"An American tale--the little truck that said it can!": (Health care's shifting universe).
Subject: Health care reform (Laws, regulations and rules)
Health care reform (Political aspects)
Prospective payment systems (Medical care) (Laws, regulations and rules)
Prospective payment systems (Medical care) (Political aspects)
Political parties (United States)
Political parties (Evaluation)
Author: Jimenez, Carlos C.
Pub Date: 03/01/2010
Publication: Name: West Virginia Medical Journal Publisher: West Virginia State Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 West Virginia State Medical Association ISSN: 0043-3284
Issue: Date: March-April, 2010 Source Volume: 106 Source Issue: 2
Topic: Event Code: 930 Government regulation; 940 Government regulation (cont); 980 Legal issues & crime Advertising Code: 94 Legal/Government Regulation Computer Subject: Government regulation
Product: SIC Code: 8651 Political organizations
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 223908170

It was an old story of the little truck that said it can, and did it redux in Massachussets! Burl Ives sings of the saga of the little engine whose mantra was, "I think I can, I think I can," and finally did.

The recent win of Republican Scott Brown over the Democratic candidate, State Attorney General Martha Coakley was one of the most improbable electoral victories in recent U.S. history. He won with fifty two percent (52%) of the vote while Miss Coakley garnered forty-seven percent (47%). The GOP victory means Democrats will hold only 59 seats in the senate and this creates a major obstacle in completing healthcare reform in its present form, as Brown has said he would vote against healthcare reform legislation.

As the Democratic leaders are scrambling to save healthcare reform legislation, what are the possible scenarios that could occur?

Scenario 1 -- Full steam ahead. Abandon the White House and Democratic congressional leadership, abandon the House-Senate negotiations and work out differences between the two bills. Instead they push House Democrats to approve the Senate bill as is. However, it is not clear whether the House votes are there to pass it. This causes significant political risks for the Democrats as they would appear to be acting against mounting public opinion.

Scenario 2 -- Find a new 60th vote in the Senate. President Obama has been on the phone regularly with Senator Olympia Snowe (RMaine), who voted reform out of the Senate Finance but withheld her vote on the Senate floor. Anything is possible, but he is unlikely to bring Snowe back on board.

Scenario 3 -- Alternatively Democrats could choose to slow down the legislative train and reopen debate on healthcare reform. The likely result is either no legislation on healthcare reform during 2010 or a significantly trimmer package -nothing close to universal coverage.

Earlier Conchita and I visited the Capitol. Driving by the river, several times, I found that the view of the river even from the same vantage point changes every time. It was then I remembered that it was not a novel idea, Heraclitus 2,600 years ago dipped his toes in a river in Greece and instantly understood that change itself is the only unchanging reality. He realized that he could never, as hard as he might try or as much as he might like--step into the same river again.

Change and innovation will come despite our attempt at stalling and standing firm. Flexibility is the ongoing practice of moving with life. So let's move on.

With healthcare reform in limbo, we need to focus on the repeal of the Sustained Growth Rate Budget Neutrality enacted in 1997. Congress wins again, as it has side-stepped a permanent SGR fix by kicking the can down the road until March 1--the shortest distance on record.

The deferral appeared as an amendment to a defense appropriations bill signed into law by President Obama December 19, 2009. To gain a sense of the recurring nightmare this annual stopgap has become for us, consider that in 2005 the deficit was $48.6 billion or a 3.3% cut. By 2009 it has ballooned to $245 billion or 21.2% in Medicare and Tricare (insurance provider for our military and their families) payments to providers.

Unless another deferral takes place, West Virginia physicians will face an across-the-board Medicare reimbursement cut of 21%, with more cuts likely to follow over the next few years due to a flawed payment formula, the Sustainable Growth Rate or SGR. This formula was put in place by Congress over a decade ago and both Democrats and Republicans agree it needs fixed, and the time to fix it is now. At least seven times in as many years, Congress has stepped in at the last minute with a temporary fix to limit reimbursement cuts. Each time, however, it causes future cuts to grow larger and, once again, we are facing a 21 percent cut.

We should be concerned that Medicare cuts will further erode seniors' access and choice of physician as we already have one of the worst patient-physician ratios in the country. Congress needs to fix the formula once and for all so patients can be assured of continued access to care and choice of physician.

West Virginia is one of twenty-one states and the District of Columbia that made the American Medical Association's "Access Hot Spots" list, which highlights areas where patients already face problems getting patient care, and the problem will get worse unless Congress repeals the broken Medicare physician payment formula.

With nearly one in five West Virginians covered by Medicare, we have the largest proportion of population on Medicare of any state. Access problems for West Virginia seniors are very pronounced, with only 13 practicing physicians per 1,000 Medicare beneficiaries, which is one of the nation's worst, and 29 percent of seniors on Medicare living below 150 percent of the federal poverty level.

In addition, 44 percent of West Virginia's practicing physicians are over 50 years old, an age at which surveys have shown many physicians consider limiting their patient care activities.

Let me be clear: West Virginia physicians want to care for seniors and military patients--but we cannot keep the doors open to all patients when the government does not cover the cost of providing that care. These cuts will make a bad situation worse for seniors and military families.

Previous momentum spurred hope that healthcare reform would encompass a permanent fix to the SGR, and the first House draft bill included an SGR restructuring. This provision was scrapped after the Congressional Budget Office (CBO) analysis indicated that it would add $245 billion to the bills' final cost.

In any scenario, the rising antigovernment spending sentiment will pressure the President to initiate a serious bipartisan effort at deficit reduction in 2010. When Washington looks at deficit reduction--Medicare providers--look out!

