Texas Senator Cornyn proposed an amendment last week in the Senate Finance debacles to mandatorily enroll himself and all fellow Senators in the Medicaid program! Wouldn’t they love that?! I loved it.

The committee members voted to soundly defeat it. Gee. Why? They wouldn’t want to be in a program that pays the doctors 40% of what underfunded Medicare does? Cornyn deserves an award for this.

The Congress is proposing to expand the Medicaid program massively in all of the current bills. But none of them would even think of being enrolled personally -- it’s woefully underfunded.

*** Sen. John Cornyn, official Senate photo. ***

Last week and this week in Washington have been even crazier than any before in the health care reform soap opera of 2009. I recently heard a modern philosopher opine (can't remember his name) that "life is a first-class opera played by a tenth tier cast." If you tuned in to C-Span this week to observe the Senate Finance hearings, you’d understand.

Actually, this health reform debate is more a soap opera, at least as Mr. Baucus' long awaited bill was received. Baucus likes the bill very much. I’m not sure anyone else in his Chamber does. Nonetheless, I predict it will be the platform for the final bill for two reasons: first, the CBO marks up the costs over ten years at less than $900 billion ($856 B), AND they say it will actually save money over time. The other two major bills cannot claim this distinction.

Second, at least one Republican might vote for it (Snowe—R-Maine). But most of what the bill contained when Baucus put it out will likely be amended away. It’s becoming a platform, not a plan. Democratic colleagues Rockefeller and Wyden have been the most critical of Baucus, particularly in requiring coverage with insufficient subsidies for lower income families.

Tri-Com Bill
Meanwhile, House leaders still think their Tri-Com bill (HR 3200) will be the real platform, with Ms. Pelosi and others clarifying that the 'public option' (not included in Mr. Baucus' bill) must be in the final legislation. But their proposal is more expensive -- even though they ‘fix’ the SGR. They don’t finance the SGRrrr fix though -- they just sort of write it off as part of the debt, not part of the next budget.

The Senate doesn’t buy that approach. They say it has to be paid for (adding $245 billion to the House bill cost if so) -- hence the Senate chose to band aid patch it for one year only to prevent the 21 percent cut in physician reimbursement from kicking in this January, even though it kicks in the following January. (They don’t yet seem too concerned about the 27 percent cut to cardiology practices looming in 2010 relating to the Medicare Payment Rule, however. The Rule has nothing to do with health system reform and these bills -- it’s just an ugly manifestation of the present mess -- but it’s a worse predicament).

It is clear that neither Democrats or Republicans on the committee are completely satisfied with the final product and those not included in the “Group of Six” negotiations over the past weeks want to have their voices heard. 

Hearing
After opening statements by members, the markup started with a tense tone as Chairman Baucus, committee members, and CBO Director Doug Elmendorf held a contentious discussion over the “safe speed” of CBO’s work to produce budget scores on the proposal and amendments. Republicans have called for “transparency,” with several hours of debate on an amendment by Sen. Bunning requiring final legislative language and CBO budget scores 72 hours prior to the committee’s final vote (the amendment failed).

The markup is slow going, with hundreds of amendments lined up dealing with coverage, delivery system, and financing and debate over many amendments lasting hours and at times becoming heated. Several attempts to strengthen the bill’s provision on medical liability have failed so far, as did an attempt by Sen. Cornyn (R-TX) to address the SGR fix. Sen. Cornyn also offered an amendment to strike the controversial Independent Medicare Commission from the proposal, but it failed. Later, an amendment by Sen. Rockefeller to modify the Commission, which is based on a bill of his, passed. So far the MedPAC on steroids piece is alive in there. The “public option” is not. 

One very controversial aspect is the creation of a new system of modifiers to payment based on quality of care in relation to resources spent. This provision would thus penalize higher spending regions with lower payment. It’s true that variation in spending is very uneven. The Dartmouth Atlas folks (Wennberg and Fisher) deserve credit for publishing that variation based on Medicare spending per capita, but it’s based entirely on claims data. And, it doesn’t include socioeconomic and credible risk adjustment data, and that must be included before variation can be fairly linked to payment or to fair comparisons of geographies. ACC has proposed using clinical data (NCDR) to help look more carefully into this variation. 

The markup continues next week.  All eyes continue to be on Sen. Snowe, who may be the lone committee Republican to vote with Democrats for passage of the bill.

