Congressman Gordon (D-Tenn.) has convinced House Energy and Commerce Chair Henry Waxman (D-Calif.) to allow his medical malpractice amendment in H.R. 3962. Gordon’s amendment would facilitate “certificate of merit” systems in states that achieve the reductions in premiums claimed in Ohio, Michigan and a few other states when such a program is designed and implemented properly. But the good Congressman has informed us he’s interested in a broader tort reform agenda, and we should help make it happen! During these tough and financially tight times, a reduction in med-mal premiums could be a godsend.

The other idea we are exploring is to provide a set of protections and/or safe harbors for those physicians who achieve the health IT-related “meaningful use.” I am working with a coalition (that we are helping to create) to explore this idea. The meaningful use process of the Office of the National Coordinator (ONC), David Blumenthal, MD, builds on allowing the federal stimulus benefit dollars to go to only those doctors who qualify as “meaningful users” of health IT. Basically, meaningful use will involve phased-in application of electronic health records, e-prescribing, clinical decision support systems, privacy and security protections, computerized physician order entry, and perhaps a few more elements of an e-office. If incorporating health IT could be accompanied by a significant reduction in medical malpractice costs (even if only for Medicare and Medicaid patients), it would be an additional big incentive to go electronic (not to mention being able to receive over $40,000 from the feds to help do it).

The PINNACLE Network™ concept is in fact the pathway to meaningful use for cardiologists and other physicians who care for cardiovascular patients. This is all happening rapidly, and we will talk to Congressman Gordon and others about expanding on his idea and giving the trial bar a run for their money before this reform process is completed.

And here’s an additional plus: This week, Chairman of our Working Group on Malpractice Insurance Bill Oetgen, M.D., F.A.C.C., and I met with the CEO and CMO of the nation’s largest physician-owned medical malpractice insurer, the Doctor’s Company. We discussed some exciting ideas that could reduce premiums for cardiologists at the same time reducing the risks of adverse events and patient safety-related incidents. This was a dynamite meeting.

Photo: http://www.flickr.com/photos/mindgutter/ / CC BY-NC-ND 2.0

The Senate Finance Committee voted earlier today 14-9 to approve the America's Healthy Future Act. All the Dems voted for it, and Sen. Snowe was the only Republican who voted for it. The committee's approval allows the process to proceed to merger with the Senate HELP bill and then to the floor. The Congressional Budget Office (CBO) has estimated that the bill would cost $829 billion over the next decade and reduce the deficit by more than $80 billion. One reason it's less costly than the House bill is that it doesn’t fix the SGRrrr.

The CBO has slowed activity in the House as they analyze costs and debate whether the House SGR fix must be added to the cost of HR 3200. So, floor action there is unlikely in the next two to three weeks; and the Senate will take some time to sort through their issues as well as they try to merge the Finance and the HELP Committees bills. In terms of more details about the activities on the bills:

First, on the House side:

• The caucus considered several options for reducing the gross cost of their bill to $900 billion, none of which had great appeal to House members.  But that does seem to be an agreed-upon goal. And CBO is watching.
  
  
• The conversation regarding the public option revolved around a version that would use Medicare +5% rates, negotiated rates, or “some combination thereof.”  The last reference appears to suggest a trigger-like mechanism for starting with negotiated rates but moving to Medicare-like rates if savings targets are not achieved – an idea discussed in some of this morning’s press reports.  In sum, a “robust” public option appears likely in the House.  Leadership’s strategy is that is the best means of producing the left-most version in conference, although with the Senate heading for 60 or 61 votes at most, how far that issue can shift in conference is dubious at best.
  
  
• One means of lowering the cost of the bill that’s being considered in the House is to raise the Medicaid eligibility threshold from 133% of poverty to 150%, with the federal government absorbing most, if not all, of those incremental costs.
  
  
• The high-end insurance plan tax is unlikely to be included in the first House-passed bill, although many caucus members acknowledged some version of it is likely to come out of conference with the Senate.

Then, on the Senate side:

• “Rule 28”, which prohibits extraneous provisions from being included in House-Senate conference negotiations, will apply to the HELP-Finance merger process.  Staff for both committees have been adamant that provisions not included in either the final HELP or Senate bills will not be considered at this stage.  We predict that “rule” (more of a “guideline,” as Dr. Peter Venkman would say) will get broken at least once, but it is an added barrier to new issues being introduced to the process in the near term.  The “Manager’s Amendment” laid down once the Senate has moved to the reform bill could include new provisions, and there will likely be extensive consideration of amendments on the floor.
  
