For the past several months I awaken each morning hoping the CMS 2010 Physician Payment Rule issue is merely a nightmare, and I can get up and help the College once again focus on constructive engagement in health care reform. No such luck. It is a nightmare, but one that is part of our reality.

Friday at 4:30 PM -- 30 minutes before the issuance deadline, the CMS (Centers for Medicare and Medicaid Services or See-a-Mess) dropped a bomb.  In a call from Jon Blum, the top political insider in CMS, he said I have “good news and bad news.”

The BAD news: the Rule adopts the AMA-collected practice costs survey data, meaning cardiology gets an average practice cut of 27-40% in private practices. (Note that academic, hospital, and integrated system salaried cardiology is largely insulated from the cuts initially, but the effects could eventually reach everywhere through market forces).

The allegedly GOOD news: CMS will phase in the cuts over four years, meaning they will impose an average of 5-7% cuts in 2010. But, what he told us is not accurate in the language we see that nuclear codes (SPECT) will be cut as much as 36% in 2010. We are working to analyze the language in the final rule, but this isn’t good news, and the Secretary and the White House have signed off on it.

Bottom line: The Four-Year-Phase-In is far better than having the full impact hit in 2010, because it will allow us to survive to get valid data and reverse the cuts completely in 2010 if necessary. BUT WE NEED TO FIGHT THIS DECISION NOW, NOT WAIT UNTIL NEXT YEAR. We need to mount a strategy to prevent even the 5-7% average cut in January and in particular reverse the nuclear/stress cuts.

Next steps
After all the hard work and excellent advocacy we’ve witnessed from all of you these past months, I regret telling you we’re not through. But, please don’t allow discouragement to cause you or others to give up. We’re not done here.

*** Image from morgueFile (jdurham). ***

In yet another attempt to reach the president and administration officials about the proposed 2010 Medicare Physician Fee Schedule, the ACC tomorrow will run an ad in four different major newspapers -- Washington Post, New York Times, Chicago Tribune and USA Today -- decrying the cuts. We're just a couple of days away from the release of the final rule; we must pull out all the stops in preventing these cuts from being finalized.

President Bove, SVP for Advocacy Jim Fasules FACC, and I met with the top brass at CMS last week to try to ascertain what’s going to happen.  We met with CMS Acting Administrator Charlene Frizzera, Deputy Jonathan Blum and several CMS physician division chiefs for a long discussion on the implications of the Rule if it proceeds as proposed. 

The CMS principals had not considered the likelihood that this rule would devastate private practice of cardiology as it will (they have been considering those predictions merely exaggerations of the effects by us). In essence, they continue to see this is an 11 percent cut (bad enough!), not wanting to connect that to the cuts in support staff, support services (echo and stress testing, etc.) that create the actual 27 percent average reduction in practice revenues. CMS leaders did cringe at the contemplation of a 27 percent cut, and I believe they are now going to have to look squarely at the implications of it for the Obama administration; this will cause a number of problems on their watch that they have not anticipated, including:

• About two-thirds of CV patient care access will be threatened as practices close — the worst effects will be in rural states, suburbs and away from large academic centers and integrated systems. Seniors will scream bloody murder.
• The same hospital-based cardiology clinic and diagnostic services cost two to four times more than equivalent payments to private practices in the outpatient setting — this will drastically increase Medicare costs at a time when “bending the cost curve” is the big goal. We must not forget that CV care is 43 percent of Medicare, and this will have an impact they have not anticipated. It’s dumb.
• The shift of cardiologists to hospital employment and other employment venues will have significant repercussions for chronic disease management. Such has occurred in parallel when a large number of general internists were forced for financial reasons to close their practices and become hospitalists.
• Medicare beneficiaries will suffer a Part B premium increase as the costs of lab services, etc., rise. It’s a veritable tax on seniors as well.

CMS wants to continue to message that the survey reflects the current environment of practice expenses fairly (perhaps with a few inevitable glitches), and that their processing of the AMA survey data was not done with any political purpose or manipulation. I believe they are sincere in this. But, one could tell they were disturbed as they confronted a 27 percent cut as reflecting accurately the actual practice costs of cardiology over the past year -- and then they weren’t thinking about implications. It just doesn’t make sense. 

