Posted by Phillipa on September 8, 2009, at 20:36:33
Nursing newsletter on new health care reform. Posted here as busiest board. Phillipa
August 31, 2009 The healthcare-reform debate boggles the mind, whether it's the trillions of dollars at stake, the thousands of pages of legislation cranked out by Congress, or the superheated rhetoric in townhall meetings. How did the subject of insurance coverage for all morph into euthanasia?
Then again, with healthcare amounting to a cradle-to-grave issue for every individual and accounting for almost 18% of the economy, it is not surprising the current debate has taken on historic, if not hysterical, proportions.
The role played by physicians, too, is historic. Organized medicine has traditionally opposed government intervention in healthcare, but the first full-blown piece of reform legislation to emerge HR 3200 in the House has won the support, albeit qualified, of the American Medical Association (AMA), the American College of Physicians (APC), the American Academy of Family Physicians (AAFP), the American College of Surgeons (ACS), the American Osteopathic Association, the American College of Obstetricians and Gynecologists, and other medical organizations.
Contrary to what many of their constituents believe, these organizations assert that the proposal to extend coverage to the uninsured, partly through a controversial government-run plan, and to more tightly regulate private insurers doesn't represent the bogeyman of socialized medicine. They also argue that the bill benefits physicians, primarily by scrapping the Sustainable Growth Rate (SGR) formula for setting Medicare pay and averting a 21.5% across-the-board cut next January.
"If you come to 2010 without fixing the SGR, this would have a catastrophic affect on primary care and other specialties," said ACP president Joseph Stubbs, MD, from Albany, Georgia.
HR 3200, the product of 3 House committees, is only a rough draft of reform for Congress, which reconvenes in September after summer recess. The House committees will continue refining HR 3200 while Senate committees craft their own bills; these will eventually be merged.
The House and Senate will then vote on their respective unified bills, which, if approved, would need to be reconciled so an identical bill would go to each legislative body for a final vote. Although HR 3200 might not exactly resemble the end product, it nevertheless provides a good look at the bullet points of the healthcare-reform debate of 2009.
All But 3% of Legal Residents Would Have Coverage
The centerpiece of HR 3200, dubbed America's Affordable Health Choices Act, is the Health Insurance Exchange. It is a marketplace in which individuals, families, and small businesses with annual payrolls not exceeding $250,000 will be able to shop for insurance plans, and which will include a "public option" operated by the government (this plan might be taken off the drawing board, though more on that later).
Cash-strapped individuals and families would receive "affordability credits" on the basis of income, and small businesses would receive tax credits toward purchasing coverage. In contrast, larger businesses are obliged to "play or pay" either provide coverage for employees or pay into a fund to finance coverage through the exchange.
All individuals are required to obtain coverage through their employer or the exchange, or they will have to pay a penalty. If they already have coverage through an employer or an individual policy, they can keep it, although grandfathered employer-sponsored plans must satisfy the bill's requirements by 2018. Meanwhile, the bill would expand Medicaid eligibility, bringing 11 million more people into the program by 2019, according to the Congressional Budget Office (CBO).
HR 3200 also rewrites the terms of insurance coverage, authorizing a minimum menu of benefits including preventive services with no cost sharing that will be a template for all plans offered through the exchange and, eventually, those available from large employers. Health insurers would be prohibited from denying coverage on the basis of an individual's preexisting conditions or dropping coverage for sick individuals (except if they have perpetrated a fraud). Furthermore, they could charge premiums only on the basis of age, geography, and family size not health status or sex.
The CBO estimates that the bill would reduce the number of uninsured from a projected 51 million in 2010 to 17 million in 2019, 9 million of whom would be illegal immigrants who wouldn't be eligible for premium subsidies. In effect, 97% of legal residents would become insured.
Competition Enhancer or Killer?
The public-option plan is designed to give individuals and small businesses an alternative to private insurers, especially in markets where 1 or 2 companies dominate.
"It would be nice to see some competition," said William Jessee, MD, president and CEO of the Medical Group Management Association, which has not taken a position on HR 3200. "Membership satisfaction with Medicare is very high, so the idea of having another government-operated program doesn't frighten me. It would push private insurers to pay more accurately and promptly."
However, other physicians, such as former AMA president and general and vascular surgeon Donald Palmisano, MD, view the public option as the Trojan horse that would usher in a government-run single-payer system by unfairly squeezing out private insurers. "Having the government for a competitor is like playing against a football team that's doubling as the referee," said Dr. Palmisano, a spokesperson for a group called the Coalition to Protect Patient Rights. "It will move the goal posts when you're ready to kick a field goal."
Such fears strike Stanford University economist Alain Enthoven, PhD, as realistic. By paying providers based on the Medicare rates, the public-option plan would enjoy a cost advantage over private insurers and their higher rates, said Dr. Enthoven, who authored the concept of "managed competition" that figured into the failed healthcare-reform proposal of the Clinton administration. And although HR 3200 stipulates that the public option is to be financed strictly through premiums, Dr. Enthoven expects that Congress would eventually allocate tax dollars.
"It strains credulity to suggest that the public plan wouldn't be unfairly subsidized," Dr. Enthoven said, noting that "some of the enthusiasts for the public option admit offline that its purpose is to drive private insurers out of business."
Various groups have attempted to precisely calculate the impact of a public plan on private insurance. The CBO projects that the number of privately insured Americans would increase 9% through 2019, to 161 million, under HR 3200, even as enrollment in the public plan reaches 11 to 12 million.