The House bill would have postponed the insolvency date of the hospital trust fund by five years; the Senate bill by ten years and if the big bill fails, we are back to insolvency by 2016-2017, physicians and hospitals would still face reimbursement perils.

What do health policy experts debate? Where should reform go? Their viewpoints articulate the clashing philosophies that underlie the current deadlock in Washington.

Stuart Butler, of the right-wing Heritage Foundation, points out that even small reforms could have large unintended consequences. For example, he notes that the Office of Personnel Management (OPM) now administers the Federal Health Employees Benefit Program like a large private employer, without laying a strong regulatory hand on the health plans that compete for government workers' business. If the provision in the Senate bill that would let OPM supervise a menu of plans for individuals and small firms were passed on its own, he suggests, the OPM would take a much harder line with the plans, which would eventually come to resemble the public option much reviled by the right. Butler concludes that Congress is better off doing nothing until every last possibility has been puzzled out.

John Goodman, another Republican policy maven, does not favor any of the Democratic ideas, either. While he agrees with ultra-liberal Paul Krugman (shudder) that the proposed insurance reforms would fail if they were adopted incrementally, he proposes replacing them with a raft of ideas derived from the consumer-driven healthcare concept he's associated with. Just as in consumer-driven health plans with health savings accounts, these ideas revolve around having each person insure themselves against their own personal risk, rather than spreading the risk across the sick and the healthy, the old and the young. This reflects the Republican thinking of every-person-for-himself-or herself--non redistributive philosophy, but it's hard to see how it would help expand coverage or reduce health costs, except by denying care to those who need it the most.

Joseph Antos, a less conservative thinker at the American Enterprise Institute, also acknowledges that a slimmer bill is unlikely because of the interconnectedness of the issues involved. "One cannot simply pluck a few provisions out of the bill and expect to have legislation that achieves ambitious goals," he points out. But he thinks that the current legislation over reaches and that Congress should focus on incremental reforms to achieve targeted goals.

For example, he would change the way Medicare reimburses providers (an approach that is promoted in the current bill), and he would cap the federal contribution to Medicaid programs (an idea the states would be ecstatic about).

He would replace the individual mandate to buy insurance with a system in which those who maintained lifetime coverage would have lower premiums than those who interrupted their coverage or tried to buy insurance only when they got sick. Antos maintains that this would be the best way to persuade everyone to buy insurance.

Finally, there's Henry Aaron of the liberal Brookings Institution, who insists that the only way forward is to pass the current legislation, using the budget reconciliation maneuver to "fix" the Senate bill that the House would have to pass. "The start-over, do-it-in pieces strategy is an invitation to time-wasting failure," he states, pointing out that each piece would need to attract 60 votes in a Senate where the Democrats now have only 59 at best. Moreover, Aaron points out, a "reform lite" package that expanded coverage to a smaller group would not work: "It is not possible to institute serious insurance market reforms without assuring a balanced pool of enrollees. It is not possible to mandate coverage. It is not politically correct to institute serious insurance market reforms without assuring a balanced pool of enrollees. It is not possible to mandate coverage without providing subsidies to make insurance affordable to low and moderate income people. And it is not possible to prevent subsidies from boosting deficits unless one is prepared to boost taxes or cut other spending, which reform opponents have consistently refused to do and which would certainly require sixty Senate votes."


Back in West Virginia, we have just concluded the WVSMA Mid-Winter Business Meeting, and those who were in attendance enjoyed and benefitted from the Physician Practice Conference. Certainly, Barbara Good has chosen very well. Rose Moore's Management Tips for a Successful Practice are up to date and necessary. The RAC update is timely and much needed. Pam Harvit's, Office Protocol and Etiquette garnered the most number of pearls.

I can still remember Sister Janet Marie who taught us on the deportment of young men with good breeding. There's considerably more than hype to the contemporary concern about courtesy, manners and style. Such concerns have a long and venerable history. The oldest book in the world, is a dusty Egyptian papyrus, containing advice from an Egyptian father to his son on polite conduct. The Proverbs of Solomon provide shrewd and pithy counsel on personal conduct, but Shakespeare dispenses literature's most unforgettable tips on good Manners--when in Hamlet-Polonius declares to his departing son- "Give every man thy ear but few thy voice,

Take each man's censure, but reserve thy judgement,

Costly thy habits as thy purse can buy,

But not expressed in fancy; rich not gaudy;

For the apparel oft proclaims the man,

And they in France of the best rank and stations

Are of a most select and generous chief in that.

Neither a borrower nor a lender be,

For loan oft loses both itself and friend.

And borrowing dulls the edge of husbandry.

This above all; to thine own self be true,

And it must follow, as the night the day,

Thou canst not then be false to any man."

One such classic I must tell you of is "The Book of the Courtier," published in 1528 by Baldassare Castiglione, during the height of the Renaissance. Indeed he was a man of impeccable manners, a "courtier" who learned the art of chivalry at the court of the Duke of Urbino in Northern Italy, and he coined the word sprezzatura, an almost untranslatable word whose nearest English equivalent is - "unstudied nonchalance," the ability to show a cool lack of concern when the going gets sticky. Certainly in my estimation, President Obama lacks sprezzatura!!

My father who would have been 100 years old in January said it best--"A man must be like tea--grow stronger in hot water."

Everywhere we turn, there's sad news--the sad state of the economy, SGR and impending Medicare cuts, Haiti.

Yearning to feel hopeful I try to catch a glimpse of hope wherever I can.
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