Revisiting earlier topics…

If you’ve been reading this briefing, you know that I’ve tried to examine issues that have been overlooked or marginalized in the national debate and media coverage. As you can probably tell, I think this bill is one really ugly baby.  But as I’ve seen a bunch of articles over the past several weeks addressing some of the issues I’ve tried to bring light to, I thought I’d give an update of what’s happened to the other 5 issues I discussed in previous emails.

Doctor Shortage
Kaiser Health News had a story last week about the primary care doc shortage.  It’s a great article and includes a graph (yay!).  “I don’t see anything in the legislation that will greatly increase the primary care pipeline,” said Dr. Russell Robertson, chairman of the Council on Graduate Medical Education, which advises Congress. In addition to making sure patients have access to care, increasing the number and proportion of primary care doctors is crucial to lowering health costs, he said. Primary care doctors make up about a third of all physicians, though in most industrialized nations they make up half.

“We can’t bend the cost curve without increasing primary care providers,” said Robertson, who is also chair of family and community medicine at Northwestern University’s Feinberg School of Medicine in Chicago.

One idea, to increase payments for primary care docs is supported by Dr. Ted Epperly, a Boise, Idaho, family doctor who is president of the American Academy of Family Physicians.  He says family doctors would need about a 30 percent increase in pay to encourage more young physicians to enter primary care.  Some think Medicare should help pay for this raise, but this idea is basically considered dead on arrival, because the money would come from payments to higher-paid specialists.  These guys and their professional societies, aka unions, unsurprisingly oppose the pay cut.  Nothing against them, because we’re all looking out for our best interest, but yeah, that approach won’t work.

The direction we’ve been going with this bill in recent months will grow the numbers of the insured substantially, and expand entitlement programs like Medicare and Medicaid.  After Massachusetts in 2006 required residents to have health insurance, the demand for care totally overwhelmed the state’s doctors.  The only way to get more primary care docs in the pipeline is to increase residency positions for them… Senate Majority Leader Harry Reid is proposing that Medicare pay for 15,000 residency positions — a 15 percent increase that would favor more primary care training.  This was also nixed because of its $10B price tag… an amount that I have to say seems like pocket change compared to the rest of the bill.

Soo no real news here, but check out this article to see the graph: http://www.kaiserhealthnews.org/Stories/2009/October/12/primary-care-doctor-shortage.aspx

The Mayo Clinic Model

The Washington Post reported last week that the Mayo Clinic is no longer accepting some Medicare and Medicaid patients.  Suddenly the administration realized that want to temper its enthusiasm for the organization as a model for health care reform. Interestingly, as I pointed out, Mayo is a real stakeholder in this debate – they have an interest here and are a lobbying force unto its own, especially considering its increased celebrity status.

Mayo announced late last week that its flagship facility in Rochester, Minn., will no longer accept Medicaid patients from Nebraska and Montana. The clinic draws patients from across the Midwest and West, but it will now accept Medicaid recipients only from Minnesota and the four states that border it. As it is, 5 percent of Mayo’s patients in Rochester are on Medicaid, well below the average for other big teaching hospitals, and below the 29 percent rate at the other hospital in town.

The WaPo story says, “The model centers have capitalized on their status to insert into health-care legislation provisions that would result in higher Medicare payments for hospitals that do well on the Dartmouth rankings while punishing those elsewhere — mostly, big cities and the South — that spend the most per Medicare patient.”

Mayo of course says this decision to limit Medicare/Medicaid patients was a business decision, saying that they can’t continue to provide the same level of care making do on current Medicare payment rates.  This raises a very important question –  can hospitals and doctors provide top notch care, attract great doctors and pay for the best equipment out there on public sector reimbursement rates?  A recent report by MEDPAC found that hospitals relying most on Medicare and Medicaid, without a big private-payer base, report per-procedure costs in line with Medicare rates — suggesting that those hospitals can make do with Medicare payment levels.

In my opinion, this news story is really small BUT it embodies a central issue — who is going to insist on cost-containment?  The government?  Can the government even do that?  And if so, are businesses going to let it?  And if the government DOESN’T do it, will businesses do it on their own?

