Tuesday, June 1, 2010

Who should doctors be angry at?

Instead of blogging (again) about Congress's failure to stop the 21% Medicare SGR cut, which went into effect today, I could just re-run my April 16 post. I wrote then:

"It is the failure of both political parties, over many years, to honestly deal with the SGR, including the cost of getting rid of it, which has resulted in the current ongoing SGR farce. And yet members of Congress wonder why the public holds them in such low regard."

Blogging in DB's Medicare Rants, Dr. Bob Centor captures the outrage felt by most physicians:

"I am mad. Every physician I know is mad. Patients should join us in expressing anger. Physicians cannot trust Congress if they cannot repair this absurdity."

(Bob references ACP's statement, released on Friday; click here to read it in its entirety.)

That Congress allowed politics again to get in the way of doing what is best for patients makes my blood boil. Voters can and should hold them accountable.

But I also have to tell you, anger directed at ACP by some members also makes my blood boil. Typical is one who emailed that "ACP has been suckered just like everyone else" for "trusting" Congress to fix the SGR in exchange for supporting health care reform.

The effort to link the SGR to ACP's position on health care reform makes my blood boil, because the SGR has been around since 1997. It has nothing to do with health reform. The fact is that Republicans and Democrats alike have been unwilling over the past decade to come up with the political will (and money) to repeal the SGR, and we now are facing the accumulated consequences of their failure. (To be fair, a majority of the House of Representative passed legislation late last year to repeal the SGR, but it never advanced in the Senate.)

Here again, Bob Centor has it right when he explains that he supported health care reform because "addressing the problem of the uninsured was so important that it trumped the weaknesses in the bill."

Bob continues: "This was the chance to start down the road to universal coverage. I see SGR as a totally separate issue. The lack of the SGR fix represents profound weakness of our political process. This issue tells us that both parties are more interested in posturing than solving problems."

It makes my blood boil when uninformed people cynically allege that ACP supported health care reform in exchange for SGR repeal. The thing is, there never was any such deal, nor should there have been. ACP favored health reform because every American should have access to affordable health insurance coverage, and because the legislation advances most of the organization's policies on coverage, workforce, and delivery system reform.

Yes, repeal of the SGR is and was a top priority, with or without health reform.

And yes, it is maddening that we can't get a majority of the House and 60 U.S. Senators to vote to fix the SGR, once and for all.

Members of Congress, Democratic and Republican alike, need to hear from doctors and patients that you are mad, and why.

Anger may help light a fire under Congress' feet, but it probably won't be enough to ensure 60 votes in the U.S. Senate for getting rid of the SGR.

Instead, it is going to fall to doctor's professional organizations, like ACP, to do the hard work of finding an approach that will actually pass. Sure, be angry - but direct your anger at those responsible for the SGR debacle, not at those of us who are trying to fix it.

Today's question: Are you angry about the SGR? If so, what are you saying to your members of Congress?


W. Bond said...

Or, perhaps, physician groups could lobby Congress to stop wage and price controls, rather than to argue how much a 99213 office visit is worth. Start small, with PCP’s only in one medium-sized state. Measure patient access and convenience measures, government expenditures, and patient satisfaction.

On technology driving costs:

How much is an MRI worth? Do we perform more than we can “afford?”

What would cell phones look like, and at what cost, if there were a government mandate for equal access to quality and affordable cellular communications complete with subsidies and price setting? Would we own more cell phones than we can “afford?”

(Hint: despite the best intentions to the contrary, only one economic system has ever created exponential growth in wealth and productivity).


Jay Larson MD said...

Anger is such a waste of energy. Anger also compromises effective communication.

Congress just simply needs to know that if the SGR cut is not stopped that there would be a mass exodus of participating physicians from Medicare. Physicians would opt out of Medicare completely. Medicare patients would not have access to medical care, unless they want to pay for it out of pocket. This would then lead to upset senior citizens (a large voting block) wanting to oust the incumbents.

Congress is playing with fire and will get burned if the SGR is not fixed.

PCP said...