Despite the controversies, and after all the amendment hubbub, the Dems should still have the votes to get a bill out in both Houses in my view. In the Senate, after Massachusetts Governor Deval Patrick on Thursday appointed Paul G. Kirk Jr., a former aide and longtime confidant of the late Sen. Edward M. Kennedy, as an interim senator, that 60^th vote should be there soon. We’ll see. 

*** Image from Flickr (Brent and MariLynn).***

Last week I spoke with Anne Underwood of the New York Times for a Prescriptions Blog entry she was writing about physician payment based on quality. In the interview, I discuss with her the inherent problems of the fee-for-service system and how virtual quality networks could change the way we practice medicine. I encourage you to check it out. However, you need to know that a lot of what I said was not included -- that many smaller and non-integrated practices produce very high quality; and that some integrated systems do not.

A lot of folks thought this showed ACC leadership in leading the quality and payment reform debate, but some did not (and I can see why, given what was edited out). One ACC member, David Perloff, M.D., F.A.C.C., thoughtfully objected to the comment: “Doctors get rewarded for more tests, more volume, more hospital admissions, more visits in the current system.” Dr. Perloff believes comments like these “make cardiologists out to be money-motivated opportunists who simply over-order tests to make more money!” He believes that instead we should “counter these accusations by insisting that, in general, our test ordering is based on either appropriate guidelines or because we are forced to over-order tests to protect us from a broken liability system.” Too bad he wasn’t able to hear my entire interview.

I am in complete agreement with Dr Perloff. Most cardiologists -- indeed most physicians -- are motivated by their patients’ needs. But, our payment system and our physician liability system are fundamentally flawed. And, frankly, everybody is not as conscientious as he and the ACC are about this. But, the Congress, along with many supportive consumer, union, and employer groups, are pushing to eliminate or greatly reduce fee for service and replace it with the Harvard Business School longstanding proposal for reward better outcomes, evidence based care, and efficiency. We better make sure such future systems are designed by physicians and organizations like the ACC -- and not those who are only ‘playing doctor’ in the policy agenda.

If you've read the interview, I'd like to hear your thoughts. Leave a comment below.

As I'm sure you know, the Senate Finance Committee on Tuesday began a markup of its health care reform legislation ("America's Healthy Future Act of 2009"). The ACC likes some pieces of the bill (like its attempts to expand coverage to every American and strengthen Medicare) but isn't so fond of other provisions (including its one-year fix to the SGRrrr rather than a permanent fix, as included in the House bill) -- see ACC's full comments on the proposal for more.

But now I turn to my readers: What do you think of the bill? Do you think it should pass as is? Undergo major revisions? Die? As always, leave your full comments in the comment section below.

Yesterday I arrived in San Francisco for the TCT (Transcatheter Cardiovascular Therapeutics) conference, a yearly interventional cardiology meeting. Meetings like TCT provide an opportunity for interventional cardiovascular professionals to stay up-to-date on the latest science, technology and procedures. When it comes to cardiovascular education, the traditional paradigm is under attack and a new -- and more relevant -- platform is emerging. Not only are there new tools linking education and quality, but CMS, Congress and others are increasingly focused on education linked to licensing, certification and credentialing.

The ACC is actively addressing these issues by providing an integrated approach to life long learning. This includes developing opportunities for cardiovascular professionals to measure, track, and improve their performance, and, thus the quality of care they provide to patients. We are planning to help members meet and excel in the face of these new requirements. I like to think we’re leading the revolution in cardiovascular life long learning.

Meanwhile, we’re leveraging ACC’s quality resources like our registries, guidelines, performance criteria and expert faculty to facilitate this revolution. A great example of a new tool is our IC3 Program – our pioneering registry focused on the ambulatory setting. IC3 allows participants to benchmark their clinical performance, compare with others, and make adjustments where necessary -- and to participate easily in various new payment incentive models. 

All this talk of education and measurement isn’t going away anytime soon. We’ve got to adjust and take steps to thrive in a changing environment -- by directing and leading the change.

That said, if the frustratingly ill-crafted proposed CMS 2010 Physician Payment Rule is not taken off the table for cardiology, we’ll be diverted away from leading in the health reform charge in order to deal with a vestigial example of what's very wrong with the current environment and payment system. The proposed Rule would reduce practice revenues in outpatient cardiology by 20-40 percent, essentially devastating community cardiology practice. This is occurring in parallel to an opportuntiy for real and positive system change. What tragic timing -- and what a painful example of the problems and archaic nature of the current HHS and CMS systems (see my last post for more of my views on this). 

