Will the Doctor’s Hang in There?

In July, the American Medical Association surprised a lot of pundits when they threw their weight (See “Random Thoughts” below) behind healthcare reform.  In joining the hospitals and insurers (at least for the time), the AMA urged House leaders to pass a far-reaching healthcare reform bill.  But, James Rohack, MD, President of the AMA, intimated caution on Thursday afternoon when he stated, “We don’t believe doing nothing is a good solution …  We are going to work until we can no longer work.”  What does that mean?

While the AMA is a much leaner version of the heft it once demonstrated when it represented nearly 90 percent of the nation’s physicians and blocked Harry Truman’s efforts to create a National Health Service program, it is still a political contender with just under 30 percent of the nation’s physicians as members.  The change in healthcare over the last half century has reduced the member roles significantly as physicians shifted their alliances away from the generalist organization to more specialty specific associations.  In the past, the AMA could be counted on for a secure and unbending “no” related to healthcare reform.  So with their support last July, it becomes incumbent upon the Obama Administration to keep them in the tent.  But, what do they want?

As I alluded to last week– to quote from a long lost friend Dr. Gary Maynard – it’s not the money, it’s the money.  The problem started over a decade ago when, in an effort to control the upward bound costs of Medicare, Congress passed legislation to reduce physician pay by passing the Sustainable Growth Rate (SGR) bill.  In essence, the SGR places a cap on Medicare payments.  But every year or so, Congress passes overriding legislation which essentially pushes the pay cut out a year or two.  The problem is that the accounting for Medicare includes the pay cut.  So, Congress and the doctors have a problem.  If nothing is done, the physicians will see a 21 percent cut in pay beginning next year.  The House bill (supported by the AMA) provided $228 billion to keep doctors payments from falling for the next decade.  The House added this provision, and each side got some concessions from the other so that – on the whole – the politicians and doctors were supportive of one another.  But, the Senate Finance Committee bill – in an effort to keep their package under the $900 billion total amount called for by Obama – in an effort to include all of the other bells and whistles, nixed that idea and indicated the pay cut would only last for one more year (wink, wink, nod, nod).  The end result – we are looking at the cliff, and it is not very pretty. 

Rather than a wink and a nod, the reality of putting things off is coming to the foreground here in .   Senator Debbie Stabenow (D-MI) sponsored legislation that would repeal the SGR and erase the 21 percent cut scheduled for 2010 by freezing the current conversion factor at 2009 levels on a go-forward basis.  Senate Majority Leader Reid seems inclined to have the debate go to Senate floor as early as Tuesday of this coming week.  But, it appears that there may not be sufficient votes for the measure to be brought to the floor.  Furthering the problem with the Stabenow proposal is the fact that while doctors will be satisfied in the short-term, a freeze now means increases will need to be made on the “frozen rates” in the future.  So, the issue would be debated again in a couple of years (i.e. we’re simply putting off a discussion that needs to be considered).  On the House side, the approach is more complex and would completely replace SGR with a new target growth rate for services, including a new rate update schedule.  There for, the House’s approach is more comprehensive and is contained in the Tri-Committee legislation.

With all the brouhaha over the insurance industry this past week however, it seems that a prime concern for the Administration is to keep “the doctors inside the tent” on healthcare reform.  As Jonathan Oberlander, Ph.D. , a healthcare reform political scientist, noted, “If they went national with an ad campaign [in support of Congressional legislation] that would have a tremendous political impact … They have the ability to shape this debate.”  So, it’s not just the money, it’s also the reality…

Kevin Fickenscher, MD

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