  
• Due to the fact that the $81B “surplus” in the Finance bill is “off budget” – because it is derived from new payroll/Social Security tax revenues – we think it is unlikely that the provider “fees” and other offsets and revenue raisers in the bill will change meaningfully during the merger process with HELP.
  
  
• Many Senate Democrats do not consider this the final word on, or even as necessarily relevant to, the public plan debate in that chamber.  Sens. Carper and Snowe continue to push their approaches to a fallback public plan, with the key distinction being Carper’s is almost exclusively state-managed, while Snowe’s would entail a single, federally-chartered corporation that would administer the state-based plans where the trigger has been pulled.  Neither appears to have made significant concessions to the other at this point, but inclusion of some compromise version looks probable via an amendment on the Senate floor.

Every day these and other issues are being debated and debated. We’re in there, pushing for the SGR fix, tort reform, and protection of the physician right of ownership, among other issues. And, we’re always reminding everyone about the 2010 Payment Rule debacle -- and asking they do something about so we can turn our attention to reform.

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). ***

GREAT editorial in today's Wall Street Journal on "Obama's War on Specialists." I highly recommend you check it out. Here's a teaser:

From Senate Finance Chairman Max Baucus's health-care bill to changes the Administration is pushing in Medicare, Democrats are systematically attacking specific medical fields like cardiology and oncology. With almost no scrutiny, they're trying to engineer a "cheaper" system so that government can afford to buy health care for all—even if the price is fewer and less innovative ways of extending and improving lives.

The Journal continues: "We have nothing against primary care physicians, and clearly the country could use more of them. But then, it could probably use a lot more doctors, including specialists, as the boomers age and the prevalence of obesity, diabetes and other chronic diseases rises. The increase in specialists has tracked advances over 50 years in medical science and technology. Democrats look at these advancements and see only the costs, not the benefits." 

*** H1N1 Virus, from CDC.gov. ***

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.

Texas Senator Cornyn proposed an amendment last week in the Senate Finance debacles to mandatorily enroll himself and all fellow Senators in the Medicaid program! Wouldn’t they love that?! I loved it.

The committee members voted to soundly defeat it. Gee. Why? They wouldn’t want to be in a program that pays the doctors 40% of what underfunded Medicare does? Cornyn deserves an award for this.

The Congress is proposing to expand the Medicaid program massively in all of the current bills. But none of them would even think of being enrolled personally -- it’s woefully underfunded.

*** Sen. John Cornyn, official Senate photo. ***

Last week and this week in Washington have been even crazier than any before in the health care reform soap opera of 2009. I recently heard a modern philosopher opine (can't remember his name) that "life is a first-class opera played by a tenth tier cast." If you tuned in to C-Span this week to observe the Senate Finance hearings, you’d understand.

Actually, this health reform debate is more a soap opera, at least as Mr. Baucus' long awaited bill was received. Baucus likes the bill very much. I’m not sure anyone else in his Chamber does. Nonetheless, I predict it will be the platform for the final bill for two reasons: first, the CBO marks up the costs over ten years at less than $900 billion ($856 B), AND they say it will actually save money over time. The other two major bills cannot claim this distinction.

Second, at least one Republican might vote for it (Snowe—R-Maine). But most of what the bill contained when Baucus put it out will likely be amended away. It’s becoming a platform, not a plan. Democratic colleagues Rockefeller and Wyden have been the most critical of Baucus, particularly in requiring coverage with insufficient subsidies for lower income families.

Tri-Com Bill
Meanwhile, House leaders still think their Tri-Com bill (HR 3200) will be the real platform, with Ms. Pelosi and others clarifying that the 'public option' (not included in Mr. Baucus' bill) must be in the final legislation. But their proposal is more expensive -- even though they ‘fix’ the SGR. They don’t finance the SGRrrr fix though -- they just sort of write it off as part of the debt, not part of the next budget.

The Senate doesn’t buy that approach. They say it has to be paid for (adding $245 billion to the House bill cost if so) -- hence the Senate chose to band aid patch it for one year only to prevent the 21 percent cut in physician reimbursement from kicking in this January, even though it kicks in the following January. (They don’t yet seem too concerned about the 27 percent cut to cardiology practices looming in 2010 relating to the Medicare Payment Rule, however. The Rule has nothing to do with health system reform and these bills -- it’s just an ugly manifestation of the present mess -- but it’s a worse predicament).

