Not to be outdone by the White House and their televised summit on health care reform (which I'll talk about further over the next couple of days), the ACC is holding a similar meeting of the party minds at ACC.10. I hope many of you will be there in Atlanta and able to attend this special session. “ACC.10 Health System Reform: Where Are We Headed?” takes place on Sunday, March 14, from 12:15 to 1:45 p.m. in Hall B100 of the Georgia World Congress Center. The session will bring together a policy leader on health care from each party. House Republican leader Paul Ryan and Democratic strategist and former Clinton White House advisor Chris Jennings will define and debate the issues and give us the latest update on health care reform. Then, we’ll have the unique opportunity to advocate on behalf of our patients and the entire cardiovascular specialty as we share our ideas with them.

President Fred Bove, Jim Fasules, ACC member Douglas Wood and I will offer our input on the importance of patient access to care and discuss ACC quality initiatives, our perspective on health care reform and physician payment reform. Plus, Richard Anderson, MD, CEO of the Doctors Company, will offer his perspective on the need for tort reform as part of health care reform. Be there. I think this will be a very compelling session, and one that should demystify the health policy issues for you. Of course, ACC.10 is also the premier scientific and clinical care venue in cardiovascular care anywhere worldwide. Don't miss it.

The president has at long last put out his own official health care reform proposal. I must admit I’m somewhat surprised that Obama didn’t propose a slimmed down and more simplified proposal that might have more acceptance with moderate Republicans and Blue Dog Democrats. He actually adds additional costs and more provisions to what the Senate has proposed, which I think bodes poorly for getting this passed by the House of Representatives. They only passed HR 3962 by five votes as it was, and there are a lot of things in the Senate bill that House Democrats don’t like, and a number of them still are there.

I’m hoping that the president has a strategy of being willing to appease some of the irritated constituencies in this first go-around, and that he might be willing to really horse trade on TV with moderate Democrats and Republicans in attendance to get to a slimmed down version capable of passage by both chambers.

From ACC’s point of view, a proposal should have a means of involving physicians and other professionals in helping to design means of improved quality and care coordination through a payment system that incentivizes such results. And, some kind of assurance to businesses and working families that health care will not bankrupt the nation. I think all of us in medicine know there is a pathway to success in these regards.

So, the summit of 36 to 40 bipartisan members of Congress who will gather at the White House Thursday to take us to the next step should be a thing of interest to behold. I won’t “beholding” my breath.

** Official Obama portait. **

The Senate is not seemingly getting closer to an SGRrrr fix. Not even a one- or two-month postponement. It is conceivable the cuts could go into effect March 1 unless they come to their senses. The House is ready to do a long term fix by just writing it off, but the Senate insisting it be largely ‘paid for’ (they agreed to write off only $82 Billion of the $210 debt) -- where’s the money? There are some members of the Senate who want to see if doctors will really stop seeing Medicare patients if the cut proceeds we suspect. This is a risky game.

AMA has led the advocacy campaign on trying to get this solved, and we’ve been working closely with them, but this is getting crazy at this point. ACC's CardioAdvocacy Alliance sent out the following action alert last night -- I urge you to take action:

Congress returns from its President's Day District Work Period this week, with only a few days left to intervene to stop a 21.5 percent Medicare physician payment cut from taking effect on March 1. In just seven days, the current temporary freeze in Medicare physician payments will expire. Although the House of Representatives passed a bill to eliminate the cuts (H.R. 3961) this past November, the Senate has been unsuccessful in passing similar legislation (S. 1776). Please call your lawmakers this week, even if you already have, and urge them to work with their colleagues to enact a permanent replacement of the flawed sustainable growth rate (SGR) formula.

Act now! Call your members of Congress at (800) 210-7193 or contact your Representatives by clicking here and your Senators by clicking here.

The entire House of Medicine is urging Congress to provide a permanent solution to the ongoing physician payment dilemma. This is even more important cardiovascular professionals given the recent 2010 Medicare cuts to cardiology. Contact your members of Congress today!

Thank you for taking the time to speak on behalf of your patients and your profession.

Remember when it seemed like reform was a sure thing to pass the Congress? Well, now it’s far from certain to pass. Something dramatic is surely needed to address the impending unsustainable rise in health care costs. The Fed raised the base bank borrowing rate by ¼%, meaning the recession is really over, even if hiring hasn’t bounced back. But rising health care costs represent our dirty little problem -- Wellpoint put off their proposed 39% increase in individual rates under political duress (for only 2 months), and while Republicans are switching to tea parties, Democrats are going to need some powerful triple espressos to get through the next phase of health reform. 

While the upcoming (this week!) Obama ‘bipartisan’ health summit proposes to assemble the surly parties to compromise on a reform strategy, and, believe me, I’d love to see it happen, I’m not holding my breath. Nonetheless, Obama’s team was ordered to come up with a unique, simpler compromise bill -- and they say they have it. Supposedly it will cull the best elements of the House and Senate bills, and will be released Monday. 