Where was Organised medicine in 1997 when SGR was passed? Why was it passed on Medicare B but not on any other parts of the healthcare system eg Medicare A?
Why then much later when Medicare D was formed was it not subject to such an unworkable formula?
I have a problem when those in organised medicine fail to see that they need to represent their membership, as their first responsibility.
When they do not do that, then their membership falls, and their clout weakens and they become less effective. This is the story of the AMA.
If organised medicine did not include the SGR fix as its top priority in the single largest rewrite of the health care system in a half a century, and instead become amongst its biggest cheerleaders on ideological grounds, then they cannot claim to have done everything they could to get the SGR fixed.

Here are the facts. The Gov't has promised more to people and they cannot afford what they have currently promised given current (already low) payment rates.
Now in order to try to make this unworkable scenario work, the Gov't will do all it can do, and that is to let one of these cuts stick, and/or dilute the value of currency and let inflation do its work, keeping our payments flat.

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

I am astonished at the new calculation for the beginning of 2012. 33% is just incredible. There is no comparable approach whatsoever for cost controls on any other front. The mandates of quality reporting, medical homes, HEDIS collection, and meaningful EHR use, all involve greater overhead. It is absolutely foolish to believe that independent outpatient practices can accept this perpetual under-funding at this juncture.

The nerve of using Pay As You Go to justify the passing the buck again, after all the effort to extend insurance coverage in the Health Care Reform Law, is also astonishing. Are we that wedded to the absurd pricing that permeates health care? It is a slap in the face to the Medicare recipients of this nation. The continued failure to rein in drug prices and new technology costs has lead to the usual assumption that doctors are to blame.

I am angry that I must confront my patients with these realities and have no hope of seeing the type of practices that has defined the best of medical care for the last half century survive within the mainstream.

Shame on Congress for failing to have the vision to understand health care realities sufficiently, embracing consolidation and standardization without realizing their downsides, and thereby threatening to destroy a heretofore successful Medicare program.

Steve Lucas said...

Again from the outside a couple of points concerning the comments:

Doctors have threatened for years to leave various programs and have stayed. The result is this has become an idle threat.

We also have to consider, given our current political climate, the possibility that the government would mandate participation based on national need. Doctors need to remember that many in political circles view them as “owing” them their careers due to government sponsorship of teaching slots.

Secondly: The AMA is not really a doctor organization. Representing less than 17% of practicing physicians their real force is economic and political.

Along with profiting from various programs and sponsorships, they control the very codes and payment schedules currently under debate. There is a good review of this on Health Care Renewal, and if you have access to the archives, fee required, The Wall Street Journal.

My sad truth is that many in medicine have engaged in questionable business activities at the expense of the front line doctor who continues to soldier on, with ever increasing pressures and requirements, trying to deliver a reasonable service while facing an ever increasing decline in income.

Steve Lucas

Jay Larson MD said...

Physicians opting out of Medicare due to a 21% cut in Medicare reimbursement may seem like an idle threat to some. Crying wolf too often does result in less vigilance. At some point, though, the wolf really does come for a visit. Cognitive based medicine has a low to nil profit margin when taking care of Medicare patients. A 21% cut would mean these physicians would have to lose money to care for Medicare patients. This can be sustained only for so long before the practice goes belly up financially.

Steve Lucas said...


I do not disagree.

Steve Lucas

Phil 314 said...

We spend 50% more per capita than the next highest nation (Switzerland) and for that our outcomes are no better (certainly not THE BEST) and we still can't cover 1 in 7 Americans. So it seems that more money can't solve this problem. So we'll need to shift resources. So.....

31% of all health care expenditures go to hospitals. However, much of that spending is driven by the physicians pen (or keystroke)
25% of all expenditures go directly to physicians.

So physicians control or "strongly" influence over half of every dollar spent on health care. What would physicians recommend to "fix" this situation? (More money is not one of the options.)

And on a related note, we've known for some time that Medicare would go bankrupt in about 2017. What cuts do physicians recommend?

Unknown said...

I am no longer "angry." I think "disgusted" is a more accurate description of how I view the president's so-called healthcare "reform," and the responses of organized medicine to same.

I am also "amazed" that ACP, whom I wrongly expected was intelligent enough to lobby for SGR cuts in exchange for support of obamacare, felt that this monstrosity (PPACA) was so good for America that it endorsed it wholesale, without any political "give and take." NOW, since we didn't stand up for what we needed/wanted during that debate, we have to come back to these same weasel-ly politicians to beg them to "fix" our pay?? yeah, right - good luck with that. Maybe we can blame all the mean republicans.