It is clear that neither Democrats or Republicans on the committee are completely satisfied with the final product and those not included in the “Group of Six” negotiations over the past weeks want to have their voices heard. 

Hearing
After opening statements by members, the markup started with a tense tone as Chairman Baucus, committee members, and CBO Director Doug Elmendorf held a contentious discussion over the “safe speed” of CBO’s work to produce budget scores on the proposal and amendments. Republicans have called for “transparency,” with several hours of debate on an amendment by Sen. Bunning requiring final legislative language and CBO budget scores 72 hours prior to the committee’s final vote (the amendment failed).

The markup is slow going, with hundreds of amendments lined up dealing with coverage, delivery system, and financing and debate over many amendments lasting hours and at times becoming heated. Several attempts to strengthen the bill’s provision on medical liability have failed so far, as did an attempt by Sen. Cornyn (R-TX) to address the SGR fix. Sen. Cornyn also offered an amendment to strike the controversial Independent Medicare Commission from the proposal, but it failed. Later, an amendment by Sen. Rockefeller to modify the Commission, which is based on a bill of his, passed. So far the MedPAC on steroids piece is alive in there. The “public option” is not. 

One very controversial aspect is the creation of a new system of modifiers to payment based on quality of care in relation to resources spent. This provision would thus penalize higher spending regions with lower payment. It’s true that variation in spending is very uneven. The Dartmouth Atlas folks (Wennberg and Fisher) deserve credit for publishing that variation based on Medicare spending per capita, but it’s based entirely on claims data. And, it doesn’t include socioeconomic and credible risk adjustment data, and that must be included before variation can be fairly linked to payment or to fair comparisons of geographies. ACC has proposed using clinical data (NCDR) to help look more carefully into this variation. 

The markup continues next week.  All eyes continue to be on Sen. Snowe, who may be the lone committee Republican to vote with Democrats for passage of the bill.

Despite the controversies, and after all the amendment hubbub, the Dems should still have the votes to get a bill out in both Houses in my view. In the Senate, after Massachusetts Governor Deval Patrick on Thursday appointed Paul G. Kirk Jr., a former aide and longtime confidant of the late Sen. Edward M. Kennedy, as an interim senator, that 60^th vote should be there soon. We’ll see. 

*** Image from Flickr (Brent and MariLynn).***

On Friday I spoke with MedPage Today about the Senate Finance Bill, potential tort reform and the revisions necessary to the SGRrrr. The final video is below.

As I'm sure you know, the Senate Finance Committee on Tuesday began a markup of its health care reform legislation ("America's Healthy Future Act of 2009"). The ACC likes some pieces of the bill (like its attempts to expand coverage to every American and strengthen Medicare) but isn't so fond of other provisions (including its one-year fix to the SGRrrr rather than a permanent fix, as included in the House bill) -- see ACC's full comments on the proposal for more.

But now I turn to my readers: What do you think of the bill? Do you think it should pass as is? Undergo major revisions? Die? As always, leave your full comments in the comment section below.

The ACC earlier this morning issued the following statement on Baucus' health reform proposal. I'll have more on this in coming days (I'm about to get on a plane for the annual meeting of the Japanese College of Cardiology), but here's our first take on the proposal.

****************************

ACC CEO Dr. Jack Lewin’s Statement on the Baucus Draft

 WASHINGTON, D.C. - Dr. Jack Lewin, CEO of the American College of Cardiology, made the following statement Wednesday regarding the Baucus draft:

"We appreciate Chairman Baucus's hard work on this very important piece of legislation.

 "I am excited to see the CMS innovation center idea that will focus on better payment and outcomes in this draft. We are also happy to see a mention of tort reform which is a step in the right direction, and we hope to see tort reform in the final package.

"While we appreciate the effort to stop the 22 percent cut to physician reimbursements under Medicare scheduled to take place next year, we believe you can't have complete health reform until you permanently eliminate the flawed Sustainable Growth Rate (SGR) payment formula.  I shudder to think of how that 1-year band-aid will lead us to spend the next year trying to fix that formula to prevent a payment disaster instead of working on the quality projects patients deserve.  Failure to permanently eliminate the SGR means patient access is threatened while Congress plays chicken with Medicare benefits year after year.

