Thursday, March 18, 2010

It's a wrap

Today, the House leadership released the final "corrections" bill that will modify provisions in the legislation passed by the Senate on December 24, putting it on track to be voted on by the House on Sunday. Politico has a good summary of key changes made by the legislation. Earlier in the day, the Congressional Budget Office released its "score" of the legislation. And President Obama postponed his planned trip to Indonesia and Australia to be present through the voting on the bill.

The CBO report should help innoculate the bill from the charges that it is fiscally irresponsible. Instead, CBO concludes that it will lower the deficit by $130 billion over the next ten years and by more than a trillion dollars over 20 years while covering 32 million more Americans - 95% of all legal residents. And, the CBO shows that the vast majority of Americans - more than 162 million of us - will continue to get coverage from private, employer-based health insurance, not a government-run plan.

What about the charge that the package will harm the Medicare program? Actually, as the House leadership has also pointed out, the Medicare savings in the bill (which are mainly reductions in the rate of increase in payments to hospitals and other non-physician providers - which in the case of the hospitals, was negotiated with their approval) will extend the life of the Medicare Part A trust fund by seven years. That's right - seven more years before Medicare goes broke if this bill is passed than if it isn't.

The final package has an important improvement from the Senate bill that ACP championed. Medicaid payments for all evaluation and management services by primary care physicians in 2013 and 2014 will be increased to no less than the Medicare rates. ACP will work to make this a permanent change so it doesn't expire after 2014. But this change, combined with the 10% Medicare bonus for office and outpatient visits by primary care internists and other primary care clinicians, are important first steps toward addressing long-standing payment disparities.

I'll have more to say about the legislation in tomorrow's blog, but the bottom line is that the changes made from the Senate bill, and the CBO report, confirm ACP's view that the legislation will advance key priorities on coverage, workforce, and payment and delivery system reforms, while reducing the deficit and helping to keep Medicare afloat.

Oh, and as always, I invite your reaction and comments on today's blog and the latest news, but let's try to keep the dialogue free of name-calling or attacks on the integrity and motivations of those you disagree with. Today, I reluctantly allowed a comment to be posted that disparaged those of you who regularly post comments on this blog, which I don't think really helped the argument of the person making the comment. I know that emotions are running strong, and passionate responses can be expected, but can't we all at least try to be respectful of those we disagree with, and assume that they too are motivated by doing what they think is right, even if you or I disagree with them?

Today's question: What is your reaction to the final legislation and the CBO report?


Rich Neubauer MD said...

Thank you for this concise summary of where things stand. Assuming passage of health care reform, we will soon be on a pathway of change.

Naysayers will lament, but there are so many compelling reasons for change and you have done a superb job of outlining these reasons in this blog.

I anticipate that primary care will benefit, that the physician community as a whole will adjust and thrive as reform permeates through the system, and that the citizenry of our country will also benefit in many ways.

Who knows? Maybe there will even be changes to our dysfunctional congressional processes as a result of the very public way that how congress "works" has been displayed in the making of this bill.

Understanding that this bill is flawed in many ways, you have done an excellent job of reasoning why it is still best to advocate for passage while continuing to advocate to correct the imperfections. Assuming passage occurs, the work will not be done, but without passage it won't have a chance to even start.

Realistic said...