But, given that Democrats have lost their filibuster-proof majority in the Senate, Harry Reid, Nancy Pelosi, and White House chief of staff Rahm Emanuel met quietly yesterday to review the President’s ideas, AND to discuss how to use ‘budget reconciliation’ to pass a reform bill if Republicans will agree to nothing. Reconciliation can be used to speed the approval of legislation calling for tax cuts or increases or funding changes in programs like Medicare. A reconciliation bill needs only 51 votes to pass, and filibusters are limited. (The Alliance for Health Reform has a new toolkit on budget reconciliation if you are interested). Of course, some Republican leaders are saying they will boycott the summit unless the Dems will start over on reform -- meaning the President’s new bill may be a non-starter. The 'summit' is likely to be more a 'circus.' 

President Obama has been telling everybody that he would be willing to compromise with Republicans on their health priorities, including tort reform. The trial attorneys (American Association for Justice) are cautioning him against any hasty decisions on tort reform, or the 'party’s over' on their hefty funding of Dem campaigns. The Dems feel they must pass a reform bill, and the Republicans will do anything to block that. This looks to be tragically entertaining. This week will be interesting!

*** Image from Flickr (Suviko). *** 

The SGR fix remains a top priority in Congress, with the House still wanting a long-term fix and the Senate unwilling to pay for that. As a result, Thursday of last week Senate Finance Committee chair Max Baucus (D-MT) and ranking member Chuck Grassley (R-IA) proposed a bipartisan jobs bill, known as the Hiring Incentives to Restore Employment (HIRE) Act (pdf), in which they would extending current Medicare physician payment rates for seven more months, through Sept. 30, 2010, once again postponing the 21.2 percent cut that was scheduled to take effect on Jan. 1. 

We hear this 7-month reprieve represents a compromise between Senators who wanted a one-year payment fix through Jan. 1, 2011, and others who were seeking an even shorter bridge period to supposedly give Congress time to pass a permanent repeal of the Medicare sustainable growth rate (SGR). 

The HIRE Act is getting trashed as a real jobs creation bill. Majority Leader Harry Reid (D-NV) wants the health aspects out of any Senate jobs bill. HIRE includes extensions of unemployment insurance benefits and COBRA premium assistance for terminated workers, and would extend a number of health care provisions that expired at the end of 2009, including GPCI geographic payments to rural doctors. These provisions are hardly what ‘jobs’ advocacy has been all about, and so this will likely not end up as an SGR vehicle after all.

Along with the AMA, the ACC wants Congress to permanently repeal the formula once and for all.  The short-term, band-aid approaches used in the past to stop imminent cuts only made future cuts steeper and increased the cost of a permanent solution. If Congress had fixed the problem in 2005, when physicians faced cuts of  3.3 percent, the cost would have been $49 billion.  5 years later we face a 21% cut at a cost of $210 billion.

Here’s AMA’s statement of yesterday -- I’d say we’re right with them on this:

”Congress has passed legislation to reinstate statutory pay-as-you-go (PAYGO) rules, which require bills that would increase federal spending to include provisions that offset those costs through spending reductions or revenue increases.  That legislation would also exempt from PAYGO requirements $82 billion of the currently estimated $210 billion cost of a permanent SGR repeal.  The AMA is continuing its advocacy efforts to secure permanent Medicare physician payment reform, and will continue to oppose further short-term fixes.”

Let me translate that -- a much better solution to the HIRE bill idea is to pay it all off at once, with a discount write off of $82 billion, meaning they would have to come up with about $128 billion to get rid of it. They should.

Does White House Chief of Staff Rahm Emanuel’s now famous remark (uttered in various ways by countless others previously) that one should “never fail to take advantage of a good crisis” pertain to cardiology right now?

Are we taking advantage of the nightmare we’re dealing with? The traditional management view about ‘what is a crisis’ is that it is an event that can destroy or adversely affect an entire organization or business. However, according to Northwestern University economist Daniel Diermeier, the strategic view is that a crisis is ‘a decisive moment, a turning point for better or worse.’ 

What turning point(s) are we approaching with the Medicare Rule and erosions of clinical practice revenues, health system reform, generational changes, and/or the explosion of scientific knowledge and consumer information? For me, delivery and payment system reforms that will become essential as the nation works to slow the rise in health care costs will create monumental changes. How do we respond? Do we react or lead?

It seems to me that the ‘better or worse’ possibilities will be dependent less on what we independently decide to do as compared to how what we do affects our customers -- that is our patients. We’re engaged now in a crisis management strategy related to the Medicare Rule and to negative potentials in health care reform. We are definitely reacting in these regards. That is necessary; but we also better have an achievable vision of what a viable, sustainable future of health care might be -- one that works for a majority of patients (voters). 

The current administration and Congress have at least for the moment lost the trust of a majority of citizens. Individually, patients still seem to trust their own doctors. But trust is more complicated than that. Economists claim consumer trust and credibility for businesses have been demonstrated to be related to 4 major factors:

• Competence and expertise -- 15-20% of the total trust pie;
• Honesty and openness -- 15-20% of the pie;
• Dedication and commitment -- 15-20% of the pie; and finally
• Empathy and caring -- 50% or more of the pie!!!!