Next Steps
So, what now? The secretary still has not opined on the staff submission of the Final Rule, nor apparently has OMB (Office of Management and Budget) in the White House. I would think the attendees at this meeting will probably be making a few phone calls to ask what should be done -- if anything. They were pretty frank in asking us a recurring question: “What can we tell the Secretary or the President that would explain why we shouldn’t follow our regulations and put the rule out as prescribed?” We gave them plenty of things they could say, like, “You did not validate the data;” “AMA did not validate the data;” “The data for CV practices is not valid;” “The implications on the adverse effects to private practice of cardiology will be horrific;” and “I don’t want to be here when this happens.” Neither do we. 

It is possible that some heroic measure will be attempted. But we need to start developing our legislative, legal and other contingencies because this was not an encouraging meeting. But, we’re doing a lot more than meeting again with CMS:

First -- On the Congressional front, the ACC is keeping up the pressure on Capitol Hill. More than one-third of Congress has registered concerns about the proposed rule with either by letters or calls to CMS and Health and Human Services Secretary Kathleen Sebelius. We continue to hear from members of Congress that your individual calls, letters and visits are making a difference. In several cases, the personal stories about the impacts of the cuts on patients and practices have made such a difference that members are prepared to support emergency legislation should it be necessary. 

Second -- I have met directly with Obama administration officials to highlight the gravity of the cuts, particularly at a time when the administration is looking to increase access to care as part of its health care reform agenda.

Third -- While I can fully assure you that we are at the table and working to stop the cuts, we are also working to mitigate the impacts of smaller cuts on your patients and practices, including those related to new nuclear codes slated for Jan. 1. In an effort to help your practice plan for these changes, the ACC has developed a practice expense calculator that you can use to gauge the impacts on your practice. (This is also a useful tool when talking to members of Congress about the specific affects of the proposed rule.)

Further -- See the ad mentioned above. 

Finally -- ACC President Fred Bove, FACC, and I will be hosting an all-member call on Nov. 12 from 4 p.m. to 5:30 p.m. (EST) to discuss the 2010 rule. RSVP for the call now. I strongly encourage you to attend this call, where we will provide an overview of the final rule, as well as answer your questions about next steps.

If this rule goes through as is, it will literally devastate the private practice of cardiology and outpatient access to cardiovascular care. We can’t let this happen.

Earlier this week, I pointed out an editorial in the WSJ about the "War on Specialists." The article makes some great points about what's going on currently in the health care world, but I think it's important to remember that the ACC is supportive of President Obama's efforts. So for today's Friday Poll, I ask The Lewin Report readers: Is President Obama waging a war on specialists?

 

The President, despite all the vilification and misinformation surrounding his views on health reform, seems the voice of reason and moderation to me of late. Take a look at his “plan,” which I included below. There’s not much in there we couldn’t get behind, particularly as compared to all the controversies in the major bills. He goes mainly after insurers. He has made it clear he’s not 100% dependent on a public option; he’s open to discussion about the MedPAC idea. The main concern I have about his commitment to ‘no contribution to the deficit’ in funding reform is that Congress has to propose how to do that -- and they could go after us. But Nancy Ann DeParle, his Health Czar, seems very clearly unwilling to go after doctors further to finance reform.

AMA, ACP, AAFP, and AAP (pediatrics) have all been gravitating toward aligning with Obama, who has by far the most moderate and flexible approach here of the options before us. They’re not dummies in this. They plan to be at the table when the really tough decisions are being made in the next 2-3 months. I’m thinking we should be there too. We could offer more real insights on payment and delivery system reform than any of the aforementioned. We may also need some big time help from the Administration on the final deliberations on the Rule this year. After the HHS Secretary weighs in, the final decision on that must also go through the OMB (Office of Management and Budget—Mr. Orzsag). It wouldn’t be bad to have some friends in high places, folks.

Look at the President’s agenda carefully -- the Dems are in power and are going to get something through. Would we not want to find a way -- but of course without robotically agreeing to anything they want -- to align with this moderate approach for now, rather than with all the disturbing details in the other bills?  We need to be at the table when the really scary stuff starts to happen. We better think this through carefully. Obama’s got the most middle of the road strategy here so far…

Also, I'm including below a revised statement on the President's Rose Garden Address...

