Friday, June 18, 2010

The SGR and Health Reform

Today, the Senate - in a rare stroke of bipartisanship - voted by unanimous consent to reverse the 21% SGR cut and provide positive updates of 2.2% through November, 2010. The legislation is fully paid for by offsets in other spending programs. Unfortunately, though, the cut remains in effect and claims are being processed at reduced rates, because the House of Representatives has recessed for the weekend and won’t be back until Tuesday. At that time, I expect that the House will pass the Senate's six month reprieve and Medicare will make doctors "whole" for the period of time that the cut was in effect.

Not that any of this is a cause for celebration. In the meantime, claims still are being paid at reduced rates, creating havoc for physicians and patients. Kicking the can down the road for another six months doesn't get us any closer to a permanent solution. It doesn't lower the overall cost, now estimated at over $200 billion, to dig out of the SGR hole. It doesn't provide the stability and reliability that physicians and patients need to view Medicare as a trusted partner. It does mean that we will be back again, this summer and fall, fighting to forestall another double-digit cut.

My views on the current SGR mess were quoted today by Politico:

"With nearly three weeks worth of Medicare bills being paid at 21 percent below 'normal' levels, providers are getting angry. The American College of Physicians warned that lawmakers of both parties are 'playing with fire.' I have never seen physicians more frustrated with the cuts and cynical about Congress' willingness or ability to do the right thing for patient access, ACP lobbyist Bob Doherty told Pulse."

Now, with the latest developments on the SGR, we are being accused (again) by some of failing to ensure that the SGR would be taken care of in the health reform law itself. That's interesting, because it ignores the facts leading up to the current SGR mess. It also overlooks the multitude of other policy reasons why ACP supported health reform.

As I wrote today in response to my earlier post on "Who should doctors be angry at", ACP supported health care reform legislation because it advanced ACP policies to provide almost all Americans with affordable health insurance coverage, to end insurance practices that deny people affordable coverage because they have a pre-existing condition or lose their jobs, to create incentives to train more primary care physicians, to pilot-test innovative payment and delivery models like the Patient-Centered Medical Home, to fund research on comparative effectiveness of different treatments, and to cover preventive services with no cost-sharing.

Policies that will help keep alive the tens of millions of Americans that studies show die each year because they lack health insurance. Without health reform, the Census Bureau estimates that more than 60 million people, one out of five of us, would lose health insurance over the next decade.

We supported health reform because it begins to reduce the disparity in Medicare and Medicaid payments for primary care.

We supported health reform because it will allow for pilot-testing and expansion of innovative programs to reduce the rate of increase in health spending.

I will put our record against anyone's of successfully influencing the legislation to include policies long advocated by internists, particularly on coverage, workforce, and payment and delivery system reforms.

Our support was not unqualified: as I have stated many times before, there are parts of the law that we don't like, but on balance, the legislation was the right thing for patients.

It would have been the height of cynical deal-making, the kind that our critics decry, for us to say that the only policy that mattered in the health reform debate was repealing the SGR. The SGR is important, but it doesn’t trump every other policy designed to make affordable health care available and affordable to tens of millions of Americans. We would never cynically trade all of our other policies to support better patient care in order to achieve a single policy objective, even one as important as the SGR. The SGR matters, but so does providing almost all Americans with access to affordable coverage.

And, let's be clear on the history: the SGR was passed by a GOP-controlled Congress and signed into law by a Democratic President, Bill Clinton, in 1997. The current state of affairs exists because Republicans and Democrats alike for more than a decade have failed to work together in a bipartisan fashion to enact a system to replace the SGR. We would have been dealing with the SGR even if health reform had never seen the light of day.

Finally, I sincerely doubt that those who now criticize our support of the health reform legislation because they philosophically disagree with its overall approach would be supporting it now if the SGR fix had been included in it. Let's at least be honest on this point.

Today's question: What do you think about the efforts by critics to link health reform and the SGR?


Jerry M said...

I am very concerned that passage of the Health Care Reform Bill aggravated the SGR problem. I brought this possibility up at Leadership Day. Some people in Congress feel the bill is spending too much and others feel the bill will place more control over the other third parties making the threat of physicians refusing Medicare patients less likely.

We have heard many times the items in the Bill that seem to favor our objectives to supply good health care to all but to practicing internists who pay for their own liability insurance, rent, personnel, billing service, repairs, equipment, supplies, accounting, bookkeeping, workman compensation, business insurance , CME and health insurance, SGR trumps these objectives. A 21% reduction in collection in a practice with 50% overhead will result in a 42% reduction in pay which will probably result in complete failure of the “objectives”. We must be careful about preaching altruism to practitioners who are in danger of completely losing their livelihood.