If our current crisis is an opportunity, we will need to keep these things in mind as we move toward solutions and a better future. We can’t promote ongoing vitality for the profession(s) and cardiology without the support of our patients, and everything we do needs to be grounded in making sure that is our central and most important consideration.

Is it unpatriotic to support continuity of the U.S. health system’s status quo, as many physicians and citizens seem to be comfortable advocating?  In answering this question, we need to consider how much health care is contributing to the debt, which itself threatens our economic vitality and national security. The accumulated national debt is currently well over $12 trillion, about 53% of the U.S. GDP for 2009. It’s about $4,000 per citizen.

As currently projected, it would grow to over 300% of GDP by 2050, and the vast majority of that growth will be the result of rising health care and Medicare costs, government economists estimate. The deficit number for this year will be $1.8 Trillion, and for the year 2011 the deficit would be $1.3 Trillion. If the SGR was to be eliminated, the number would likely be at least a half-trillion more. The dramatic growth of the deficit puts the nation’s future stability and security at great risk if not addressed. Deficit growth will be mainly related to unfunded health care costs to cover the 40 years it will take for the boomers to retire, vote en masse to demand the best health care, and die off, presumably after becoming part bionic and genetically-engineered beings. 

Tough Choices
The current partisan environment and resultant difficulty we will have to make the tough political choices needed to stabilize Medicare, health care, and Social Security represent a recipe for disaster. Without new thinking about health delivery system and payment reforms, for example, we will surely face accelerated price fixing and price cuts for doctors annually, like we have seen this and previous years for cardiology. The current SGR dilemma we face may look like a cake walk in the face of future pressures for cost containment. And doctors seem to be the easiest political victims for achieving such cuts.

Finally, it will be increasingly essential that patients bear a much larger share of their own health care costs in this future, potentially motivating more informed shopping. But, there is a finite amount of out-of-pocket spending that middle class and lower income families will be able to contribute, so political pressure for a bigger social support infrastructure for health costs will be demanded by aging boomers. Where will it come from? Probably from more cuts to health care providers. My crystal ball indicates we’re headed for a decade of tough fights like we are experiencing this year, unless we figure out how to ferret out the extensive waste in the current system to protect health care and the vitality of the profession.

There are ways this story could unfold in a more positive fashion. It would be nice if we as a species and a nation could dispense with war, for example, although this would seem to require ‘human nature’ transplants, or miracles, or both. We could tax the living heck out of everybody making more than minimum wage. But unfortunately that would kill off economic growth. 

Or, we could get engaged in preserving the profession and the patient-physician relationship, while still promoting continued innovation and scientific progress in health care. To accomplish this, we would need to figure out and refine ways to reduce health care spending increases to no more than a percent or two greater than the GDP. Could we accomplish this without killing off innovation and the vitality of the profession? I happen to think we could. I know some of you reading this are skeptical. That’s understandable. But what are the options here, folks? Leaving things to ‘evolve’ on their own in the political environment looks awfully risky.  Ironically, even if not yet realized, the nation needs for us to take these challenges on or solutions won’t likely be forthcoming. If we all allow the debt to explode, the entire economy -- including medicine -- will suffer greatly.

So, back to my original question: Is it unpatriotic to support continuity of the U.S. health system’s status quo, as many physicians and citizens seem to be comfortable advocating?   An informed answer is yes.

*** Image from morgueFile (jdurham). ***

Plans for ACC.10 and i2 Summit are in full swing, with the meeting just a little over a month away at this point. There are a lot of exciting activities planned for the meeting, including the largest online presence as of yet. I hope to see you in Atlanta!

Congress has still not figured out what they’re doing about the SGR, with the two-month extension ending in just three weeks. Chairmen Waxman, Stark and Rangel have assured us they still want to see a 10-year fix, as the House has recommended. They however note that the Senate remains unwilling to support them. There have been rumors that some physician organizations are asking for another two-month extension to have more time to convince the Senate to produce a longer term solution. Baaaad strategy.

This would be extremely dangerous, since the CBO (Congressional Budget Office) is preparing its next ten-year budgetary estimates, and speculation is that they will revalue the SGR debt much higher at between $300 and $400 billion! It would be very risky to have this projection come out while Congress is negotiating whether to give us a two-year, five-year or longer remedy, so we believe we need to move this month on negotiating as long an extension of SGR funding as possible.

My frustrated bet: They will kick the can down the road once again for a two-year fix, leaving us at risk of a half-trillion dollar funding cliff in 2012! What a mess.

In a city known for snow jobs and flakes, three feet of snow -- the biggest dump in over a century -- will surely slow down the processes of government and Congress for a week or so of digging out. This could be a good thing.

The place is paralyzed, and the peacefulness is kind of wonderful. The ACC is closed today -- most small roads, alleys, and side streets are still being cleared. The airports are slowly re-opening; and the Metro can’t run above ground until more trains are dug out and the tracks cleared.

This could slow down the health reform debate for a while. Not a bad idea. Congress probably won’t meet until Wednesday. We’re safe for now.