The ACC was in Chicago last week for the AMA House of Delegates — and the President did not disappoint a considerably skeptical audience in his historic address there. The media way over-emphasized the one, little (almost good natured) boo expressed by the House over his reluctance to supporting caps on medical malpractice damages -- notwithstanding that the rest of his remarks were punctuated by frequent standing ovations. He’s good. And this was no easy crowd. But, his big principles and ideas about reform resonated surprisingly well it seemed. That said, the details (mostly not mentioned) will be where the devils are. So, while the docs there were flattered and impressed that he came, and he clearly performed very well, there was a lot of head scratching later based on confusion about "what did that really mean for me and my practice?"  

ACC Message
Our ACC message on this topic (which I touched on briefly last week) is that we must address payment reform as part of overall reform to drive down the cost curve by incentivizing systematic improvement in quality and evidenced based outcomes. That wasn't a big theme in Obama’s message -- or in the messages coming out of Congress this week. Quality improvement is mentioned always, but I'm worried that the beef (details) aren’t there (we DON’T want to hear later that PQRI will be our de facto payment reform for now... yikes). Without payment reform that leads to quality improvement, health IT adoption, and reduced disparity and variation, we will produce another noble Massachusetts-like increase in access, but without slowing cost increases. That is a formula for disaster.

The ACC has proposed a payment reform option pilot through the development of voluntary, multi-specialty, quality-based physician networks organized around participation in CMS-approved registries. Under this proposal, physicians would be paid by a combination of budget neutral fee-for-service and virtual bundled bonus payments that reward quality improvement and improved patient outcomes. In a way our approach is a kind of glide path for non-integrated practices toward virtual and then perhaps real integration -- this is the only path I see toward substantial future payment improvement.

The Oh-So-Controversial Public Plan
The most controversial thing mentioned in POTUS' address was the need for a new public plan. I think that could get traded off as reform proceeds to appease the Republicans. But AMA and others have expressed concerns about a public plan. The House committees want to make sure the 'public plan' pays doctors better than typical private insurance -- if they could guarantee that, a lot of physicians might be interested. Regardless, the nation must move forward and expand access and coverage to all Americans, to fix the flawed SGR, to improve quality, and to institute payment reforms that promote better outcomes and value. But this public plan issue is very heated -- many Dems passionately want to see it included; and many Republicans are just as passionate that it must be killed. To derail reform over the controversies surrounding a public plan as a single provision is irresponsible.

So maybe Senator Conrad’s alternative suggestion to create purchasing 'co-ops' rather than a public plan might solve this dispute ultimately. The idea is that states might form federally sanctioned public private insurance 'cooperatives' to improve access to special populations (as already exist in some states as alternatives to traditional Medicaid). This alternative might be the 'fig leaf' the Senate Dems need to get around this issue. But, the House Dems are NOT going to let go of it on their own. This week I visited the influential Dem House leaders Xavier Becerra of Ways and Means and Lois Capps of Energy and Commerce last week, and they are insistent that the public plan must be in the final bill.

*** Official Barack Obama portrait (Wikimedia Commons). ***