Part 1

Dear Bob,
With all due respect, your “ Pollyanna-ish” views on the bill ,likely to be voted on, are out of touch with most Internists who actually care for patients . I challenge you or the ACP to initiate a valid, independently confirmed poll of ACP membership. If you do, I would wager 1000 dollars with you that real life practicing doctors {former ASIM types}, not med students, and not salaried academics would be firmly against this bill. It would be fine it the ACP found that med students and residents favor Obama Care having never been responsible for running a practice or making a payroll . Academics have a right to their opinions. They generally are not getting out of bed at 3:00AM and going to the hospital or working 70 hours per week missing their kids growing up for the sake of caring for their patients. The public really should know what the average MD who provides the major portion of US medical care thinks about this bill.
You are so celebratory over this bill. Primary care MDs get a bonus 10% increase in EM codes. Medicaid pays equal to Medicare for 2 years. Hooray , its “bongo-congo day” This is “ice in the winter .” Bob, the government will completely take over healthcare and micromanage every decision MDs make. By the time "primary care” pays the increased costs of EMRs, "quality reporting" and a host of other stealthy taxes, there won’t be any actual Medicare raise or bonus. Internists will be equated to NPs in status and pay.
We are now going to pay MDs for “quality” not “quantity”? Great ! MDs will be blamed for every suboptimal A1C , every BP not at goal, every patient who refuses to make a lifestyle change. The diabetic I have to see weekly , who refuses to monitor his blood sugar, will demand my services but I will be denied payment because I should have done something to improve his blood sugar . My fault , reduce my reimbursement , but I am required to continue to see the patient. It will be my fault when my 85 year old male with an ejection fraction of 20% is readmitted to the hospital . I have kept this man alive for over 10 years past the point of his expected natural death , but if he is readmiited too often, it’s obviously my fault , deserving a pay cut. Also , when I consult other physians on behalf of my frail complex patients, I will realize it’s my duty to accept a “fine” for over consulting . Are you really jumping for joy over this Bob? I bet my colleagues are not eagerly waiting for this .
Bob, do you think 12,000 new IRS agents working with RAC bounty hunters trying to root out the “fraud” of a level l 4 EM visit vs. a level 3 EM visit are going to impact primary care income? Wait until the "unexpected" costs "force" the Secretary to reduce primary care payments, and then we will see how well primary care has done. Bob, do you think 500 billion cut from Medicare is going to result in better patient care? All this waste and fraud, where is it? Do you know who will be hit hardest by the RAC bounty hunters? It will be the Internists and Family Physicians.
Bob do you think I am overly worried? You say that you and the ACP knows best? Well what has the ACP done for Internists for the past 20 years. We listen to ACP and called our law makers . EM codes {water boarding } to hang physicians and deny or reduce payments, No Tort reform , No SGR fix, No Medicare raise for 10 years, no relief from red tape, no change in the downside of going into primary care, no ability to pass on the increasing cost of practice , more rules every day, more unfunded mandates. ACP has literally” fiddled as Internal Medicine has burned.” Face it, if ACP were a public company the CEO and his board would have been long gone. Why should I take seriously anything you support ? Where is your track record?

Realistic said...

Part 2

Bob, both the ACP and the AMA have blown our best chance of achieving tort reform. ACP and AMA should have held out for that deal. Just look at what Obama is doing in his efforts to pass this bill. Surely, we would have been better to tell Obama, no support until meaningful tort reform. ACP by its early support got zilch. Sorry to tell you, future MDs will not be impressed enough to go into primary care with the passing of this bill.
Now Bob ,do you realize that it is likely that millions of American workers will be shocked when their employers , having decided to take the cheaper cost of the fine for not providing health insurance to their workers, dump their workers into the government exchanges. What happens if these "exchange policies” are very poor MD reimburses or pile on the red tape, do you think that will be good for MDs? Many patients will lose their MDs despite what Obama says because many MDs will opt out of the exchanges. What do you say to this Bob?
Bob , do you know what is going to happen with private health insurance premiums? The mandatory purchase will be declined by millions of healthy Americans as they take advantage of the “no pre-conditions” mandate. You know it would be great to buy car insurance after the accident also. The sick will likely stay with their insurance and it will drive up costs for the rest of us. Then we will all drop out of insurance and accept the fine of not buying the ‘government approved “ policy . We will turn to the government exchanges when we need coverage. That will put the insurance companies out of business and we will have the single payer. Do you favor single payer? That’s what you will get with this bill.
Bob ,like many Americans , I have an HSA and I carry a 5000 dollar deductible. Why do I have to give this up ? Numerous states are going to challenge this mandatory purchase of “ one size fits all “ policies at higher premium prices that I am paying. Do you support my right to buy the policy I find best for me? I don’t want a 250 dollar deductible . I carry a 1000 dollar deductible on my care and home and I save money. How could you support this unconstitutional coercion?

In summary Bob , this bill is a disaster for all MDs and patients. ACP is wrong in its support and ACP should determine what their members think .

Unknown said...

I am not in favor of ACP's support of the bill as it does not contain tort reform, and doesn't have SGR fix for medicare. I know ACP is in a difficult position. I appreciated Joseph W. Stubbs, MD, FACP email I received today titled "Update on Health Care Reform End-Game."

I will sadly be ending my ACP membership this year after over ten years of membership.

Steve Lucas said...

I look at the CBO report in this light. We are at a tipping point concerning those who pay taxes. Right now we are at the 50% level and will soon move to a minority situation.

The top 10% of wage earners pay 70% of taxes. Medicare taxes will soon be extended to dividend and interest income as well as the sale of real estate and stocks. The Bush tax cuts will be allowed to expire.

The CBO scores a very specific scenario that is intended to show a specific goal is achievable, both parties do this, and this is nothing new. In this case we have 10 years of income for 6 years of program. Part of the savings is due to the inclusion of projected savings by the government taking over the student loan program.

