Friday, February 17, 2012

“We are playing a silly little game with doctors and Medicare patients.”

This is the best description I’ve heard of the short-term Medicare SGR “patch” that passed the House and Senate today. It didn’t come from a press release from organized medicine, but from someone directly involved in the process, House Minority Whip Steny Hoyer (D-MD). Here is the full quote from his speech today on the floor of the House, minutes before it voted to extend Medicare payments to doctors for another 10 months:

“We are playing a silly little game with the doctors and with Medicare patients, and this silly little game pretends we are going to extend SGR for 10 months. That's baloney and everybody knows it. We are going to extend SGR over and over and over again. We should have done it permanently in this bill. We should have done it permanently last year in the Congress which I was the Majority Leader. We should have done that. So with respect to SGR, ladies and gentlemen, we are playing a game, and the doctors all over this country and the Medicare recipients all over this country know we're playing a game. We're giving them no certainty, no confidence that come this September, October, November, we won't have another one of these silly little debates.”

Now, a cynic would point out that Congressman Hoyer is a Democrat in a Republican-controlled House, so it is easy for him to take pot shots now. But at least he was honest in saying that getting rid of the SGR should have been done permanently last year when his party controlled the House and when he was the Majority Leader.

So maybe we should all stop referring to the Sustainable Growth Rate as the SGR, and start calling it the SLG—Silly Little Game—that has been played by Washington politicians from both political parties on doctors and patients for a decade now. But it won’t seem so silly, or much like a game, when patients no longer can find a doctor.

Today’s question: Are you going to tell your members of Congress to stop playing this silly little game with you and your patients?


PCP said...

The game bob is sadly being played n you and those of you who belive in this blabber.
While Mr.Hoyer told you this is a SLG, what he did not tell you or me or his constituents is that this is a game that both sides of the aisle like playing very much.
They actually enjoy the power that comes with being in control of the medical profession and you more than most should know all the nonsense they have stuffed down our throats whih this veiled threat in the background, they love the gratitude that comes from their constituents and doctors when at the last moment, like white onights in shining armour they heroically pass a patch to rescue granny.

You see they have managed to reduce the medical profession from a tower of strength and trusted independence to virtual beggars. They are not oblivious to the very real role we play daily in our patients lives, and they really want to seem like they are the reason that is happeneing. Just consider the nascency of 'usual and customary' and the transition to what passes for payment policy now.

Furthermore, solely by creating such a scenario do they have the opportuity to gain campaign contributions at the time of need.
So go ahead and believe this is a SLG. It is really so much more and so very intentional.
I have often said that sadly, only with the eventual collapse of medicare will the integrity of the medical profession and the sanctity of the physician-doctor relationship be restored. Even if that meant my income was cut in half overnit, i feel that would be in the nations, my amd my patients long term interests. That last prospect, I guarantee you is a scary thought to most politicians and demonstrating that is the SLG that our professionalism
keeps us from playing. Sadly our leadership did not even feel that making our support of Obamacare contingent upon this was reasonable.

Harrison said...

I would honestly be interested in your speculation of where the SGR debate may fit in with ACO's and coupling physician payment schemes with plans to reduce utilization and improve quality at the same time -- perhaps with capitation and/or pay for performance schemes.
I know that with the pioneer ACO's there are components built in that allow for improved physician payments for small reductions in hospital stays for certain diagnostic groups, or reductions in ER visits.

Is this talk, that is obviously happening at the level of the CMS, making it to Congress?
Are we wasting our breath by constantly talking about the SGR, when we really should be focusing on how to shape ACO's and future physician payment schemes?


ryanjo said...

Some recommendations for our leaders at AMA & ACP, if they really want to stop this nonsense:
-- work hard to defeat a few legislators who actively obstruct the repeal of SGR so that they can manipulate us, as PCP has pointed out. Even the defeat of a few vulnerable victims will send a message to our spineless politicians. I personally recommend for replacement Rep. Allyson Schwartz (D-Pa.). She thought it would be great to freeze all doctors payments, and then force us into a reduced pay formula over the next few years.
-- announce that you will spearhead a movement to help members opt out of all federal programs. The first step will be a pledge to stop taking new patients in all federal programs. The next step will be using all legislative & judicial measures to undo the restriction of federal programs not paying non-par doctors. Once the SGR reduction falls directly on senior voters, it will vanish.
-- announce that the feds have thoroughly screwed up the system of health care delivery in America, with their perverse incentives and insidious deals with insurers. Give examples from patients and doctors, such as was done in last year's effort against the SGR. Journalist love this this stuff. Who does the public trust, their docs or some HCFA mouthpiece?

