Category: HB 3200

House Bill Effects on Physician Income

I had a piece in the Pittsburgh Post-Gazette today on physician support of health reform.

A sadistic friend posted it on Sermo. Weee!

The subject of the effect on physician income came up on our Doctors for America and I said:

I often ask my colleagues who 1.) complain about Medicare rates and 2) say all care for the uninsured should be via charity by physicians , “Wouldn’t you rather get paid a bit less and have everyone covered so you have more paying patients?”

I doubt anyone has done an analysis of what the net effect of this would be, but perhaps the net effect would be neutral or positive, I don’t know. BUT as the NEJM survey said, most of us find it acceptable to take lower reimbursements if everyone is covered.

Our terrific Media Mogul, Mandy Krauthammer-Cohen, MD, of course, had a great bit of information:

Some additional food for thought. If you look at the Lewin group analysis….which does have a conservative bias given it is owned by United Health…physicians will actually make more money under health reform with a public option.

Testimony by Lewin states: “In the first year of the program (when public option is only opened to small businesses with less than 10 employees), physician income would increase by $10.9 billion. This reflects the reduction in uncompensated care for uninsured people as well as increased health services utilization for newly insured people. It also reflects the House bill provisions that would increase Medicaid reimbursement for primary care services to Medicare payment levels. Thus, the reductions in payment for people who shift to the public plan are outweighed by increases in reimbursement for Medicaid, reductions in uncompensated care and revenues from increased service use for newly insured people. Average net-income per physician wouldincrease by $15,237 in 2010 under this scenario.”

Read the whole testimony here.

Physician’s Perspective on Health Reform Slides

I updated my slides on physicians’ opinions on health reform for a talk tonight for the Pittsburgh Chapter of Drinking Liberally.

The new slides are here. ( I hope I fixed the link!)

I had to strip out the slides of me (and Doctors for America) at the White House, and on our way TO the White House, already in our white coats in order to get under the 5 MB Google docs limit.

Cheers,

Eight of Ten Largest Physician Groups Back HR 3200

(Original Title) “American Psychiatric Association voted unanimously to support H.R. 3200”

Medical News Today News Article – Printer Friendly:

The Board of Trustees of the American Psychiatric Association voted unanimously to support H.R. 3200, America’s Affordable Health Choices Act, as the basis for health reform.

‘In doing so, the APA is pleased to stand with the American Medical Association,’ said a letter presenting the board’s decision to the American Medical Association. ‘The APA Board of Trustees also voted to support the concept of a public plan option based upon the voluntary participation of physicians and other healthcare professionals in the ongoing dialogue of health care reform.’

‘While H.R. 3200 – like any bill – is not perfect, we recognize that it offers many positive benefits for psychiatrists and other physicians, and most importantly for our patients,’ the letter said.

This now adds the 9th largest physician organization to be on board for HB 3200, including the AMA, ACP, AAFP, AAP, AOA, ACS, and ACOG.

For completeness, #8, the American Society of Anesthesiology and #10, the Amercian College of Radiology are still against reform until they get reimbursement “fixes.”

#11, the American College of Emergency Physicians is still waiting for final form bills to commit.

Organized Medicine on Reform

***Update: Now 8 of the 10 largest organizations are on board!***

Welcome to the blog. To make this a bit easier for everyone, here are the physician organizations FOR either HB 3200 or something close to it: AMA, AOA, ACP, AAFP, ACOG, ACS, AAP, ACC, AGA, ASCO, and SHM.

Squishy middle: AAO, AAOS, ACEP

Mo’ money, then we’ll talk: ASA, ACR.

Details below…

The American Medical Association, ~240K members:

[After passage of HB 3200 out of committee -cmhmd]… the American Medical Association sent a letter to House leaders supporting H.R. 3200, “America’s Affordable Health Choices Act of 2009.” “This legislation includes a broad range of provisions that are key to effective, comprehensive health system reform,” said J. James Rohack, MD, AMA president. “We urge the House committees of jurisdiction to pass the bill for consideration by the full House.” H.R. 3200 includes provisions key to effective, comprehensive health reform, including:

  • Coverage to all Americans through health insurance market reforms
  • A choice of plans through a health insurance exchange
  • An end to coverage denials based on pre-existing conditions
  • Fundamental Medicare reform, including repeal of the flawed sustainable growth rate (SGR) formula
  • Additional funding for primary care services, without reductions on specialty care
  • Individual responsibility for health insurance, including premium assistance to those who need it
  • Prevention and wellness initiatives to help keep Americans healthy
  • Initiatives to address physician workforce concerns

“The status quo is unacceptable,” Dr. Rohack said. “We support passage of H.R. 3200, and we look forward to additional constructive dialogue as the long process of passing a health reform bill continues.”