PCP said...

Bob, Your posts are increasingly taking the tone of a Democratic partisan ideologue. Perhaps those that surround you are of that inclination and hence you develop a sense of assurance that you are doing what is in the interest of America's Internists and Patients.
The sad truth is(and on this there will be near unanimity I hope) that we as a profession have lost a lot of ground in this last decade.
We are seeing more patients, feel more pressured, are providing more services and all for less revenue. We are not machines. We are professionals whose time is our commodity and which has a value built up by long years of planned investment of time effort and money.
The value of that commodity sir is being eroded by the continuous string of promises made by politicians egged on by organisations like the ACP. You may have your ideological reasons for supporting it. I too would like to see world poverty eradicated, however, one gets the distinct feeling that ACPs advocacy lacks strategy in assuring IM and Medicine remains a viable career choice for someone willing to put forth 250K of investment and 7-11 yrs of postgraduate effort.
So to me what you see as "bipartisanship" looks more like the ultimate in "political brinksmanship".
All this does is puts off the politically unpleasant act of a medicare cut to us until after the mid-term elections.
So am I correct in inferring based on your blog that to the ACP a "universal" "affordable" coverage is the goal EVEN IF it makes the goal of a SGR fix more elusive?
That sir is the reality that the ACP and Organised medicine has put us in now.
Furthermore, lets face it the funding to train more PCPs is a pittance, and "the Pilot testing of Advanced medical homes and other methods of care delivery" is but a pilot and any benefits are mitigated in the view of many by the ACPs acceptance and even tacit encouragement of including ANP led Medical homes in this model of care. Ahh but perhaps this is ideological too.
Your perhaps unintentional slip about "tens of millions of people that die each year" is perhaps an unintentional exaggeration and reflective of the ACP being imbibed by ts social mission rather than its duty to represent the professional interests of its members.
When you say ACP supports health care reform because it reduces the pay disparity between Medicare and Medicaid, I don't suppose you realise that what we will likley be getting is the current medicaid rates for all.

So now having got little for the profession from health reform, and worse yet arguably made getting anything less likely at all, now you tell us that ACPs position was qualified?

Frankly, I do not care who passed SGR and who signed it. My question is simple, why was it isolated to Medicare B. I'll tell you why, because we were, are and as long as we stay our current course will be the most politically expendable of all health care providers. The reason is that unlike the rest of them, we think more selflessly and our political lobbyists reflect that. That I am afraid gets us nowhere in DC today but on the menu. We are about to witness that in months and years to come.

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

Dont be too sensitive to it, Bob. It is the battle de jour, and it would not have been possible without the first steps in health reform. While you defend your efforts though, I would argue that we should not expect "innovative payment and delivery models like the Patient-Centered Medical Home" or funds for "comparative effectiveness" research to be of much benefit. Cost differentials pervade and need our urgent attention.

As I think about the maligned SGR, I would say that maybe we are wrong to not appreciate it. It is the basis of all private contracting these days. It creates a level playing field in much of what comprises outpatient medicine. It's failure is not that it did not stabilize costs (I would say our sector's relative growth compares well with pharmaceuticals, hospitals, and radiology [the latter included within but should be changed]). It is that it is not inclusive of Part A and Part D.

Thank you for continuing to defend the "Docfix," a useful rhetorical device that is accurate and essential. If health-care is $2.4 trillion per annum these days and much of health care is perversely overpriced, it is time extract the savings needed to move forward. Immediate reductions in drug prices with the extension of indefinite exclusivity would free up enough for the Docfix over a few years. Imaging arena will need its careful infrastructure management. The greatest savings would come from streamlining the private insurance industry complex. Free them from paying PBM's (the fee schedule will let local pharmacies have the margin to just do their job) and order them to stop practicing medicine (wellness suggestions, testing reminders, drug switch suggestions). Oh, and don't forget to force them to divest from shareholder status. Reform is just beginning, or we are in trouble.

I think it is clear where the research is on the enterprise of health care. Insurance helps access. Access helps patients. New technologies drive cost. Rein in the extreme and leave us alone. Let the independent cottage industry support local pharmacies, good pharmaceutical companies, a state of the art hospital infrastructure, and a little stability in an economy addicted to risk and growth.

Arvind said...

Bob, this post of yours exposes the weakness of your thinking or the inability of your right and left brain to function in unison. Of course, I would not expect you to understand this, knowing that you are not a physician (but alas you are in a position to "advocate" for a physician organization. However, I will try to explain the fallacies of your (and the ACP's) presumptions below...