*** Image from Flickr (Paraflyer). ***

I spoke with the New York Times "Prescriptions" blog contributor Anne Underwood this week about physician payment reform. Here's an excerpt, but visit the NYT's blog for the full interview:

Q. What’s wrong with the way physicians’ pay is structured now?
A. We have built our system on a payment model that rewards volume. Doctors get rewarded for more tests, more volume, more hospital admissions, more visits. There are no incentives for quality of care or administrative efficiency. That’s part of why our system is more expensive than other nations.

The good news — and the reason why I’m excited about health care reform — is that the best health care in this country often tends to be very affordable. The whole discussion about bending the cost curve can be resolved by setting new incentives in payment that reward better outcomes with evidence-based medicine.

Q. The Cleveland Clinic and Mayo Clinic pay doctors a salary rather than fee-for-service. Is that what you mean?

A. At the Mayo Clinic, Cleveland Clinic, Kaiser Permanente and other integrated systems, doctors are salaried to improve quality. They’re unfettered from having to deal with the dizzyingly complicated current payment systems. And they can do it precisely because they have an integrated system.

But about 85 percent of the U.S. health care system is not integrated. Instead, it’s divided between small practices and community hospitals that aren’t linked together with incentives to coordinate care. In the hand-offs that occur between hospital care and outpatient treatment, patients sort of get lost in the shuffle. That’s one reason why 27 percent of patients with heart failure are back in the hospital one month later. They often don’t have the medications right or in hand, or they don’t understand what they need to do to help take care of themselves.

Even between the internist or family physician who generally manages a heart patient and the cardiologist who occasionally consults on the patient, you don’t have the coordination that should occur — unless you’re in one of those integrated systems, with electronic health records and incentives for coordination and quality.

... or not. A study released by the American Heart Association shows that even tiny amounts of air pollution and cigarette smoke can dramatically increase your risk for cardiovascular disease. Researchers from Brigham Young University analyzed data from more than 1 million adults, noting smoking habits and exposure to secondhand smoke and air pollution. Their findings suggest breathing in far less than one cigarette a day worth of smoke increases your risk of cardiovascular disease by 20 percent to 30 percent. Wow. We all need a breath of fresh air.

Meanwhile, two new studies -- one in the Journal of the American College of Cardiology and one in AHA's Circulation -- publishing Sept. 29 found that smoking bans cut heart attacks by 17 percent and that this effect increases over time. (See CardioSmart for more coverage of these studies.)

It was amazing being in Spain at ESC -- there is smoking everywhere, and it’s very obnoxious in restaurants and public areas. We’ve made a lot of progress in these regards, but more is needed.

*** Image from Flickr (SuperFantastic). *** 

I'm sure you all saw the headlines early this month related to the Department of Justice settlement with Pfizer over their past off-label promotions of Bextra and other drugs. The settlement will cost the company a record-breaking $2.3 billion ($1 billion in civil settlements and a $1.3 billion criminal penalty related to Bextra).

Bextra was approved for treatment of arthritis and menstrual pain, but Pfizer allegedly promoted it in doses and for uses not approved by the FDA, putting patients at risk of serious cardiovascular complications including heart attack and stroke. Pfizer voluntarily withdrew Bextra from the market in 2005.

Of course, Pfizer isn’t the only company that has been involved in off label promotions. And we physician are also involved in how off label uses occur, and in relationships with industry that are under increased scrutiny in these regards. Off label usage of pharmaceuticals is often how new therapeutic advances occur and it’s not evil. But, if we had more comparative effectiveness research and dollars (and we soon will) available to research off label use, we could more rapidly advance therapeutics of newer agents and protect patient safety as well.

HHS Secretary Kathleen Sebelius, along with Vermont Gov. Jim Douglas (R), last week announced a new pilot designed to promote the medical home. The three-year program is based on a program in Vermont and will provide financial incentives for primary care doctors to spend more time with patients with chronic conditions, keeping them healthy and coordinating their specialist care, in the hopes that it will cut down costly emergency department visits.

Any effort that could help us cut health spending and simultaneously improve quality is a good one. According to a Health Affairs analysis this week, if the growth rate in U.S. health care spending continues, it’s going to eat up personal income and economic resources.

Heck, it might eat up everything.  Even if the growth rate slowed to a pace of just 1 percent faster than per capita growth in GDP, more than half of any increase in personal income would go to health care over the next 75 years. Sobering. We’ll have to commute to work in ambulances.