The American Osteopathic Association (“represents” 67K, per their website; not clear if this is actual membership)

Why is the AOA supporting H.R. 3200?
The “America’s Affordable Health Choices Act” (H.R. 3200) contains several provisions that reflect AOA priorities forhealth system reform. These priorities include: expanding the availability of affordable health care coverage to the uninsured, increased support for prevention and wellness services, investments in the physician workforce, increased Medicare payments for primary care services without cutting payments for other services and, importantly, it represents our best hope for eliminating the current sustainable growth rate (SGR) formula for updating Medicare physician payments. The AOA continues to work with members of the House of Representatives to improve the bill by seeking additions and changes in the legislation. Specifically, we are working to include expanded graduate medical education provisions, medical liability reform, and student loan financing reforms. Favorable action on a House bill is necessary to move the process to the end game negotiations that will determine the specifics of a final bill.

American College of Physicians (ACP, represents 126 K internal medicine physicians including primary care and medical subspecialists like me):

H.R. 3200 does much of what ACP asked Congress to do in terms of coverage, support for the primary care workforce, payment and delivery system reform, based on long-standing policies that have been adopted by this organization. No bill is perfect, but H.R. 3200 delivers on our major priorities in a way that is remarkably consistent with ACP policies, policies that were developed by the College’s leadership over many years and always guide how ACP’s leadership, Key Contacts and staff advocate for internal medicine physicians and their patients.

American Academy of Family Physicians, 94K members:

On behalf of the 94,600 members of the American Academy of Family Physicians, thank you for the positive steps you have taken toward broader, affordable coverage that will mean improved health care based on primary care. We believe that the America’s Affordable Health Choices Act (H.R. 3200) will make significant progress toward payment and delivery system reforms and contribute to building a primary care workforce for the future. AAFP supports this legislation and we will be pleased to work with your committees to improve it further.
……
The public plan option developed by your committees reflects most of these principles very well.

American Academy of Pediatrics, 60 K members:

“The American Academy of Pediatrics (AAP), which represents 60,000 pediatricians, pediatric medical subspecialists, and surgical specialists, praises the U.S. House Energy and Commerce Committee for its vote today on H.R. 3200, America’s Affordable Health Choices Act, and applauds all three House Committees for their continued and steadfast work in the effort to pass significant health care reform.
“The Academy continues to support the process of bringing comprehensive health care reform to America’s children. While there is still work to be done, H.R. 3200 makes significant progress in achieving the Academy’s priorities of covering all children in the United States, providing children with age-appropriate benefits in a medical home, and establishing appropriate payment rates to guarantee children have access to covered services.

American College of Surgeons, 76 K members:

They have a letter of support for HR 3200, but you can’t copy and paste… maybe a little gun-shy about letting the membership see it!

American College of Obstetrics and Gynecology, 52 K members:

“ACOG President Gerald F. Joseph, Jr. MD provides ACOG endorsement of HR3200 (proposed America’s Affordable Health Choices Act of 2009).”

[The rest is behind a password protected section.]

American Academy of Ophthalmology, 7 K members:

Have not yet taken a position on any specific bill, but:

Meanwhile, the Academy, AMA and the American College of Surgeons have been up on the Hill pushing medicine and ophthalmology’s agenda. The Senate bill is expected to contain a rate-setting commission proposal that the Academy helped defeat in the House bill and other troublesome provisions affecting medicine and surgery.

and…

Acknowledging that the status quo in health care is unsustainable and that issues of access to coverage, quality of care and cost control must be addressed, and given legislative momentum in Congress, the Academy is advancing components for bills that protect patients and physicians. While reform discussions are still ongoing and no pending legislation is perfect, we are committed to continue collaborating with health leaders in Congress to improve bills being considered. The Academy is actively engaged with other physician organizations as key House and Senate committees debate legislation that puts a long-term sustainable growth rate (SGR) fix in play, in addition to other top issues.

American Association of Orthopedic Surgeons, ~17 K members:

The AAOS is committed to ensuring that the final bill be as beneficial as possible to the Orthopaedic community, including our patients. We will not make any decisions in support or opposition until something closer to a final bill is available.

Ooops! Perhaps phrased poorly!

