Each Patient Counts: Massachusetts Medical Society Weblog

AMA Vote Keeps Door Open for Negotiations on "Health Reform Alternatives"

The American Medical Association House of Delegates voted this morning to "support health system reform alternatives that are consistent with AMA principles of pluralism, freedom of choice, freedom of practice, and universal access for patients."

The vote follows several days of vigorous debate at the AMA, with President Obama's proposed public health plan serving as a lightning rod for opposition. Some physicians wanted the AMA to oppose a public plan outright, for fear that it would destroy private health insurance. A report in the Dallas Morning News said that Texas physicians had proposed excluding the term "public plan" from the final resolution, in an effort find middle ground. The final policy statement did not explicitly mention the public plan proposal.

MMS President Mario E. Motta, MD, said, "We had quite a boisterous and vigorous debate. In the end, the AMA came out in favor of being more than willing to sit down at the table, and work hard with others to help craft a better health care system. We're pleased with that result."

The AMA's immediate past president, Nancy Nielsen MD, echoed those sentiments at a news conference after the vote. "People did not want to close the door on alternatives," she said. "No doors were closed."

Read the AMA's news release.

Obama to the AMA: "I Need Your Help"; MMS Reacts

President Obama spoke for nearly an hour this afternoon at the AMA House of Delegates, and his message was simple. "I need your help," he said. "For most Americans, you are our health care system. We listen to you. We trust you."

Obama also spoke directly about the controversial public health plan proposal, about which the AMA has expressed some reservations. "The public health plan is not your enemy. It is your friend," he said. Obama added that the public health plan option is not a "trojan horse" for the introduction of a single, government run health care system in America, though he notes it "may be working" in some countries.

Obama said many things that drew generous applause from the assembled room.

• His plan "allows you to be physicians, instead of administrators and accountants."
• "You did not enter this profession to be bean-counters and paper-pushers. You entered this profession to be healers – and that's what our health care system should let you be."
• His plan would ban the denial of insurance coverage for pre-existing conditions. "The days of cherry-picking are over."
• He would generously fund a national health service corps to increase the number of primary care physicians because "so many of you are drowning in debt."

Obama also spoke of the medical liability system, which initially provoked almost a giddy response from the audience. That reaction prompted him to say, "Don't get too excited yet." Obama continued that while he doesn't support caps on malpractice awards (prompting a low murmur from the crowd), he supports "scaling back the excessive defensive medicine that increases costs." He did not provide details of this approach.

Following the speech, MMS President Mario Motta M.D., said, "The President's speech hit on all the major points that the MMS has been making about health care reform. Clearly, something must be done about health care costs. At the same time, a reform package must restore the ability of physicians to provide timely, high-quality care to their patients. This would be achieved by promoting and rewarding evidence-based medicine, reducing administrative burdens and the incentives for costly defensive medicine. A reform package must also promote the development of a robust primary care workforce, and encourage preventive care and healthy lifestyles. This is a vision that physicians and patients everywhere can unite under."

Watch the complete speech here, courtesy of msnbc.com.

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The complete text of his speech is available here

Obama Speaks to the AMA Today About Health Reform

After a week of crossed signals about the AMA's position on health reform, President Obama speaks to the AMA's House of Delegates today about health reform. It starts at 12:15 p.m., ET.

We'll summarize his remarks here, then follow up with comments from the AMA and the MMS leadership, who are attending the AMA conference.

MMS Comments on Public Health Plan Proposals

The MMS Committee on Legislation voted unanimously last week in favor of the concept of a public health insurance plan and outlined the following elements that would be essential for any public plan’s success:

● Physician participation in a public plan should be voluntary.

● The plan should not build on the current Medicare or Medicaid plans, particularly in their financing mechanisms.

● There should be a level playing field between public and private insurers. The public plan cannot be given any market advantage over current private insurers.

● Efficiencies must not be derived by imposing price controls, but by creating a new delivery system that promotes quality, rewards healthy lifestyles and preventive care, discourages defensive medicine, and reduces administrative burdens.

“A public health insurance plan could provide patients with choices that they don’t currently have,” said MMS President Mario Motta, M.D., “A public plan could play an important role by providing healthy competition for private health insurers.”