Public Statement from Jack Lewin, CEO, American College of Cardiology

"I am most inspired by the vision of President Obama with respect to health system reform, and his principles for effecting needed changes to America’s health care system.

I believe the principles he has provided to this conversation are in full alignment with the principles developed by the College during the past year.  I firmly believe the President has taken a pragmatic approach that will bring persons on both sides of the aisle together to get reform passed this year.  His concern and desire to address the flawed SGR payment formula and to work with Secretary Sebelius to reduce defensive medicine through achievable tort reforms is also most welcome to all physicians.  It is essential that the nation move forward in 2009 with a meaningful and historic health reform proposal.

We look forward to working with the President, Secretary Sebelius, and the Administration to help move legislation through Congress this year and then to work on the process of implementation over the coming years."

The Obama Plan_Full (2).pdf (86.72 kb)

*** Image from Flirckr (Swatzo). ***

I'm just back from President's Obama Rose Garden address on health care reform. He discussed a lot of the items in the plan he's proposed, along with the other Democratic plans, including coverage for prevention, malpractice, insurance reforms, etc. He also made reference to the important role that health care practitioners can play in reform (President Obama said: "...these doctors know what needs to be fixed about our health care system.") Here's my media statement response to the event:

“I would like thank President Obama for personally recognizing the work of the ACC to help reform our health care system. I cannot agree more with President Obama’s call for doctors, nurses and other health care professionals to drive the reform effort and the need for those drafting the legislation to listen to the people who best know the health care system.

“To truly change our health care system we must change the focus of our health care system. We must focus on delivering quality health care at great value. By focusing on patients and reforming the physician payment system to reward positive outcomes rather than the number of procedures and tests, we can increase the efficiency of treating patients and cut down on wasteful spending. The College believes President Obama can lead our nation in getting these real reforms.”

Good work, President Obama -- but it's yet to be seen how health care reform will play out.

President Obama on Wednesday addressed Congress with a plan for health care reform that would cost $900 billion over 10 years and address rising costs, access to care issues and professional liability. Obama’s plan would:

• Provide several consumer protections against insurance companies, including barring insurance companies from denying coverage for pre-existing conditions, rescinding coverage, placing year or lifetime caps on insurance benefits and limiting on maximum spending for out-of-pocket expenses
• Create a new “insurance exchange,” which he described as a “marketplace where individuals and small businesses will be able to shop for health insurance at competitive prices”
• Require individuals to have health insurance, and require medium and large businesses to offer coverage to employees or pay into a fund to cover the costs of their works
• Create a public insurance option

Obama promised that the plan would be budget neutral and said the savings would result from eliminating waste and abuse within the existing health care system, as well as reducing payments to Medicare Advantage plans. Another form of financing would be a fee for insurance companies’ highest cost plans to “encourage them to provide greater value for the money.” Obama also addressed medical malpractice. He said, “I am proposing that we move forward on a range of ideas about how to put patient safety first and let doctors focus on practicing medicine.” He proposed authorizing the Health and Human Services secretary to test potential solutions as demonstration projects in states.

Reflections
President Obama is a remarkable orator, no doubt about that. He made his case for health system reform fairly effectively despite the Republican cold shoulder and overt heckling. It was pretty apparent to me that the public option wasn’t “off the table” from the smile and almost jack-in-the-box bobbing up and down of Speaker Pelosi behind him during his remarks, but there were some code messages in the address that may not have been apparent to many.

First, his apparent enthusiasm for the public option was tempered significantly by his acknowledgment that it was not an essential part of the strategy. That frees Mr. Baucus up to propose something different (the Snowe amendment).  And his comment that health care reform will not contribute one dime to the deficit is another way of possibly approaching that the solution for getting a bill passed will be reconciliation. Reconciliation is an extreme measure in the U.S. Senate that only requires a simple majority of 51, rather than the 60 votes otherwise required in the Senate. To use reconciliation, which the Republicans will hate (although they used it to get the Bush tax cuts passed), the net has to be budget-positive or budget-neutral.

There are some problems with reconciliation that could affect our issues in reform. Under our health care reform campaign, Quality First, the ACC has endorsed six principles for health care reform, including: universal coverage; coverage through an expansion of public and private (pluralistic) programs; focus on patient value—transparent, high-quality, cost-effective, continuous care; emphasis on professionalism; coordination across sources and sites of care; and payment reforms that reward quality and ensure value. However, among many other reasons, not all of these are able to be scored by CBO, which would make them more difficult to include in a bill pushed through with reconciliation.