American College of Cardiology, 37 K members:

On behalf of the American College of Cardiology (ACC), representing 37,000 cardiovascular members, I am writing to commend you for H.R. 3200, the “America’s Affordable Health Choices Act of 2009.” This legislation makes a significant financial commitment to comprehensive health system reform and we are committed to working with you on this effort.
ACC is especially pleased that H.R. 3200 takes extraordinary measures to extend coverage to every American and takes positive steps to strengthen Medicare. Among the Medicare provisions the College supports include:
• Funding to eliminate the accumulated debt from the flawed Sustainable Growth Rate (SGR);
• Establishment of a positive Medicare physician payment update (MEI) for 2010
and favorable spending targets for updates in the future;
• Significant payment and delivery reform models such as incentives for physicians to participate in Accountable Care Organizations; and
• Expansion and improvements to the Physician Quality Reporting Initiative (PQRI) to encourage successful participation;

American Society of Clinical Oncology:
Can’t find anything on their website. The American Cancer Society, on the other hand, has made access to health care via serious reform their top priority. And, by the way, on palliative care? They’re for it.

American Gastroenterological Association, 17 K members:

On behalf of the American Gastroenterological Association (AGA), representing over 17,000 physicians and scientists who research, diagnose and treat disorders of the gastrointestinal tract and liver, I am writing to express our appreciation and support for several provisions in H.R. 3200, America’s Affordable Health Choices Act. The AGA appreciates your leadership and shares in your goal to expand health care coverage to the uninsured, improve coordination of care, and enhance quality.

American College of Emergency Physicians, 27 K members:

“It is important to note, however, that a common theme supported by members of the House and Senate (Democrats and Republicans), as well as the White House, is to extend coverage to nearly all Americans, although there are differences of opinion as to how this objective is best achieved. ACEP supports this endeavor to provide universal health care as a benefit for patients and its outcome of drastically reducing the burden of uncompensated care provided by emergency physicians.
ACEP encourages you to discuss and promote these issues with your members of Congress during the August recess. Your message to lawmakers:
These provisions will improve your constituents’ access to vital emergency medical care services and they must be part of the final health care reform package that is sent to President Obama.
Due to the fragmented, unpredictable nature of the process, and the lack of a final product in the House or Senate, ACEP has refrained from taking a public position on the overall legislative proposals. This has been, and remains, a very fluid process and we want to assure you that ACEP will continue to monitor these plans and advocate
for the needs of emergency physicians and your patients.”

American Society of Anesthesiology, 43 K members:

“ASA members may be confused by a request for support of H.R. 3200 by other medical associations, including most recently the AMA. ASA CANNOT AND WILL NOT SUPPORT THE BILL IN ITS CURRENT FORM. Members are strongly encouraged NOT to respond to AMA’s request to support H.R. 3200. The bill, the ‘America’s Affordable Health Choices Act,’ includes a public plan option based upon Medicare payment rates for anesthesia services. A Medicare rate-based public plan would be detrimental to the medical specialty of anesthesiology.

“ASA has consistently urged lawmakers to address anesthesiology’s ‘33 percent problem’: the fact that Medicare pays 33 percent of what private insurers pay for anesthesia services (while Medicare pays an average of 80 percent of what private insurers pay for most other medical specialties). This 33 percent payment level simply does not reflect the costs of providing anesthesiology medical care. As such, Congress must not use this payment level as a model for any health care plan.

“We acknowledge that there are many laudable provisions included in H.R. 3200. Still, many issues remain unresolved, and questions linger about how various provisions would impact anesthesiology. We must remember that there is no other organization involved in the reform debate that is speaking for anesthesiology. In fact, some groups are actively lobbying for provisions that would harm our specialty. Anesthesiologists’ shared voice is the only way to ensure that the important and unique concerns of our specialty, our practices and our patients are heard in the halls of Congress. “

American College of Radiology, 32 K members:

Best I could find on their website:

Unfortunately, it seems ACRs position regarding the House version of healthcare reform, HR 3200, has been incorrectly characterized. As many of the details of overall health care legislation remain fluid, the College has not taken a position, for
or against, any of the current overall congressional proposals, including HR 3200.
Regarding HR 3200, we continue to educate congressional leaders that the imaging and radiation therapy provisions, including a raise in the equipment utilization rate assumption to 75 percent and a further 25 percent cut to contiguous imaging, are flawed ideas that will ultimately harm patient access to care particularly in rural areas.
Until negotiations regarding such provisions are complete or are clearly at an impasse, ACR will not take an official position on the entire House bill. Any information that ACR has offered its support or opposition to HR 3200 is incorrect.