"Ironically, the highest quality care in this country is not the most expensive care.  The most effective way to bend the cost curve is to put the incentives on the table for doctors and hospitals to improve quality and care systematically by using evidence-based tools. 

"The American College of Cardiology is well positioned to lead this effort.  With over 43 percent of all Medicare dollars spent fighting heart disease, the ACC has tools in place to eliminate waste, fraud and abuse out of the system.

In its afternoon breakout session yesterday, the ACC held a panel on medical liability reform featuring James Paluskiewicz from the office of Rep. Michael Burgess (TX) and Dana Lichtenberg from the office of Rep. Bart Gordon (TN). So far in the 2009 Legislative Conference, medical liability reform has come up several times as an area that needs to be addressed in health care reform. The cost of medical malpractice (malpractice premiums and legal defense) is estimated by CBO to be at least 1 percent, or $22 billion, of overall annual health care spending in the nation.

However, the big number is the cost of defensive medicine. While the amount is controversial, it has been estimated by a number of legitimate sources (PricewaterhouseCoopers, etc.) to approximate $200 billion. Therefore, a little bit of malpractice relief could save a lot of money in reducing defensive medicine. If, for example, tort reform was able to save $50 billion per year in defensive medicine, it would add up to $500 billion over 10 years -- over half the projected costs of health care reform spending.

The ACC has long-held that caps on non-economic damages and other reforms, such as those contained in California’s MICRA, have the most significant impact on stabilizing malpractice premiums. However, realistically, there's a low likelihood such reforms would make it through the legislative process. Other options that could be included in reform or for demonstration projects:

• Health courts: Health courts are specialized administrative courts designed to handle medical injury disputes
  
  
• Certificate of Merit: Requirement to obtain a written statement by an appropriate licensed professional, certifying that there exists a reasonable probability that the treatment fell outside acceptable standards and that such conduct was a cause in bringing about the harm
  
  
• Collateral source rule: Eliminating the collateral source rule would allow juries to take into account payments from our sources when calculating awarded damages
  
  
• Periodic payments: Allows the defendant to make periodic payments of future damages over $50,000, if the court deems appropriate, instead of a single lump sum payment. It would ensure that funds continue to be available to the plaintiff to cover these future cost as they occur and avoiding the mismanagement of a lump sum payment
  
  
• Adherence to practice guidelines: This provision would offer limited liability protections to the physician or health care professional who offered care within nationally-accepted clinical guidelines
  
  
• Expert witness: Requirement that expert witnesses meet certain qualifications prior to testifying, such as must be a licensed physician and must be in the same or similar specialty as the defendant. Expert witnesses must also have been in practice within the past five years, which can include academic or clinical research programs.

The ACC supports the amendment offered by Rep. Bart Gordon (D-TN) to H.R. 3200 that would provide incentive payments to states for enacting certificate of merit requirements and early offers programs. There are many ways that we can begin to reform the malpractice system to reduce costs associated with defensive medicine. We just need to get started.

*** Image from Flickr (walknboston). *** 

In the first session for today’s 2009 Legislative Conference, two important Congressional staffers joined ACC members to discuss “Health Care at the Crossroads: A View from the Hill.” The first was Wendell Primus from the Office of the House Speaker Nancy Pelosi (D-Calif.), who spoke about the opportunity we face to move to higher quality, lower cost care. Wendell noted that Congress needs our help in making this happen. He said: “We need you to work with your members of Congress and your Senators to make the point that we need to control costs, improve quality of care and increase access.”

Joining us from the House Ways and Means Committee was Geoff Gerhardt. Geoff discussed some of the highlights of the House bill (HR 3200), including coverage, payment reforms, prevention and public health, and medical education. Gerhardt talked at length about coverage – specifically the provisions in the House bill intended to expand coverage. Some of the items mentioned include an insurance exchange, protections for those with pre-existing conditions and protections against coverage rescissions. Geoff said that the hope is that people will have a real choice of insurance companies to go to.

The session also provided a lengthy question-and-answer session with members. Members covered a variety of topics, including expanding Medicaid coverage, combining Medicare Part A and Part B, using a unique patient identifier to track patients through registries to understand outcomes, implementing interoperability standards for health information technology, and much more.

Clearly, there are a lot of health care issues on the minds of ACC members. Hopefully over the next day, Legislative Conference speakers will be able to provide some clarity into many of these issues. The better we understand the issues that affect us, the better advocates we’ll be tomorrow during our Hill visits.

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). ***