1) "tens of millions of Americans that studies show die each year because they lack health insurance" - this is the biggest mistake. If the ACP really wants to learn how well patients without insurance (as we know it now) do, all you have to do is visit our practice (like Dr. Barr did) and interview all our uninsured patients that continue to get their highest quality care at reasonable cost and without delay.

2) "We supported health reform because it begins to reduce the disparity in Medicare and Medicaid payments for primary care" - this is great, except for the fact that you left about 33 % of your membership (sub-specialty dues-paying members) hanging by actively jeopardizing their practices' well-being.

3) "SGR is important, but it doesn’t trump every other policy designed to make affordable health care available and affordable to tens of millions of Americans" - this ultimately shows the lack of understanding of the business side of medicine. Did it ever occur to you (or the ACP) that when payments fall below the cost of providing a service, either the service is not provided or the quality of that service will be really poor? So what good is "affordable insurance" when it cannot get the card carrier any service?

4) "I sincerely doubt that those who now criticize our support of the health reform legislation because they philosophically disagree with its overall approach would be supporting it now if the SGR fix had been included in it" - you are probably correct, but the fact remains that you (and the AMA) did not even try to get a permanent SGR repeal included in the Bill, which is now law. It is evident that the country simply cannot afford the obligations that Medicare and Medicaid have promised. And, an arbitrarily price-fixed payment structure is simply unworkable. The only solution in this scenario would be a transparent, open-market solution, where consumers get to decide where they get their care from, and what service they find value from; and pay for such services, with a guarantee from the Feds/third party payers of reimbursement of a % of their cost and a tax adjustment for the remainder of their health-care cost.

So if I were in your position, I would be looking for a face-saving strategy right now, since you and all the other major physician organizations have pretty much lost the confidence of their memberships.

It does not matter how many times you say it - a mistake is a mistake. This one just happens to be of mammoth proportions, one that will definitely kill the profession of Medicine and the physician-patient relationship. Perhaps, you can be proud of this achievement.

Unknown said...


I am amazed at the continued efforts to somehow distinguish the "SGR mess" from the PPACA, and ACP's and others (the AMA) stance that these are two separate, distinct, and non-related issues.

No matter how those in the ACP and AMA want to "spin" the facts, the bottom line issue is if you want to extend free healthcare to 32 million people, SOMEONE has to PAY for it. And we don't have the money now, and we sure are not going to have it later. Whether you include the money that congress doesn't have to pay doctors, it has to come from somewhere, doesn't it?

Everyone knows that the ONLY reason the SGR fix was not included in "ObamaCare" is because for those in DC to have to actually face the hard facts of accounting, i.e., "how do you pay for it?" - meant that the CBO would score the pricetag for Health Reform at well over a trillion, which was the politically-predetermined "magic benchmark" - to allow Obama, Reid, Pelosi, et. al. to lie to the American public and claim this massive giveaway was "paid for."

Yes, I am one of those radical taxpayers who thinks our government should not be spending trillions of dollars on things we cannot pay for. Imagine that.

ACP asserts they supported the Obama plan because they wanted more to have health insurance. (They say now that the support was "qualified" - but I didn't see any white-coated doctors taking "qualified" photo ops with the Prez in whe rose garden).

I want more people to have healthcare insurance too, but at what cost? At what point is too much bureaucracy, too much government control, and too much cost on our grandchildren's children, finally enough??

How can you have "health insurance reform" and ignore how you are going to pay doctors? Isn't that a semi-important part of the program? Does't ACP have a responsibility to make sure that programs it endorses are fiscally positive for the country?

BDoherty said...

There was an inadvertent error in Friday's post--I meant to say the tens of thousands (45,000 according to one recent study) who die each year because they lack health insurance, not tens of millions (although it stands to reason that over the decades that the U.S. has failed to provide affordable health insurance coverage, the numbers rise to millions). See the following sources:

So yes, getting rid of the SGR is imperative, but so was providing coverage to the tens of millions of Americans without it, and the tens of thousands who studies show die each year as a result. They should not be viewed as goals that are in conflict with each other.

Unknown said...

"Never read medical books . . . you could die of a misprint!"

-Mark Twain

PCP said...

In response to Bobs post and statement.

"They should not be viewed as goals that are in conflict with each other."

You and the ACP may choose any idealistic position of your choosing. The reality remains and it is a stubborn one. The net result of this catastrophic decision for the viability of medical practices, by organised medicine will be borne by us over the next decade.

For those of you interested in this issue. There was a story on NPR about this today. It lays out the issue quite clearly and explains why tactically ACP/AMA were so wrong.

Sooner or later this blunder will be laid bare. Trusting politicians to do the right thing is not a strategy to accomplish anything.