Update: I almost forgot to include some rather contrarian sentiments from the South Carolina Medical Association, as well as some “Old School” conservative physicians to round out the round up. They are not alone, as some other deeply red states’ Medical Societies have expressed similar dire warnings. But for them, this is really about ideology, not solutions.

Update II:

Society of Hospital Medicine ( ~6 K members, represents hospital based physicians):

On behalf of the Society of Hospital Medicine (SHM), I am writing to express our support for provisions in H.R. 3200, the “America’s Affordable Health Choices Act of 2009” regarding delivery system reform. SHM represents the nation’s hospitalists—physicians whose primary professional focus is the general medical care and management of hospitalized patients. We agree that the time has come for comprehensive health reform and appreciate your leadership and commitment in pursuit of this worthy goal.

AMA Conference Call on HC Reform

The AMA is doing regional conference calls on health care reform. The one for my region (PA, NY, MA, maybe others) was tonight. I gather it was the first one they’ve done so far, but they indicated they would be doing more.

On the call for the AMA were Immediate Pat president Nancy Nielsen, Jim Wilson, Political Education Programs Manager, and Richard Deem, Senior VP for Advocacy.

I was pretty pleased with the call and the positions that the AMA seems to be taking, so you may be pleasantly surprised.

The call started with some comments by Dr. Nielsen, then questions from the group (transcribed for the AMA reps, who read them to us), and a brief closing statement.

Dr. Nielsen opened with a discussion of HR 3200, presumably because of the push back the AMA has gotten from its more conservative members. HR 3200, in its original release addressed in positive ways, many of the AMA’s highest priority goals. These included extended coverage for the uninsured, preserved choice of health insurance plans, fundamental Medicare reform including elimination of the SGR, encourages mangament of chronic diseases and coordination of care, increased payment to Primary Care Physicians with no reduction in fees to specialists.

The things in 3200 the AMA wants changed: addition of Medical liability reform; change in plan for public option fees to be 5% above medicare; and restrictions on physician ownership of hospitals.

Ammendments introduced so far include “modest” liability reforms (AMA speak for anything that is not “caps” on damage awards), including encouraging states to give incentive payments for certificate of merit and “early offer” programs, and she reaffirmed, essentially, that we’re all about caps at the AMA. Also ammended, public plan participation by physicians will not be mandatory and public plan fees will be negotiable and not fixed to medicare rates.

Compromises still being sought include, in the Senate HELP committee: Public Plan similar to HB 3200; negotiated payments; the plan must be self sustaining, and compete on a “level playing field.”

In the Senate Finance Committee, the bipartisan “Gang of 6” are seeking compromise legislation, but we have not seen an actual bill yet. But all indications are that this bill will NOT fix SGR (only another one year fix, then replay the annual ritual of rganized medicine fightinng to fix this again. The AMA wants to fix this with Senate FLOOR VOTE. Also concerning are possible penalties for PQRI non participation and that we may end up with co-ops rather than PO/PP. Dr. Nielsen preemptively addressed the question of why the AMA has postioned itself where it has re: HB 3200: We need insurance market reform because insurance is tenuous to the public, it is tied to jobs, it is limited by preexisting conditions and because we all pay for care given to uninsured anyway. Getting rid of SGR is a big deal for the AMA as is avoiding other financial penalties (such as with PQRI) and we do all have to be worried about costs.

She also points out that we physicians are being dealt with very fairly in HB 3200: Hospitals are going to get cuts, home health gets cuts, as do others while physicians get $230 Billion (erasing SGR debt is part of this number, but also includes higher fees for PCPs including incentives for coordinating care and dealing with chronic care patients)

Why did AMA support HB 3200 so quickly? Dr. Nielsen said that early support means something and gives us more influence; we are working with leaders in both houses and they understand Medicare must be strong(!). The AMA did not “give away” support; it was negotiated and we got things: No mandatory participation in a public plan, more money.

She points out that ranting is not useful, quiet negotiation does and is working.

QUESTIONS FROM AUDIENCE:

Q: Socialized medicine!!! Slippery Slope!!!! (I paraphrased here.)
A: NO: Americans will not tolerate it. Expanding coverage is not socialism.

Q: Will there be rationing under Medicare or under any public option.
A: NO NO NO

Q: Wwhy support anything without “significant” liabilty reform?
A: We’re still fighting!

