Senator Debbie Stabenow (D-Mich.) produced what could turn into a major miracle in Congress this week with the introduction of S. 1776. The bill would eliminate the (un)Sustainable Growth Rate (SGRrrr*) formula for the next 10 years, without creating the budgetary impact of $245 billion of accumulated debt associated with the formula that the Congressional Budget Office (CBO) requires to ‘pay for it.’ In essence, Stabenow would consider paying off the SGRrrr debt by making it a contribution to the multi-trillion national debt, not a 2010-2020 budget cost. The bill thus would eliminate the Pay-Go rule. Although Congress has taken similar actions for the Stimulus and to pay off part of the Alternative Minimum Tax hit, recognize that this is done VERY rarely.

The House attempted to do something similar to get rid of the SGRrrr in HR 3200, which prompted the AMA and American Academy of Family Physicians to support the entire bill; but including the SGR elimination as part of health care reform causes the CBO to chalk up the debt cost as part of the cost of reform. S. 1776 is a better and parallel approach.

ACC was called by Sens. Reid and Baucus this week and asked to support this radical move, which Mr. Reid (D-NV.), Mr. Dodd (D-CT.) and Mr. Baucus (D-MT) also believe is necessary. No problem getting our support -- we’ve been trying to get rid of this nightmare for 10 years. Action on S. 1776 will of necessity have to move with lightening speed. It will move fast, or die fast. Getting this albatross off our necks would be a major plus for all of medicine.

If S. 1776 doesn’t pass, Congress will definitely kick the SGRrrr can down the road and propose another one-year band aid patch on it as they do every year.

Again, the AMA deserves great credit for delivering on this SGRrrr issue if it happens. To underscore how much momentum is behind it, AARP is teaming up with AMA to get S. 1776 enacted and is contributing 50 percent of the advertising cost to a major multi-million national TV campaign. We need our constituency to call your Senate office and ask them to vote YES on S. 1776 this coming week to promote security and stability in seniors’ access to Medicare physician services.

(* note  --“SGRrrr,” for those of you new to the Blog, just adds a ‘growl’ to SGR)

*** Image from Flickr (YardSale). ***

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.

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.

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.

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.

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 ACC submitted comments on the damned 2010 Physician Fee Schedule last week. How could the agency have miscalculated (almost absurdly) that cardiology practices have had a 30-40% reduction in practice costs over the last year, warranting a parallel reduction in Medicare reimbursement? Because it is an underfunded agency lacking empowered leadership, and which is obviously using a very flawed process, incapable for calculating practice costs accurately (this is not a good advertisement for a new public plan!).

If implemented in January 2010, the effects of this CMS 2010 Payment Rule would be devastating for outpatient cardiovascular services and the patients who need such care, and would hardly be consistent with the new Administration’s bold and welcome intention to reward improved quality and outcomes for a specialty that has led the way to the stunning reduction of US cardiovascular morbidity and mortality by 29% over the past 8 years alone! 

Not only will the rule affect services and patients, it's going to affect health care reform. Don’t miss a great Bloomberg article about the impacts of CMS’ proposed cuts on overarching health reform efforts. The article is absolutely correct that the “backlash” being generated by the cuts is “undermining the president’s health-care overhaul.” Even Mark McClellan, former head of CMS and currently an analyst with the Brookings Institute, says:

“The fight by physicians who work with the most expensive patients is weakening support for Obama’s broader goal, legislation to remake the health system ... If you can make the health-care debate all about moving slices of the pie around, it’s very easy to generate opposition and very easy to get derailed.”

ACC President Fred Bove is also quoted in the article, saying: “The cuts could have the unintended consequence of rationing care, especially in rural regions with a large number of Medicare patients.”

There were some exciting late-breaking clinical trials presented here today and yesterday, and ACC leaders were widely quoted in the media on the implications of what was discussed. 

I took a little time out yesterday from the international scene to hold a panel with the American Heart Association to examine AHA and ACC’s vision for the future of U.S. health care. The panel featured me, Fred Bove, Clyde Yancy and Robert Califf.  Part of the purpose was to help cardiologists and CV professionals understand better the differences and areas of collaboration between AHA and ACC. We focused on the positives, which are numerous, rather than on areas on competition. As I’ve said before, the future of health care should be rewarding for continuous outcome improvement and providing patient-centered care.