ACC President Bove and ACC leadership have asked staff to get in the weeds a little bit more around some of the controversies swirling around health care reform, such as the public option, the "MedPAC on steroids notion," what the minimum benefits should be, how quality will be incentivized, and so on. We have very little time to get such ideas agreed upon and on the table, but we are committed to doing so. A few of the ideas that we believe ought to be incorporated could include:

• Payment and delivery system reform. While this critical need is a minefield of extraordinary complexity, we believe at least one new provision must be added that would create significant resources to fund pilot projects and experimental demonstrations around payment reform, bundled payments, accountable care organization concepts, the patient-centered medical home and other such ideas that will never come to fruition without significant funding and experimentation. We believe that new funding approximating 1.5 to 2 percent of Medicare spending for hospital, physician and other provider reimbursement should be made available to the secretary of HHS for such payment reform experimentation -- and with new dollars. That would provide about $4 billion out of a $450 Medicare billion overall program -- not even 1 percent of total spending. That money could not only fund a broad array of pilots that could extend to smaller practices and hospitals, but it would allow the CMS (Centers for Medicare and Medicaid Services) to expeditiously hire the kind of expertise and capacity-building resources it will need to help the nation make these transitions gracefully and effectively, and to work with the profession to make it happen sensibly.
  
  
• The SGRrrr needs to be obliterated. HR 3200 wipes it out for 10 years, but not completely. I think Mr. Baucus will just fund a one year fix -- that’s unacceptable. Let’s move on.
  
  
• Tort reform has to be included. The cost of defensive medicine is widely argued. HHS estimates it at $126 billion per year including almost $60 billion in Medicare and Medicaid, but Pricewaterhouse Coopers estimates it at $210 billion (I trust them more than HHS), and others claim it may even be higher. So, what’s to argue? It’s a lot of wasted money, not to mention the legal costs and hassles! What if we cut the defensive medicine estimates by 75% to, say, an estimate of $50 billion a year? Saving $50 billion annually would result in a $500 billion savings over the 10-year budget period for which expanded access to care is estimated to cost $1 trillion -- the cosmically sized number Congress has not yet decided how to pay for. Dang! Why not fund half the cost of reform by reducing the hemorrhaging of health care dollars into the legal system? While we know the U.S. Senate won’t vote for the most comprehensive reforms we would like to see, we believe the current pressure for bipartisan action could open the door for significant tort reform progress that would save that $50 billion of defensive medicine target I referred to. ACC is working on convening specialties, states, consumer groups and others to get this issue back on the table!
  
  
• Primary care: Nobody would disagree that primary care is more devastated than the rest of medicine, even though workforce shortages in cardiology, CT surgery and other specialties will also impair the system in the future in significant ways. But primary care really is a disaster in terms of supply. So, why not fund a renaissance of primary care as part of the $1 trillion investment, rather than the “robbing Peter to pay Paul,” nickel-and-dime approach currently before us? These approaches won’t work in terms of saving primary care; they divide the House of Medicine, and they will further impair access to specialty care. HR 3200 puts some new funding in for primary care, but it will be insufficient to even persuade one medical student to move in that direction.
  
  
• Benefits: If the cost of universal access exceeds what Congress is willing to spend, why not consider having the minimum benefits consist of USPHS-approved prevention services and high deductible coverage (perhaps over $2000) at minimum? People would still have to pay for some outpatient care, but nobody would be bankrupted by health care anymore, and any serious condition would be covered. This isn’t perfect, but it is so much better than we have now.

Weighing in on Other Controversies
We probably do need to help Congress find its way to work around the public option dilemma, the MedPAC on steroids idea, and other divisive issues. But if we were to succeed in getting the previously mentioned objectives moving, these controversial provisions might iron themselves out on their own, given the lack of consensus about them in the Congress. In other words, we might do better to be emphatic and clear about what we want to happen than to spend all of our energy on what we don’t want.