Monday, President Obama is scheduled to speak about health reform at the annual meeting of the AMA House of Delegates in Chicago. Last week, the AMA issued a statement clarifying its stance on health reform, following a New York Times article indicating that the AMA was flatly opposed to a public plan.

AMA President Nancy Nielsen, M.D., said, “Make no mistake: Health reform that covers the uninsured is AMA’s top priority this year. Every American deserves affordable, high-quality health care coverage.”

Nielsen continued, “The AMA opposes any public plan that forces physicians to participate, expands the fiscally-challenged Medicare program or pays Medicare rates, but the AMA is willing to consider other variations of a public plan that are currently under discussion in Congress. This includes a federally chartered co-op health plan or a level playing field option for all plans. The AMA is working to achieve meaningful health reform this year and is ready to stand behind legislation that includes coverage options that work for patients and physicians.”

Federal Health Care Bills Start to Emerge

Three major approaches to federal health care reform began to emerge this week on Capitol Hill, from both Republicans and Democrats, in both the Senate and the House.

• Sen. Edward Kennedy's Committee on Health Education Labor and Pensions released a bill with some, but not all, of the concepts that members have been discussing. It does not include, for example, language creating a public health insutrance plan, nor about an employer mandate. Sen. Kennedy said in a written statement that Democrats and republicans are still negotiating those issues.
  • Read a summary of the bill on the Boston Globe's website.
  • Download the the 615-page legislation from the HELP Committee's website.
• Republican Sen. Tom Coburn released a health care bill that differs from Kennedy's in many respects. A key feature is its reliance on tax credits to help individuals purchase health insurance.
  • Read Sen. Coburn's outline of his bill on The Huffington Post.
• A group of three House committees issued its own health bill. This "TriComm" bill is similar in many respects to the HELP bill.
  • Read the committees' summary of its legislation.

One more committee has yet to submit its own bill - the Senate Finance Committee, led by Sen. Max Baucus of Montana. That bill is expected to be released next week.

The next few weeks will be consumed with committee hearings and revisions of the bill (known on the Hill as "markups").

Kennedy's Committee Releases (Parts of) Health Reform Bill

The Senate Health Education Labor and Pensions Committee (HELP) today released a long-awaited health reform bill, but it does not include the proposed public health plan that Kennedy has been touting, nor does it include a proposal for an employer mandate.

In a written statement, Kennedy said the committee is still trying to negotiate with Republicans to find common ground on these issues.

• Read a summary of the bill on the Boston Globe's website.
• Download the the 615-page legislation from the HELP Committee's website.

Payment Reform Commission Posits Framework for Shift to Global Payment

A framework for making an effective and orderly transition to global payment was the main topic at today’s next-to-last meeting of the Special Commission on the Health Care Payment System.

The commission’s transition framework relies heavily on the creation of Accountable Care Organizations (ACOs), virtual or actual provider networks that integrate health care services and improve coordination of patient care.

The structure, scope, and function of ACOs was one of many parameters that an independent board to oversee the transition would be charged with, according to the framework. The board would also be responsible for identifying adjustment factors for global payments and tracking milestones, among other tasks. The framework calls for board intervention if certain milestones are not met, which sparked debate about state rate setting and the stick-or-carrot approach to incentives. Commission member Alice Coombs, M.D., MMS president-elect, called for a “nurturing” approach to help providers make the change rather than penalty-based incentives.

The timeframe set forth in the framework for a completed transition to global payment is five years or less, and it encourages providers who are in a higher state of readiness to move more quickly.

There was also debate about the so-called “complementary strategies” that many stakeholders say must be addressed in tandem with payment reform. These include malpractice reform, health plan benefit redesign, and administrative simplification. Some commission members, including Dr. Coombs, insisted that these strategies are inextricably linked to payment reform, while other commission members said such matters could distract the board from its primary purpose.

The commission’s final meeting, originally scheduled for May 26, has been postponed until late June. Between now and then, the commission will iteratively draft a final report of recommendations for the Legislature.

To view the slides from today’s meeting, visit the Payment Commission’s website.