A large number of those who will be insured will be covered by Medicaid. It was announced yesterday that a national pharmacy will no longer accept Medicaid prescriptions due to payments not covering cost. Can doctors operate on a Medicaid reimbursement schedule?

Collectively I see this bill as more of a driver for societal change. Over half of the population will not pay taxes. Educational loans will be controlled by the government. The government and unions own or control two major car manufacturers. Now medical care and payments will be dictated by the government.

We do need to reform our medical system. The ACP goals are fair and attainable. The public is aware of this need and are willing to work on new solutions to this vexing problem.

This bill harkens back to the “smart guys” comment I made some time ago. In an effort to reform health care we are also seeing a change we may not want. Once people are given something for “free” they will not want to go back to paying for it. Health care will quickly become an entitlement, one I feel the Democrats will use to rally future support.

Think of Greece. While essentially broke, it was the government workers, unions, and students who rioted to preserve their positions and income. Can we expect any less?

Steve Lucas

ray said...

status quo is not an option. I don't like many parts of the bill. I saw this patient who lost his insur while he was still in the hospital, his family brings him the letter that his insur was terminated and rest of the stay was his responsibility. He was so stressed and begged to be discharged and left against medical advice eventually. So for this patient Status Quo will not work.

PCP said...

We are most certainly jumping from the frying pan into the fire.
I don't like the status quo either, but I am certain that Obamacare will be far worst for us.
We lost income over the last decade, now we are losing our professional dignity.
ACP and AMA are going to pay a very dear price for this. Doctors will rebel once the details of this become clear, and their anger will be squarely directed at organized medicine which most already feel has sold us out.
I agree with the former poster "Realistic" who articulated very well the woes of the hard working private practitioner. All whilst the idealist dreamers in academic ivory towers and medical leadership positions keep slitting our throats. The impossibly busy silent majority have been co-opted by an elitist academic vocal minority.

The value we provide is not being recognized. So for some inexplicable reason the ACP feels the way to solve it is to support policy that will marginalize us, and make us permanently irrelevant.

The ACP(American College of Physicians) is soon to be the ACNP(American college of Nurse Practitioners). I assure you this will not make the system any less costly either and in no way better.

Physicians have not been dealt with fairly in this legislation. We have gotten ZERO in return, yet our professional leaders are the giddy cheerleaders for Obamacare.
I truly feel ashamed of how our profession has been allowed to be taken advantage of in this debate by our so called advocates.

Everyone understands that this moves us leftward in our health care system. ACPs advocacy for an Internist is akin to a CHC job and this will soon be laid bare. I have worked in the NHS. I quite simply know in which direction this takes us. This is a gut wrenchingly wrong direction for America.

My one consolation is this, at the end of the day, a system is only as good as its actors. The way I see doctors ticked off today, the impact of this is going to be felt long after the vote on Sunday.
Older doctors will retire, younger ones will unionise and work 36-40 hrs a week.
Sadly, Doctors will develop a part timer mentality instead of an ownership mentality, I have seen this in the UK.

All stick and no carrot makes for a ticked off doctor. It is politically incorrect to say anything but that Doctors are doing X,Y or Z badly, this is all propaganda from the left, how about a little pat on the back once in a while.
Doctors have gotten nothing but sticks for the past 15 yrs, and the worst part is we have been betrayed by our own.

Realistic said...

PCP Bravo!

Check out

Jay Larson MD said...

About 3 years ago, I was as frustrated and angered at the health care system as Realistic. Not only was I tired of being beat on by insurance companies but no one seemed to be addressing the trend that general internal medicine was going extinct. Almost left practice after 20 years. In our current health care system, general internal medicine is very under appreciated. Despite trying to explain what an internist does, no one, and I mean no one knows what it is like to be a general internist than another general internist.

Over the past couple of years, I have closely watched the health care reform legislation develop. Politics is a very messy and is more about what is better for the politician, not about the general public.

The term “Obamacare” does not do the health care reform legislation justice. Health care reform legislation started long before Obama became president. If anything, it should be called “Senate Finance Committee-care” because that is where a substantial part of the legislation was hammered out. Just go to and watch the hearings over the past couple of years.

We all have our different opinions about the legislation and how ACP represents its diverse membership. The bottom line is what is best for most people in the United States.
Personally, I feel that the legislation is the right direction for our country (though it may not be the right direction for certain individuals). The ACP has done strong advocacy work on behalf of internist. It does a good job representing general internists like me who slug it out daily trying to keep their head above water.