Regarding an empowered MedPAC, Sen. Rockefeller (D-W.V.) has introduced a separate bill on this topic. We will need to think about what we agree with. His bill would:

• Reform MedPAC as Executive Agency Modeled After the Federal Reserve Board
  
  
• Elevate MedPAC to be an independent, executive branch entity, like the Federal Reserve, with the power to implement recommendations that are more insulated from special interests, and more accountable to the American people
  
  
• Inform new research in health services to adequately address deficiencies in the evidence
  
  
• Test new and innovative payment models for provider reimbursement, and
  
  
• Expand the capacity to evaluate basic and health services research for reimbursement. 

President Obama tonight will address Congress on health care reform "in understandable, clear terms [with] what our administration wants to happen with regard to health care, and what we are going to push for specifically," according to Vice President Biden. Let's see if he addresses any of the items I've outlined here.

*** Image from Flickr (WilWheaton). ***

With Congress back in session today, the party’s over in terms of bipartisan planning, and the POTUS will address a semi-reluctant joint session of Congress Wednesday evening to lay out what the “at minimum” health reform agenda needs to be.

Gang of Two
The Senate Finance Committee is hurrying to get their proposed bill out before the big speech Wednesday. Chairman Baucus has apparently lost the support of the Gang of Six, except for Senator Snowe (R-ME), who’s still talking with him. He’s going to put the bill out anyway. He has leaked some details of his proposal, including that it will provide access for all Americans, and cost about $900 billion over 10 years.

Families and individuals earning less than 133% of the federal poverty level ($29,000 for a family of four) will be covered in the expanded Medicaid program at government expense; those who earn more than 133% of the FPL but less than 300% ($66,000 for a family of four) will get subsidies on a sliding scale to help buy private coverage through new insurance exchanges. Those above 300% of FPL must purchase it themselves through the exchanges, or be covered through their employer, or face some kind of tax penalty. Employers will be encouraged to cover all their employees, but not forced to do so. However, if they don’t, they must pay for part of the coverage costs by contributing into state insurance exchanges that will help uninsured persons get affordable coverage, have a choice of plans, and have portability of coverage if they change jobs or move within the state.

He will not include a “public option” in the exchanges, but will promote insurance reform and publicly owned insurance coops (such as Group Health of Washington State, which is organized and owned by its beneficiaries). He has trimmed back the mandated minimum benefits to try to keep costs down and premiums more affordable (and interestingly, Snowe apparently thinks he has cut benefits back too far). He raises some of the funding through a new tax on insurers who offer coverage that is over the average costs of family coverage (about $13,000 per year for a family of four). This is a clever switch from taxing people with coverage over that amount, as proposed by others. I don’t know if he will have ‘MedPAC’ on steroids “federal reserve’ body to oversee health policy decisions for Congress (with less politics and more expertise). That’s all I know. 

It’s somewhat strange to me that how we’re going to pay for reform isn’t the headline issue being debated: Instead, the controversy is all about the public option, the base closure commission idea (MedPAC on steroids), death panels, whether federal money can be spent on abortion, and other matters. It does seem like most of Congress and most Americans are still prepared to support expanding access to all Americans, to propose needed insurance reforms, and to figure out a way to put the brakes on rising costs to ensure that health care and health care spending remain affordable. (We would add with respect to the latter goal that improving quality is the proven means of reducing the cost curve, and that there is no effective way of doing that in the bills proposed thus far. So, it will be interesting to see if Mr. Baucus includes any of the pilot ideas we have proposed to incentivize and improve quality.)

Socialistic Europeans?
There were quite a few chuckles at the European Society of Cardiology about the incessant bashing by some members of Congress of the National Health Service (NHS) and other allegedly “lefty strategies supposedly diminishing the lives of those socialistic Europeans.” Most European cardiologists I talked with at ESC felt this is almost humorous, even though they recognize that cardiologists and physicians in this country in general are the most highly compensated on the planet, and that our hospitals often have much more technology and money to spend than theirs. The difference in outcomes are not great, and clearly Europe is ahead of us in some areas. And, despite problems in every country, Europeans have a lot of pride in the progress their nations are making as they should.  Incidentally, I was interested recently to see income comparisons between compensation of American versus European physicians based on ‘purchasing power.’ When that comparison is made, American physicians aren’t doing much better than many of their European counterparts.