The nonpartisan Urban Institute forecasts a 9% drop in the number of privately insured during this time if a public plan materializes. Perhaps the most negative assessment comes from the Lewin Group, a consulting firm owned by health insurer UnitedHealth Group. It predicts that the public plan under HR 3200 would cover 34 million Americans by 2019, while the number of privately insured would decrease 20%, to 138 million, if eligibility for the public plan is limited to small firms. If it is extended to larger employers something the bill permits public-plan enrollment would grow to 103 million while private-plan enrollment would shrink 48%, to 89 million.
With the public plan drawing flak, President Obama and lawmakers have suggested that they might replace this component of healthcare reform with regional or state-wide health-insurance cooperatives, akin to those in rural America that provide electricity or water. A few such cooperatives already exist in healthcare witness the Seattle-based Group Health Cooperative but expert opinion is mixed as to whether these member-owned organizations would be large enough to negotiate favorable rates with hospitals and physicians and compete effectively with private insurers.
What HR 3200 Does for Medicine
A healthcare system with more insured patients will need more primary-care physicians to treat them, and HR 3200 attempts to put more in the pipeline. Among other things, the legislation boosts funding for the National Health Services Corps, which finances a doctor's medical training in exchange for working in underserved areas, and creates other grant and loan programs for primary-care trainees.
The bill also tries to improve physician compensation, especially for primary-care doctors. The legislation eliminates that the much-maligned SGR formula for Medicare would have subjected physicians to an overall 21.5% cut in 2010.
Pegged to changes in the gross domestic product (GDP), the SGR sets a target for Medicare expenditures on physician services each year, and if actual expenditures exceed the target, physicians face a corresponding pay cut the following year.
Physicians complain that the SGR underestimates healthcare inflation and the way it affects their own costs. Since 2002, spending on physician services has regularly overshot the targets, triggering cuts. And year after year, Congress has cancelled scheduled reductions in response to physician outcry, but the SGR "debt" continues to accumulate, topping $300 billion as of last December, according to the CBO. This mounting debt makes future reductions even deeper.
In a single stroke, HR 3200 would eliminate the scheduled cut for 2010 by erasing the accumulated SGR debt from the books. Instead, Medicare would raise its rates next year based on its estimate of inflation in physician-practice costs. By averting a compensation train wreck in Medicare, the bill also would forestall reductions by private insurers, noted Dallas general surgeon John Preskitt, MD, who sits on the ACS Board of Regents. "Some plans base their rates on Medicare's."
Gradual Rise in Woefully Low Medicaid Fees
Beginning in 2011, a new formula kicks in, creating 2 separate spending targets for physician services under Medicare. One target is based on GDP plus 2% or evaluation and management services and preventive care a nod to cognitive-oriented primary-care doctors and the other on GDP plus 1% for all other physician services.
This break for primary care in the revamped formula is just 1 way in which HR 3200 attempts to attract more trainees to this field and avert a workforce shortage. The bill boosts Medicare rates for primary-care physicians by an additional 5% 10% for those in medically underserved areas. And the woefully low fees they receive from Medicaid would gradually be raised to Medicare levels.
In addition, the government would spend more money to experiment with new ways to deliver care such as patient-centered medical homes and accountable care organizations that would reimburse physicians on the basis of quality and cost-effectiveness, concepts foreign to the fee-for-service model.
A number of leaders in organized medicine view such "pay-for-performance" arrangements as the ultimate cure for the Medicare pay problem, relieving doctors of the need to perform more and more services to make up for shrinking reimbursement.
"We're looking for a value-based system, not a volume-based system," said Philadelphia cardiologist Alfred Bove, MD, president of the American College of Cardiology.
Is Healthcare Reform Affordable?
With the federal deficit projected to hit $1.6 trillion in 2009, and anywhere from $7 trillion to $9 trillion through 2019, proposals to overhaul the healthcare system must convince budget hawks that they pass the affordability test. The CBO estimates that HR 3200 will add $239 billion to the deficit through 2019 after new revenues and cost savings in Medicaid and Medicare are subtracted from outlays.
Significantly, CBO director Douglas Elmendorf told Congress that he saw nothing in the bill that would fundamentally bend the cost of healthcare downward. Likewise, a competing healthcare-reform bill from the Senate Committee on Health, Education, Labor, and Pensions would produce roughly $1 trillion in red ink during that period, according to the CBO.
To Dr. Joseph Stubbs of the ACP, HR 3200 essentially pays for itself, as opposed to increasing the federal deficit, if one subtracts the cost of retiring the accumulated SGR debt in Medicare a position taken by some House Democrats.
In addition, Dr. Stubbs said the CBO did not factor in potential cost savings from new healthcare-delivery models, such as the medical home, which could save $175 billion over 10 years through improved coordination of care.
Myths Abound
Critics of HR 3200 have raised a blizzard of objections, some fact-based and some far-fetched. Take the assertion, for example, that the bill authorizes bureaucratic "death panels" that will ration care and promote euthanasia. It arose from a provision on reimbursing physicians for counseling patients about hospices, palliative care, and other end-of-life issues a provision applauded by none other than the gray-haired American Association of Retired Persons.
"People who receive this kind of counseling feel better about the choices they make," said Dr. Stubbs, adding that "it's all voluntary."
Groups including the ACP and the AAFP recently issued a joint statement rebutting the "death panel" myth, along with several dozen others, among them the notions that free healthcare would be extended to illegal aliens, that the government would gain access to all financial and personal records of citizens, and that the bill would subsidize abortions.
"It's a sad commentary that the public debate has become fueled by misinformation," said Dr. Jessee of the Medical Group Management Association. "Some of it is innocent; some of it is intentional, I think. It's also a commentary on how complex the issue is and how much our citizenry would like to have a simple solution."
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thread:916131
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