The ACC has a health care reform campaign, called Quality First, which, like the name suggests, advocates for payment incentives for quality care, along with increasing the focus on patient value (which we define as transparent, high quality, cost-effective, continuous care), better coordination across sources and site of care and emphasizing professionalism to increase partnerships with patients. Reform would also provide universal coverage through an expansion of public and private programs. (You can read more about Quality First and specific examples of how to make it a reality in ACC’s “Blueprint for Reform.”)

Of course, making sure all of this is included in health care reform is quite a tall order, which is why the ACC is working with lawmakers and the White House to make sure that they know what we feel is best and how best to achieve it. We’ll know soon enough if we’ve left an impact.

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.

I asked this question back in March during ACC.09, and the winner was payment reform, closely followed by malpractice and access issues. Given everything going on now, let's see how it changes.

 

We’ve been hitting the media particularly hard with our messages about both reform and the outrageous proposed payment cuts in the parallel 2010 CMS-issued proposed Medicare Physician Payment Rule, noting our membership’s focus on reform has been completely diverted to trying to undo the impending payment rule. People need to be clear that “health reform” and the “Medicare Rule” are 2 different and almost unrelated topics. The Rule is just the annual CMS announcement about changes in payment they will institute (supposedly based on sound data and methodology -- NOT!).

On the rule: All the CV societies and the Cardiology Advocacy Alliance are working together with us (as is Oncology) on getting the word out about how unfair the proposed Rule would be if implemented. At this point, we have about 12 House members ready to sign on to the Gonzales-Roger letter to the Secretary, asking that the CV aspects of the Rule not be implemented. We think there are more willing to sign, but with them out on recess it’s hard to know yet. On the Senate side, Senator Lincoln sent a letter for American Society for Therapeutic Radiology and Oncology addressing the cuts in the Rule, and we have other letters pending. Our Board of Governers and Chapters have been cranking out the letters and visits to members in the Districts. This is great advocacy, and we are all soooo grateful here to those who are working so hard.

On reform: the ACC conducted a satellite media tour on the topic from the National Press Club, reaching 15 stations across the country. An ACC op-ed appeared in Roll Call online, making our point that “basing health care reforms on quality and driving down costs will allow us to provide more coverage and make available more resources for education, the environment and other critical societal needs.” On some of these stories we were able to get the flawed Medicare Rule in there also, as something that exemplifies what a mess the current CMS payment structure is, and how this issue is stealing the energy for reform as we fight to get the Rule reversed before it is issued.

Also on reform: With little notice (somebody important probably cancelled out), I was asked to depart early from the NY CEO meeting to rush over to FoxNews.com Live with Alan Colmes on a panel to discuss the push for health care reform. We debated tort reform (me positive), the single payer option (me skeptical), and the need for payment reform (me positive) in what was a very stimulating conversation — so stimulating in fact that my fellow hospital administrator panelist (CEO of Universal Hospitals) was so frustrated apparently about hospital cuts and ‘public options’ questions that he walked off the set. I wasn’t able to get the Rule issue raised in my few minutes there though, but asked Colmes if we could have another chance to get our leaders on to talk about it.

Other societies have been busy beating the health care reform drum, too. Our own J. James “Jim” Rohack, M.D., F.A.C.C., President of the American Medical Association, appeared on “Larry King Live” to discuss health care reform and give us some background on why the AMA endorsed HR 3200. Dr. Rohack carefully avoided throwing his full support behind the details of the bill, saying the AMA endorsed it “to move the process forward” in order to increase access. Former Sen. Bill Frist, another panelist on the show, strongly rebutted the AMA position, saying we need to “stay at the drawing board” and listen to senators who are working toward bipartisan legislation that will “bend the cost curve.” The AMA is getting beaten up based on a lot of misinformation, and I told Dr. Rohack we'd send around a letter he’s writing to get straight the facts about AMA’s positions on the controversial issues.

Dr. Rohack did make an important note that “the reason HR 3200 is very important is there is a fatally flawed formula (SGRrrr) … that will affect seniors’ access to Medicare.” He continues that “at least … the House bill … fixes this fatally flawed formula once and for all.” 