Next Steps
So what happens now that the Congress is back?  The House will start entertaining amendments to HR 3200, similar amendment discussions are ongoing with respect to the Senate HELP bill, and when this week the Senate Finance is announced, the Senate has to put its two bills together into one proposal, which will be no easy task. Once that happens, the House and the Senate will appoint a conference committee to take the amended House proposal and the amended and combined Senate proposal and try to craft a unified proposal to be passed by both the House and the Senate, and that the President will be willing to sign. That has to happen between now and the New Year.

So, despite Congress still being out -- this has been quite a month! This month of September and the two months following are likely to be one hell of a rollercoaster ride. More on the Baucus bill below.

*** Image from Flickr (peve.de). ***

The Obama administration's team held a conference call last night for interested physicians to help get us up-to-speed on all that is happening in health care reform. They agreed to try to answer questions by e-mail. While the call was a great idea -- to get us engaged and accurately informed on their policy recommendations to Congress -- it's tough to pull this kind of communication off well. The reforms proposed are overdue. IF, that is, Congress enacts them.

There really is a lot of BS (Blatant Scare-tactics) out there, but there is also a lot of concern over the deals that insurance, hospitals, and others have cut with the Administration to be supposedly immune to further injury: the deals are in favor of those industries and won't create the "bending the cost curve" savings needed to pay for expanded access (emperor's clothes are missing).

Doctors may be the only low-hanging fruit left to prune. The WH staff are not into that tactic, but are they boxed in if Congress moves in that direction? I think those who didn't e-mail in their questions in time last night were shouting those kinds of futile concerns on the call. Nobody heard them.

However, I think that many physicians -- such as our members, and oncologists, nephrologists and other specialists who got the short straws in the absurdly unscientific 2010 Physician Fee Schedule proposal -- are so focused on protecting their practice viability by opposing the proposed rule that there’s no time or energy left over to focus on the critically important issues of health reform. That's worrisome. 

Think of my wistful but sincere Kennedy tribute. We're going to get something in a health reform bill -- and it is needed. But what will we get?

The insurance industry will come out OK, I suspect. We're generally helping them by our expressing with them our misgivings about a public plan. But is insurance helping us? Duh (they're very busy right now).

The semi-tragic reality is the President and his Administration really DOES want to empower us. They sincerely acknowledge how important the contributions of physicians and other health care practitioners are to meaningful reform. I believe them on this. They see why that IS important to patients and the future. But I don't see it happening in what's in the bills so far. And the massive donations to Congress of the other constituencies (we tend to be loud but cheap) bother me in terms of what Congress will actually do. The call was a nice gesture. But we still have our work to do! The fall will pass quickly and then the winter approaches. It's almost pruning time.

At a CEO forum last week in New York, many of the industry leaders reported feeling mugged by Congress in the health care reform process. Certainly our members are frustrated and angry about the recent Medicare proposed rule -- that’s a real mugging. But, it seems everybody -- hospitals, insurers, pharma, device companies, nurses, businesses, consumers -- feels like somebody’s raining on their parade. Nobody seems happy with where we may be going yet. But I question the notion that there have been many muggings thus far:

Hospitals
Hospitals have agreed through the American Hospital Association to pony up $155 billion over 10 years as their collective commitment to the costs of reform. That’s only $15.5 billion a year, folks. Hospitals get more than $10 billion a year ($100 billion over 10 years) just from DSH (‘dish,’ or disproportionate share) funds for covering uninsured persons. Cutting that is logical. The additional $5 billion a year they need to make this up isn’t going to be a big deal, and they know it. That’s not a mugging. That’s a good deal.

Of course, bigger problems for hospitals might be related to reducing admissions and re-admissions if payment reform comes into place and if payment reform shifts toward capitation or global budgeting. Reductions in inpatient care (resulting from better outpatient care and prevention) could put real skids on hospitals’ ability to capitalize equipment and facilities in the future. Paul Levy, M.D., CEO of Beth Israel Deaconess, told me his board is worried about Massachusetts moving toward capitating private coverage again. He thinks doctors may do fairly well under a new version of global budgeting, but not hospitals in his state, and he fears that Partners (which Levy feels has a monopolistic market share) has the upper hand.

PhRMA
PhRMA seems to have successfully convinced the Obama Administration to put Medicare negotiation of drug rates on the back burner for now, using their pledge for $80 billion in savings over 10 years as the means of encouraging that. That’s no mugging either. Given that Obama is very committed to science and research, I think PhRMA and the device world are not in such a bad position going forward, unless the regulatory side of government in this administration and era becomes more aggressive. But PhRMA also pledged $150 million in pro-reform advertising to the administration last week also, and that sounds like they are pretty happy.