Q: How does AMA support 3200: It’s awful.
A: No, it isn’t. SGR!

Q: Can we have physician council to guide HC?
A: AMA may be filling this role in guiding legislation, but not clear if tere would be a way to do some far reaching council.

Q: Anything restricting physician patient relationship?
A: The AMA is FIRM in that there can be no interference in care decisions. CER will never mandate what a doctor may offer to a patient. MC is easier to deal with than PHIs(!!!), she said, from her perspective as a primary are physician. Less hoops with MC! We also want best evidence! Mr. Deem: No penalties on PQRI in HB 3200

Q: How can we support bill we haven’t seen? Aren’t we being used/abused?
A: Physicinas are necessary in this debate. Congress has brought actors together and said we are all in this together and we have to do this. NN thinks we are participating, not being used and we believe we have influenced the process significantly, but perhaps not on CAPS.

Q: HB 3200 better PCP fees?
A: Yes; also increased coordination of care fees.

Q: Did you read 3200?
A: Yes. We have a team that does that and they analyzed it. I have read it as well.

BIG POINT HERE: She calls out the BS email about he facts of HB 3200 as “outrageous,” and notes that the AMA has reviewed, and agrees with the rebuttal provided by politifact.com.

Q: Massachusetts seems to be working well except cost controls, what now?
A: We need to learn from MA; getting people in system but costs are big issue; bigger question is how do we come to grips with our responsibility as citizens and patients and physicians and insurers? MA has shortages in work force, nursing and derm and gen. surgeons; We don’t need to wait for workforce to be online before we reform HC; lead time too long for physicinas in particular. Choice of doctors and insurers key.

Q: 70-83% of peopple are satisfied with coverage; maybe they won’t be if we change things; maybe Congress will lower reimbursement after the bill passes?
A: We are all nervous; but we are also the unhappiest MDs in the world. Prez says you can keep what you have; AMA is concerned about this and we want to preserve choice.

Q: Will Public Plan crowd out private insurers?
A: Bill is written so choice to join PP is limited (to the uninsured, small businesses and some others) but this could change and we must be vigilant.

Q: Why should we trust this administration?
A: Trust but verify. This is about influence and we are critical to change. It is important for us to pay attention and focus on what we agree on, and not on divisive issues.
Mr Deem: Adminstration trying to fix/improve payment formula and did something about MD administered drugs that AMA has been asking for for 8 years and we are just now getting it.

Dr. Nielsen made the point here that Obama’s example of non-indicated tonsillectomy example. She thinks that was Really Bad; we know it is not like that; they got big push back.
[CMHMD: I actually agree that he really mangled this one; “inartful” was the kind way to put it, I thought.]

Q: Will there be an independent body, such as an uber-MEDPAC or IMAC, that will rule the roost?
A: Dr. Nielsen expressed concern that there seem to be expenditure targets for physicians, but not for any of the othr big players. She indicated the many if not all of these issues are “in process,” and the AMA is expressing our concerns.

Dr. Nielsen added that she thought a view expressed what she called a “minority view” of physicians is that an independent council would be better than dealing with congress. [CMHMD: I don’t think this is a minority view. Many health policy big wigs think having Congress function as the “Board” for Medicare is a bad thing that needs fixed.]

Q: CBO score for Senate Bills?
A: We don’t know when we’ll get them.

Q: Other countries physicians’ have less financial pressure coming out of training.
A: We agree and are working on it.

Q: What should physicians be doing now?
A: AMA is happy to help and reach out. Like this call. Hard to say what to do; gives example of tea baggersand cautions that physicians need to be rational and let people know we want to take care of patients without government interference and make sure uninsured get in system and don’t saddle kids with crushing debt. Don’t fall for labels and rhetoric.

Q: What happens to HSAs?
A: Mr. Deem: HSAs stay in so far. And we will push for that.

Q: Geographic variation?
A: AMA pushing for money for IOM study. Gypsy payment floor (?)

Closing, Dr. Neilsen: This is moving target. What’s the difference between an echanges and a co-ops? Exchanges are like a mall to shop; co-op like a single store where owners are also customers.
[CMHMD: I’d call this mutual insurance, and it could be a good thing if well regulated.]

CMHMD final comments: I fouund this very encouraging. There was the expected conservative push back, but that’s OK, Dr. Nielsen did a great job of keeping things focused on what are truly high goals for physicians: universal access and fairness in the system. She also stuck to the markers she must or get pummelled by the membeship on tort reform and “choice,” but, hey, pretty good from where I’m sitting!