I guess "enlightened" would be another word that describes my mental state. I am "enlightened" that it appears many (daresay "most"??) within ACP have ONLY the goal of a single-payer system, and thus seem to have no problem with the backroom, backhanded, slick-dealing, funnymath of omitting the $250 BILLION SGR fix from a comprehensive healthcare overhaul?

Come to think of it, perhaps just "disappointed" is a better description . . .

BDoherty said...

Joseph has it wrong. 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, to cover preventive services with no cost-sharing, and because it advances many other policies long supported by the organization. Policies that will help keep alive the tens of millions of Americans that studies show die each year because they lack health insurance. We supported it because without it, 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 it because now 95% of all Americans will have access to affordable coverage. We supported it because it begins to reduce the disparity in Medicare and Medicaid payments for primary care. We supported it because it will allow for pilot-testing and expansion of innovative programs to reduce the rate of increase in health spending.

The fact is that ACP did succeed in influencing the legislation on a whole host of issues important to members, and we had a particular role in developing the provisions in the legislation to address the primary care workforce crisis and payment reforms to support patient-centered primary care. The law's overall approach to expanding coverage--tax credits, purchasing pools, and Medicaid expansion for the poor--all are remarkably consistent with ACP's own plan, released in 2002, to provide affordable coverage to all. I will put our record against anyone's of successfully influencing the legislation to include policies long advocated by internists.

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 Joseph decries, for us to say that the only policy that mattered in the health reform debate was repealing the SGR, and that this issue alone trumped all of the other policies 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.

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. And it is also a fact that the House of Representatives voted in November to repeal the SGR, once and for all, and replace it with a better payment system--with President Obama's support. The problem, as always, is with the Senate.

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.

Unknown said...


Maybe we should now be angry at Nancy Pelosi, since she is primarily responsible for holding up the SGR fix?

I guess she can't recall that we were her best friend just a couple of months ago?

Unknown said...

Colleagues (& Bob!),

No matter how you "spin" it, the SGR "fix" cannot be teased out from the Healthcare overhaul. It was unbelievably disengenuous for anyone to assume or suggest otherwise. Yet, our ACP (and others) continues to tell us that the two are somehow separate and distinct issues, as if PAYING for healthcare somehow has nothing to do with "healthcare reform."

And yes, Mr. Doherty (who I actually like and respect a great deal!) is correct about one thing, I probably would NOT have supported spending more than a trillion dollars of our tax money for a plan that even included the SGR fix, but if we are going to be stuck with this monstrosity of a healthcare bill, let's at least know that we can get paid.

But we know why SGR was NOT included in the obamaplan. Because it would have gone over the politically magic number of a $TRILLION bucks, at least the way it's scored in the fictional goofy world of the CBO, so it got "carved out." Purely a political move, nothing else, so that the president and his pals could "sell it" better, 'cept pretty much nobody was buyin.

But we (ACP, AMA, others) did not even seem to TRY to get what we needed in the healthcare plan??? (i.e., to get paid!) All we heard from the AMA was "if you're not AT the table, you're "ON" the table? Well I got news for you doctors, YOU were ON the table from the gitgo.

Did ACP and others simply support this Obamacare because we thought it was so fantastic for our country? all 2,300 pages of bureaucratese that no one (including the people who voted for it) have even read?? Do we not have some sense of fiscal responsibility for how this affects our economy, and our resources, and our grandchildren?? Does it really take 2,300 pages to simply say "buy insurance across state lines, no pre-existing conditions, and increase medicaid eligibility?" Geez, I just wrote a whole healthcare bill in 13 words.

We are like that kid on the commercial who falls for the "free pony" scam, but only gets a toy pony instead of the real one. Sorry kid, you didn't say you wanted a REAL pony, did you?

Well, I guess we have learned a REAL lesson. Nancy Pelosi just told us, "OHH, you SHOULD HAVE SAID YOU WANTED REAL $$ for your Medicare services!! Ha Ha! Silly Doctors!!

Tricks are for Kids!!!

Joseph W. Blackston, MD, JD, FACP