Insurers and AHIP
Insurers and AHIP see the certainty of more insurance regulation as survivable, assuming their dreaded public option doesn’t manifest -- but in many ways, the 'party's over' related to the heyday of 20 and 30 percent returns on investment, and they know it. That doesn’t mean they can’t do very well over the long term with more stable yet lower margins (as the investor owned life insurance industry has). Non-profit insurers like many of the smaller BC/BS and Kaiser plans may have a new advantage here.

But, I have believed all along that even if a public option is included in reform legislation at the behest of the liberal Democrats, private insurance will find a way to out-compete the government plan and to ensure that Congress won’t give a public option unreasonable financing advantages. In fact, the greater likelihood is that Congress could underfund a public option -- think Medicare and Medicaid reimbursements -- that would be my worry.  Regardless, the insurers haven’t been mugged either. They get cuts in the huge added incentives they secured in Medicare Advantage plans, yes -- but, they also get millions of new insureds to cover presumably.

Doctors and Patients
There will be an enormous amount of new money going into health care benefits for the millions of patients who are now uninsured or under-insured, and a significant part of that will end up in the pockets of physicians and other providers; but as all know, there will be winners and losers there too. The primary care incentives will so far not do much of anything -- and they shouldn’t be created by slashing specialty payments (the flawed CMS Medicare Payment Rule proves that nothing yet is being done rationally -- although the CMS Rule has nothing to do with health care reform bills; it’s just indicative of a broken system of flawed formulas and administrative and payment nightmares).

As I have stated earlier, the coming pandemic of CV disease and consumer respect for cardiology is certain to make cardiology an attractive and in-demand professional venue for decade to come. Prevention and earlier intervention to reduce what’s in the pipeline may be the only ways prevent a veritable burn-out of cardiovascular professionals due to the impending high-volume demand on the horizon. Patients are going to be holding hands with doctors as reform progresses, because our fates are likely to be linked. I think that bodes well for the profession.

*** Image from Flickr (dirac3000). ***

My Statement on President Obama’s Prime Time News Conference Last Night

"Forty years ago this week, man first stepped onto the moon. It was an undertaking that took vision, commitment and sacrifice. It will take the same vision, commitment and sacrifice for this nation to meaningfully reform our health care system.

"President Obama has called on Congress to undertake this enormous task which is just as daunting as putting a man on the moon. We applaud President Obama’s leadership and we share his goal of health care reform, but we can’t settle for legislation that lacks the teeth to deliver real and necessary quality and payment reforms.

"The American people need health care reform that addresses the causes of our health care problems and not the symptoms. Hacking blindly away at costs and then claiming to have saved the system money is dangerous and punishes the very people that our health care system is meant to serve: the patients. When talking about reducing overall costs to the Federal budget during the campaign, then candidate Obama suggested taking a scalpel instead of an axe to reform, and that’s precisely how we should be reforming the health care system now.

"We must look at how we pay physicians and other care givers, and develop a payment system that incentivizes quality and positive patient outcomes. Until we completely change the way the U.S. payment system is structured, we’ll never be able to bend the cost curve of health care spending.

"Without payment reform that leads to quality improvement, health information technology adoption, and reduced disparity and variation, we will produce a noble increase in access, but without slowing cost increases. That is a formula for disaster.

"Some have proposed as a way to save money is to cut Medicare Part B reimbursements to specialists such as oncologists and cardiologists. Not only does that not achieve enough savings to be of any use, cutting reimbursement will lead to less access to vital services for people in rural areas and in underserved communities. But it really just shifts costs as the cuts to specialists will be offset by increases to primary care physicians.

"What we need are reforms that allow for the adoption of health information technology, coordination of care so that we can reduce heart failure related hospital readmissions, and the use of evidenced-based guidelines and appropriate use criteria to stop unnecessary medical procedures. And we need incentives to promote partnerships between primary care and specialists in order to better coordinate care for most expensive and complicated chronically ill patients.

"This is, as then candidate Obama suggested, a targeted approach that can achieve real reform with real results and measurable outcomes." 