C'mon Bob, don't you really want to play some hardball? This is the era of Super PACs, I bet you could raise some real money from American docs with some "in your face" lobbying. Don't worry too much about if any of these ideas actually work, since the effect from these moves will be psychological. Smoke and mirrors is the usual method of operation in an election year.

Jay Larson MD said...

This silly little game has had casualties. General internal medicine and cognitive subspecialists have been slipping away quietly into the dark. Every time SGR comes up, a more and more physicians finally break under the frustration and move on to retirement or become a hospitalist. On top of the SGR this year was the new 5010 form disaster. Across the country physicians went weeks without Medicare payments as their carriers work through the bugs. For the first time in 20 years, we had to get a temporary loan to pay our employees as we waited for Medicare to process claims. If it was not for the delightful Medicare patients that I care for, opting out of Medicare was be an easy decision.

BDoherty said...

Harrison, ACP agrees that influencing new payment and delivery models, from ACOs to medical homes, is critically important. Although the SGR may be the headline story, it is the work we are doing to make these models work for internists and your patients, so you are paid fairly fir the value of your care, is going to matter more than the SGR itself. But all if these models start with a foundation based on the current RBRVS and SGR, so we have to continue the fight to repeal the SGR so we can move to better models.

I am surprised by RyanJo's example of Rep. Schwartz as the kind of person that should be defeated. The congresswoman has been a leader on pushing for full SGR repeal, and has developed a legislative approach to repeal the SGR, provide at least six years of positive updates for all services and higher updates for primary care, followed by incentives to transition to new payment models. We worked with her on this approach and endorsed it. She is close to introducing it witha Republican co sponsor. So calling for defeat of the legislators who are doing the most to help us get rid of the SGR would be extraordinarily unwise

ACP will not tell our members or their patients how to vote. For one thing, we can't, it is illegal for charitable organizations like ACP to engage in political activities to elect or defeat candidates. (yes, we are a charity per the IRS). ACP Services PAC is a separate organization that doescontribute to candidates it concludes supports the interests of internal medicine. I don't think our members want us to tell them how to vote even if we legally could

We have provided members with information on how they can opt out of Medicare but this must be their own decision, not one we can or should promote. It is unethical for physicians to take organized and coordinated action that is intended to deny or limit access or inconvenience their patients to make a political point. Please read ACP's newly updated ethics manual for a fuller discussion.

It is never a sign of weakness to engage in the democratic process in an ethical way. Putting aside ethics and professionalism would be the worst possible choice,

ACP supports giving physicians the option to reach an agreement with patients to bill more the Medicare approved amount IF the patient has a true choice of doctor and knows in advance what he or she will be charged. But with most seniors being of very limited incomes, see my blog pst on the myth of the well heeled senior, the idea that asking them to make up the shortfall from the SGR cuts just doesnt make sense. Most couldn't afford it.

One other factual clarification: the SGR was signed into law in 1997 by Democrat Bill Clinton, but it was passed by a Republican House and Senate. So both parties bear responsibility for creating and the continuing failure to repeal it.

I understand the frustration you all have wih the SGR, believe me I also am frustrated, but ACP will not turn frustration into I'll advised, unethical and possibly illegal actions to organize a boycott of Medicare patients. Our strength comes from our commitment to ethical and constructive policies to achieve postitive change for patients and their physicians, and we must not lose sight of that.

Steve Lucas said...

The only positive sign is that members of both parties are calling for real solutions to our current fiscal situation. There is the understanding that some steps will be needed to be taken that will not be politically positive.

There is also a growing fatigue with the everything must be political attitude in Washington.

Steve Lucas

ryanjo said...

Sadly, I am not really surprised at Bob's comments above.
-- It is all well and good to have a plan, but if it consistently fails to succeed, a new plan is needed.
-- I am very aware of the type of "new payment models" that Rep. Schwartz has proposed. After freezing physician pay, followed by a small increase (a level that I would be ashamed to offer my staff), physicians are to be forced into a salary/incentive model, with decreasing payments for those who choose fee for service. What other sector of our economy is treated in this fashion? This is a lawmaker that ACP works with?
-- Thanks for the ethics lesson. I guess ethics is in the eye of the beholder. ACP feels it is better for patients if physicians are employees, and patients become "covered lives" in the ACOs of the future.

Arvind said...

I have to agree with ryanjo, Bob. You are not in a position to advise physicians on ethics, since you do not stand in our shoes.

Our patients are our greatest strength but they won't have anyone to go to if our "private" practices close. Rep. Schwartz does not understand this (expected) but neither does the ACP (unexpected & unacceptable).