MEDPAC

This issue mentioned above just doesn’t go away.  The National Journal did an EXCELLENT piece on cost-cutting measures, including a look at the “MEDPAC on steriods” idea.  Here’s the recap: “In the case of Medicare, the question of when to deny treatment has already produced a head-on, intraparty collision between the Senate Finance Committee, backed by Obama, and a powerful minority of House Democrats. The Senate faction is committed to “bending the cost curve” for Medicare and sees the billions to be saved by arming MedPAC to set binding limits as taking precedence over potential complaints from beneficiaries when cuts materialize after 2012. Senate Finance Committee Chairman Max Baucus of Montana, perhaps the quintessential utilitarian Democrat, has dubbed the empowered board the “Medicare Preservation Commission.”

In a letter to House Speaker Nancy Pelosi, 75 members — including 45 Democrats — warned that if MedPAC is strengthened, “Medicare beneficiaries and the range of providers who care for them would be greatly limited in their ability to help develop and implement new policies that improve the health care of our nation’s seniors.”  I mean, this really is sneaky… but if it’s going to happen, it has to be done by an extra-congressional body, and obviously stakeholders hate this.  It’s not the members of Congress that protest, it’s the companies, physicians, hospitals, etc in their districts.  However, the Democratic party is going to face a real problem with this, because cutting costs is absolutely essential to freeing up the money needed to insure more Americans.

Seriously this is a great article, read it:  http://www.nationaljournal.com/njmagazine/nj_20091017_7390.php

Individual Mandate

The insurance industry pulled a balls-to-the-wall move (sorry Mom) last week when they released their PWC report saying that the current health care reform bill would cause premiums to skyrocket.  I suppose someone had to say it, but since no one sees a commissioned report as objective, they were immediately on the defensive, and the central message was lost.

To recap, the individual mandate is a component of each of the reform proposals, saying that everyone has to obtain insurance coverage. There is both a moral and a fiscal argument for this — everyone should pay into the pot, and besides, without the communal support of the old and sick, we’ll end up paying through higher taxes anyway.

The Senate Finance Committee included the mandate but they significantly weakened it by making it pretty easy to say that insurance would be a financial hardship, and by making the fines for not getting coverage really weak.  As Kaiser Health News said in an article posted yesterday, “At some point, if the mandate becomes too weak, it ceases to be effective. People ignore it and then we’re back to the problem of young, healthy people opting out of the system. It’s not clear whether the reductions the Senate Finance Committee proposed went that far; experts offer different opinions. But the weakening of the mandate is, at the very least, risky.”

This author’s main point is that if the insurance industry made a good point that needs to be heard.  His other point is that if the insurance industry spent more time demanding more from the drug and hospital industry, and advocating that everyone give up their fair share of profits in order to lower costs, then we might get closer to some real reform.  It’s an interesting point.  Back in February when all the biotech CEOs were preparing for health care reform, everyone said it would be an all-out blood bath, everyone against each other.  This has kind of happened, but its actually just been more a peaceful truce and agreement by everyone to look after their own bottom line or keep quiet.  Here’s that Kaiser article… http://www.kaiserhealthnews.org/Columns/2009/October/101909Cohn.aspx

Medicaid and the States

Okay finally, the last topic.  As I said last week, the government program that provides healthcare to the poor, Medicaid, would be expanded under health care reform to cover almost one in five Americans (60 million by 2019), which would put some serious pressure on state budgets.  It would change a program aimed mostly at children, people with disabilities and elderly nursing home residents into one that includes more low-income parents and, for the first time in 45 states, adults without children. As the USA Today says, there are three big questions here.

First, can states afford it?

“The federal government paid $258 billion for Medicaid in 2009, about 57% of total costs, but would pay 90% of the expansion. States would pay about $33 billion, according to the Congressional Budget Office.  “If you go to the store and the shoes are 90% off, it doesn’t matter if you can’t afford the 10%,” says Alan Weil of the National Academy for State Health Policy.”

Second, can states handle the expansion? AKA can their ancient computer systems even handle changing eligibility requirements?  That’d be a problem for sure.

Finally, will their be enough doctors?  For this question, refer to my first brieing on the doctor shortage!

So… these topics really did come full circle. In writing these pieces, I realized that all the topics are incredibly interrelated.  It’s been great to have an opportunity to look at each topic in depth, but when I step back I can definitely see where the big questions are, as far as cost-containment, sustainability, the Democratic party trying to get things done, and many, many stakeholders pushing back.  It’s really fascinating.

Thanks again for reading!!!

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~ by Kathryn Bailey on October 21, 2009.

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