Full video of the press conference is on WhiteHouse.gov. 

I had conversations this week with a few unnamed White House and HHS health policy folks about the fact that the three well-intentioned Congressional health reform proposals emerging from the House and Senate talk a lot about the importance of improving quality and providing related payment incentives, but don’t really offer a way to achieve these critical goals. So, while the nation is poised to do the right thing — provide coverage for uninsured Americans — we do not seem to have included the means and the teeth needed to bend the cost curve downward and to actually systematically improve quality. If we add the trillion dollar price tag to solve the access problem without cutting costs over time, the system will implode.

The irony is that the highest quality care in America tends overwhelmingly to be the most cost-effective (think about adherence to guidelines, performance measures, and appropriate use criteria; and about registry-tracked progress in improving care, reducing disparities and promoting prevention).

Of course, instead of focusing on solving these problems as reform progresses, we now have once again to be preoccupied with the SGRrrr and other formulaic nightmares of Medicare. We’re going to have to do both, because the only way in the future to contain costs (which will be essential to the nation’s economic well being) will be to use blunt price controls, rather than true quality improvement incentives. This is precisely what the proposed 2010 Medicare Physician Fee Schedule is doing. It will only induce a higher volume of services in a dysfunctional system. (Side note: Make sure to tell us how you would be affected if the proposed cuts went into effect!)

In my view, the White House folks are aware of this dilemma, but don’t know quite what to do about it. We need to help, but without embarrassing Congress or the Administration.

*** Image from Flickr (Geraintwn). ***

ACC responded last week to Obama's online health care reform town hall with a video of our own. Read the comments from the post and then check out the video below from the town hall itself. 

Just moments ago, President Obama concluded his virtual town hall on health care reform. Here's the ACC response to the town hall, and I'll post the video from the White House when it becomes available.

Here's what I want to know from you: What would you have asked the president (or what DID you ask, if you submitted a question)? What's the biggest unanswered question for health care reform?

I think it’s fair to say, nobody knows how this health care reform process is going to come out after last week's disturbingly ambiguous week. Both the House tri-committee bill (at 838 pages and a CBO estimated cost of $1.6 trillion over 10 years) and the Senate Finance bill (also $1.6 trillion over 10 years) have gone back to the drawing boards, tails between legs, to try to cut a half trillion out of their perceived grandiosity. The Senate HELP bill was estimated to cost less at a little more than a trillion, but, at 600+ pages, only a few folks really read it. The HELP bill isn’t that much of a bargain because it doesn’t include the costs of Medicaid expansion to cover an additional 15% of the uninsured. The Medicaid expansion is included in the Senate Finance and House proposals.

Finance says they will soon have trimmed the $600 billion over their target out by reducing the benefits and cutting some hospital costs in their revised strategy. The details are not yet available. They still plan to include a cap on deductibility of employer sponsored health insurance; and they will tax employers up to 8% of wage to help fund the new insurance “exchanges” and to subsidize low income uninsured coverage if they do not insure their workers directly.

Does size matter?  Is 800 pages better law than 600? Or are there more things to dislike in the growing complexity of the discussion? Probably the latter. Skepticism has increased. And,  when the public -- seemingly polled to death -- was asked whether they wanted government to completely take over health care, contribute to a rising deficit, and take away their choice, they said, “duh, no.”

Polling Overload
Of course, when that same seeming deer-in-the-headlights public was asked in a different way whether they were supportive of a ‘public option’ insurance plan to compete with private insurance this week, they answered overwhelmingly YES. Since 100% of Republican members of Congress are opposed to the public option, they must have been both scarily surprised by this alleged public option support from their constituency, and are likely ready to re-poll the beleaguered and confused registered voters yet again with some better polling questions, like “would you still favor a public option if it was to cause flesh eating bacteria (MRSA) to become a greater risk to your family? It’s hard to trust these polls -- the questions can lead us to the responses we seek.

There were far too many editorials and op-eds on health reform this week to summarize here. Even reading them was tough. Common threads are hard to find, but there is at least one: people still think the status quo is not good, and some kind of reform is necessary. Phew!  Of course, that could change next week.

House Bill Details
House members this week were getting pretty bent out of shape at doctors who weren’t supportive of their bill, and unable to see that the House had been kind to the profession. They expected big physician support. More...