An Amazing Post on GIC Tiering By a Primary Care Physician

Dr. Sally Ginsburg, pediatrician from Longmeadow, has written an amazing post on the absurdities of the Group Insurance Commission's physician tiering program. It's on WBUR's "CommonHealth" blog. We heartily recommend a close, careful reading of her points.

She agrees that health care must be delivered more efficiently and that quality must be improved. But she cites many examples of where tiering clearly fails the test.

She concludes, "Look at where the BIG health care money is really being spent- high cost, end of life care and very costly and sometimes futile beginning of life care. Stop playing this out on the primary care physicians, before there are none of us left in the state."

The Massachusetts Medical Society has filed suit against the GIC to "correct the wrongs" of the tiering system. We contend that the GIC's tiering system is not only complex, it is impossible to understand. It is not only unfair, it is inaccurate. It is supposed to save money and reduce costs, but there is no evidence it does either - and there is a lot to suggest it actually does the opposite. It is unfair to physicians, and it misleads patients.

In December, a state judge held a hearing on the GIC's contention that the complaints of the MMS and five physician co-plaintiffs were without merit. A ruling on the matter is still pending.

Meanwhile, the GIC's health plans have released the tier designations for program's fourth year, and the inequities and inaccuracies seem as bad as ever, if not worse.

This isn't the way to address cost and quality. It's time to move on to something else.

Bruce Auerbach, MD
President, Massachusetts Medical Society

IOM Looking for Feedback on Comparative Effectiveness Research

The Institute of Medicine is soliciting comments from physicians on the priorities it establish for the new comparative effectiveness research program established by last month's federal stimulus bill. The bill requires the IOM to submit a consensus report and recommendation to Congress by June 30.

The IOM has posted an online questionnaire that will be available until March 27.

It is also holding a public hearing on March 20 in Washington. Fill out this online registration form if you would like to attend or make a presentation.

For more on the comparative effectiveness research provisions in the stimulus bill, read the AMA's analysis. (.pdf)

Obama's Health Care Budget: New Spending, New Cuts and Tax Hikes

The Obama administration’s budget plan this week features the creation of $635 billion “reserve fund” to pay for changes in the country’s health care system. It includes roughly equal measures of spending cuts and tax increases.

Based on various news summaries and other reports, here’s what Obama proposed. The estimated value of spending, cuts and tax increases come from the Obama administration.

New Spending

• Eliminate scheduled payment cuts to physicians. A 21% cut is scheduled for 2010; 40% over the next decade.
• Spend $330 million to address the shortage of health care providers in certain areas. This includes loan repayment programs for doctors, nurses and dentists who practice in under-served areas. Also, there is assistance for nursing schools.
• Increase cancer research spending at the NIH by $400 million to $6 billion.
• Spend $211 million at the HHS for research into autism, as well as for screening, public awareness and support services for autism patients
• Spend $12 billion in quality incentives to hospitals: $12 billion over 10 years

Spending Cuts

• Eliminate the 14% worth of higher payments that Medicare Advantage plans now get from the federal government and require them to submit to competitive bidding. Savings: $177 billion over 10 years. Medicare Advantage plans cover about 23% of Medicare beneficiaries.
• Set up a "regulatory pathway" to approve generic versions of biologic drugs developed by biotechnology companies. Savings: $9.2 billion over 10 years.
• Require drug makers to provide bigger discounts to Medicaid. Savings: $19.5 billion over 10 years
• Bundle Medicare payments for hospital and post-hospital care, to be split by physicians and hospitals. Savings: $17.8 billion over 10 years
• Cut payments for hospitals for preventable readmissions. $8.4 billion over 10 years.
• Reduce payments to home health agencies by $37 billion over 10 years.
• Use radiology benefit managers in Medicare. Savings: $260 million over 10 years
• Total value of spending cuts: $316 billion

Tax increases

• Increase top tax bracket to 39.6% (currently 35%)
• Limit deductions for mortgage interest and charitable donations by taxpayers in the top two tax brackets to 28%.
• Increase premiums for Medicare prescription drugs plans for high-earning taxpayers ($8 billion over 10 years)
• Allow tax cuts for upper income taxpayers to phase out in 2012
• Block phase out of the estate tax
• Total value of tax increases: $318 billion

What do you think? What's realistic, and what's not?