pass a framework and then go about addressing the subjugation of clinical judgement and autonomy to cost considerations. We can handle the legitimate limits set by a stable, not-for-profit, insurance industry; we cannot afford the current mismanagement. The examples of penny-wise and pound-foolish abound. Give us a level playing field, and primary care will rise to the occasion of meeting the needs of our diverse populace.

Incentives that reward comprehensive care over shot-gun approaches will need to be carefully introduced and adjusted. The correction of extreme cost differentials would be a welcome development. Unfortunately, readdressing the drug life cycle and the financing of new technologies have not been a part of the debate to date.

DrJHO7 said...

Unfortunately, the choices facing congress are political.
The repub's are trying to shed light on the sign that dorothy, the scare crow and the tin man encountered as they approached the witch's castle: "I'd turn back if I were you!"
The dem's are trying to support the addage: "You have to go out on a limb to get the fruit", but they can't agree on which tree to climb.
To those who can predict the future, it is clear that the malignant disease that is our healthcare system has a poor (terminal) prognosis.
Personally, I pray that our elected representatives have the courage and conviction to move forward with this health care reform legislation that, while imperfect, is a necessary giant step in the direction of improving the accessibility to and affordability of the health care system that is so necessary for all of the citizens of this country. There will be much more incremental work to do, going forward, and it is crucial that we establish momentum.
Turning back at this point, would be similar to when the Andrea Gail turned back in "The Perfect Storm" - we don't want that kind of ending...

Arvind said...

What a surprise indeed! The ACP has probably hit the final nail on its own coffin, and along with that signaled the beginning of the end of what is left of the physician-patient relationship and has completely reneged on its obligation of protecting the interest of small practices in America (I am extremely saddened, but not surprised, because ours was one of the 8 small practices featured on the ACP-CPII website).

In its zealous pursuit of narrow policies supporting Primary Care, the ACP has abandoned its Sub-specialist members, especially non-procedural ones. I am personally insulted that the organization that I have been a member for the past 18 years, has now completely abandoned me.

Irrespective, I will write to my Congressman to remind him to vote No, knowing full well that he will most likely vote along party lines. I will, however, make him aware of the extreme damage he will be doing to his constituents, not to mention to his chances of re-election this fall, if he chooses to follow his party's orders.

ryanjo said...

Thanks for the succinct explanation of the ACP leadership's support for this failure of a health reform package. "Good enough for now", right? This is the same logic and tacit support of bad legislation that continues the SGR, the tort crisis, the abject underfunding of Medicaid, and the general side-lining of practicing physicians in this entire debate.

Thank goodness, the public absolutely hates this bill, and in November will allow many members of the House to experience the same joblessness as their constituents.

ray said...

ACP may be scientific, terrific in it's advocacy but unless you address reimbursements/ RVU, it will continue to kill primary care and front line doctors. CRNA being better compensated than primary docs for 4 years in row according to recent data is like rubbing salt on the wound. Why doesn't ACP address this disparity more clearly and strongly, it has happening for past 2 decades, why are cognitive doctors not getting a seat a the table? Health care in this country will worsen even if current plan passes, until something is drastically done to make primary care feel valued and proud of their work. How could dermatology RVU for biopsies be so well compensated than my patient visit with heart failure, anaemia, liver failure, fatigue? The pain of Primary care will be the reason this reform will fail. There is no way NP, PA can handle my above patient, they'll over utilize tests and referrals which will spiral the costs for ever

William M. Fogarty, Jr., MD said...

I support the ACP position on the health care reform bill. It is certainly far from ideal but offers a chance to repair some of the cracks in the shattered system we now have. It is only a beginning but, without it, we will not see any reform for another decade or more. By then, the number of uninsured and the waste in the system will be far worse than what we have at present.
I agree with Bob Doherty's assessment that the bill furthers the goals that the College has established over many years and that the bill should be passed. We can be assured that the College will continue to propose policies that move even closer to the true reform that is needed.

jfddoc said...

I see that the NEJM has published a Medicus Firm survey that states that over 40% of primary care physicians would consider quitting medicine if the Bill passes.

What good is insuring millions more Americans if there is no one around to provide care? An insurance card is just a piece of paper if no one is around to accept it.

Narayanachar S. Murali, MD, FACP, FACG said...

According to Pres.Obama the insurance costs will drop by 3000%.. No! Not an error. Taken right out of one of his recent marathon speeches.


the holmster said...

The paradox for all the naysayers on these first steps of reform is that if we don't fix insurance to do what it is supposed to do, it will go away. Reform will save the insurance system of financing health care in the US. The conservative right should be clamoring for it. Without reform as proposed, the system will continue to implode and the obvious eventual conclusion will be a single payer rescue. Then we will have more power for big government. Wake up conservatives. We must reform insurance for it to remain.