Friday, July 8, 2011

"Don't cut him. Don't cut me. Cut that man behind the tree!"

The late Senator Russell Long described Americans' aversion to taxes as being a case of “Don’t tax him. Don’t tax me. Tax that man behind the tree!”

The same can be said about federal spending. Most people say they are in favor of reducing government spending and the deficit, but they want someone else—the proverbial man behind the tree—to take the hit, and pay the taxes. Not out of their own government check, or their own taxes, mind you.

Just look at the frenzied reaction from liberal Democrats to the news that President Obama is seeking a much bigger debt ceiling deal that would include previously sacrosanct cuts in Medicare, Medicaid, Social Security – and continued insistence by conservative Republicans that any increase in tax revenue is off the table. (It isn’t just the politicians: a new poll finds that most Americans are opposed to cuts in Medicare, Medicaid, and Social Security.)

Meanwhile, interest groups are going into high gear to ward off potential cuts. AARP has issued a statement and launched a massive grass roots lobbying campaign against Social Security and Medicare benefit cuts. The Association of American Medical Colleges (AAMC) has told President Obama that it is “gravely concerned” about proposed cuts in Graduate Medical Education (GME). The American Hospital Association and Federation of American Hospitals are spending millions on an advertising campaign against “further funding cuts in Medicare and Medicaid.”

And so it goes.

Yesterday, the American College of Physicians took a decidedly different tack in a press release and letter to President Obama and Congressional negotiators.

First, ACP urged Congress and the Administration to reach agreement on an increase in the debt ceiling before care of Medicare and Medicaid patients is disrupted. If a deal isn’t reached on the debt ceiling before August 2, Medicare won’t have enough cash on hand to pay physicians for taking care of Medicare and Medicaid patients.

Second, a credible and fiscally responsible agreement should eliminate the Medicare Sustainable Growth Rate (SGR), instead of counting savings from cuts that Congress has no intention of allowing to go into effect.

Third, spending growth on Medicare and Medicaid should be reduced as part of a broad agreement, but not by cutting funding for essential programs to improve access, quality and ensure a sufficient supply of physicians, especially primary care physicians.

And fourth, Congress and the Administration should partner with physicians to support bold initiatives to address the real cost drivers behind increased federal spending.

Yes, ACP’s letter, like those from many other interest groups, expressed opposition to cuts in “essential” programs “that are designed to improve access, quality, and ensure a sufficient physician workforce”—such as GME funding for primary care training programs.

The difference is that instead of drawing a line in the sand against any and all Medicare and Medicaid spending cuts, ACP proposed nine strategies to reduce per capita health care spending, which would also lower Medicare and Medicaid spending.

Provide physicians and patients with evidence on comparative effectiveness. Support efforts by the medical profession to encourage judicious and appropriate use of health care resources. Consider requiring people to pay more for less effective care. Take clinical effectiveness and cost into consideration in deciding what Medicare and Medicaid will cover. Reform payment and delivery systems to align incentives with the value of care. Establish a better process to identify mis-valued services. Reduce defensive medicine costs by enacting no-fault health courts and caps on non-economic damages. Allow the federal government to negotiate Medicare Part D drug prices. Encourage innovation at both the federal and state levels in delivery services to Medicaid patients while preserving the existing guarantee of coverage for all lower-income persons.

The fact is that it is impossible to reduce the federal budget deficit and debt without reducing Medicare and Medicaid spending—it is only a question of how. Isn’t it better for physicians to offer their own ideas to reduce health care spending, as ACP has done, instead of declaring that cuts are off-the-table and that the “other guy behind the tree” should take the hit?

Today’s questions: What do you think of the effort by some politicians and interest groups to say that Medicare and Medicaid spending reductions or increased revenues are off the table? What about ACP’s efforts to urge agreement on a debt deal that would protect key programs while offering ways to reduce per capita health spending?


PCP said...

Physician reimbursements account for about 14c out of every health care dollar. Their pens on the other hand drive much of the other 86c.
It strikes me as extremely foolish to look to the 14c for the cost savings. The difficulty with the current situation is as Medicare had evolved onto a corporate welfare system, where k street is engaged to protect and expand that 86c.
Physicians have become so marginalized in this discussion that there is increased talk/effort aimed at removing our autonomy as a profession. It is insiduous and it is slow, but it is inexorable and pernicious.
General internists are already on the doormat and the business model is clearly broken so badly that their only alternative is employment.
In all this the most shocking aspect is how complicit their professional representatives have been in the crucification of a once venerable profession.

Owen Linder said...

So well put PCP.
another arbor analogy: hard to see the forest for the trees. Doherty knows whereof he speaks. But I think he is strapped by multiple allegiances. Not me.
To wit:
Medicare has developed the allocation budget for each set of chronic illnesses.
The allocation ranges from $200 to $5000 per medicare recipient per month.
All the words which are in aforestated column actually describe how else the money could be divided among care sources.
In Managed care with full risk 70% of the total allocation is available to be spent on health care or saved for the internist.
If the internist knows how to practice cost effective medicine he can save half of what less well equipped providers spend and waste.
This is known as a low medical loss ratio.
Since allocation is severity adjusted more money is allocated for the internist who can keep a sick person alive and happy, using as much or little of the allocated pooled dollars as necessary. No need to skimp on needed care.

The newer models which come after Medicare Advantage are trying to build an "even better" system. Such ideas as accountable care organizations are in my opinion just ways for the care sources which think they have been short shrifted by the insurance industry running Medicare Advantage to regain control. Control of the money and run right over the physicians.

The whole pot is at stake. It is imperative physicians step in and take control. It can be done. It has happened in Medicare Advantage in my area. It can happen anywhere.
Just stop listening to hospital administrators, executives of BCBS, Aetna, Cigna, and United. Pious hypocrites and business people all. They play for themselves. They don't share the allocation with the physician.

Lose the fee for service mindset.
Learn and play for the whole ball of wax.