*** Image from Flickr (maliciousmonkey). ***

No vacations for the Senate ‘gang of six’ (Democratic Sens. Baucus, Bingaman and Conrad; and Republican Sens. Grassley, Enzi and Snowe). They are still meeting to try to craft a bipartisan solution, just not in DC. They must be hiding out from the very raucous ‘town hall circus events.’ Maybe they’re worried that the alleged death panels might be intended for them if they can’t come up with something tangible soon.

Baucus said on Thursday that he was reaching a bipartisan accord that would reduce spending over the House (H.R. 3200) and Senate Health, Education, Labor and Pensions bills. How he would do that is still not fully clear, but he would hit up Medicare Advantage plans, hospitals, and PhRMA as previously noted, and he would cut the $230 billion in H.R. 3200 to eliminate the SGRrrr back to a one year fix for $11 billion. He’s kicking the can down the road again. We’d have to lobby in 2010 to find $285 billion to prevent monumental cuts in 2011. Give me a break. The House bill (and AMA) is right here! Get ‘er done, folks. But what do you bet there will be no tort reform in there?

*** Image from Flickr (Dakotilla).***

If you've been reading this blog, you know where I stand on this poll topic. I want to hear what you think --

Will we have a bipartisan health solution? (Does a chicken have lips?) Senate Democrats met with President Obama at the White House before they headed home to continue discussions of health care reform. The President is still strongly urging a bipartisan bill, but apparently he acknowledges that may not happen. The only chance for bipartisanship left seems to rest in the secretive deliberations of the 'gang of six' Senate Finance Committee leaders, mainly driven by Sens. Max Baucus and Chuck Grassley. As if to illustrate Obama’s point that we may not get a bipartisan solution, members of the Republican camp are planning to redouble their efforts at ad campaigns and angry outbreaks at all meetings on reform to discourage the plans designed by the Democrats.

HHS Secretary Kathleen Sebelius has begun visibly helping the president to promote his agenda. Sebelius held a Webcast Friday (see ACC's live "tweeting" for more coverage) to discuss how health reform will benefit all Americans and to announce the release of a series of new state-by-state reports on the topic. "These reports show how health insurance reform will help Americans save money, get better care, strengthen their insurance if they already have it, and afford insurance if they don't," said Sebelius. "Every American will benefit when we pass health insurance reform.” She's also pushing the bipartisan nature of health reform -- the status quo brings both parties to their knees economically. But the proposed solutions do get very party line oriented, especially still over how to pay for reform, and over the "public option."

Sen. Kent Conrad (D-N.D.) in an apparent effort to avert the demise of the entire proposal based on one element of the plan, signaled before leaving for home that reform legislation should include health care co-ops rather than a government-run single-payer system (a.k.a. public option). In a USA Today op-ed, Conrad says his plan “opens the door to getting the votes we need to pass health reform that reins in skyrocketing health cost growth, expands coverage and improves quality.” The House Dems aren’t buying it yet though.

There still has not been enough talk about delivery system and payment reform, and no one in the Senate seems committed to paying for eliminating the SGRrrr, as the House bill heroically does. The AMA is right to push that aspect of the House bill -- that SGR albatross needs to be lifted from our necks, not simply dragged down the road for two years to the next payment crisis.

House of Medicine Food Fights
But, the food fights and party line divides are NOT just in Congress. It’s beginning to get frustrating in terms of the self-centered splits among physicians and specialties, weakening our message and making it very tough to have a physician presence at the table. ACP, despite representing cardiology, oncology and many other specialties, has supported the Medicare Rule as it is, undermining specialists! How unfortunate -- it provides only a token increase for primary care. We need a bigger primary care solution as part of the access expansion! Then some surgery and ER groups are bad mouthing the medical home concept. Divisiveness will only hurt the profession. The ACC needs to get our specialty colleagues together right after Labor Day to bring us all back to a more sane and unified position on payment and delivery reform. The AMA may want to help with that, and the larger states could also be involved.

We need to get focused on what’s right for patients first. There should be a consensus there; and then we can work on how to seek compromises that do not undermine the profession’s necessary and important role in this process.