ACP moving towards endorsing health care reform

We have talked previously about our frustrating with the American Medical Association (AMA). Many physicians do not believe that the AMA speaks "on their behalf."

On the other hand, most physicians place more stock in their respective specialty association. Since medicine is so diverse, the support needs are highly specialized by specialty and these associations cater specifically to the specialties needs. As an internist, I'm more keen to see what my association - the American College of Physicians (ACP) - has to say on the matter.

I received an email from my local ACP president which is fairly supportive of the current House bill. I'm not really following closely what the AMA has to say on the bill, but I'm glad to see that the ACP is thinking about the legislative process in a sane manner.

The last two paragraphs of this post I think are the constructive message for physicians - be a part of the process, instead of vilifying ourselves - and let's try to make this reform effort a step in the right direction.

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TO: ACP Key Congressional Contacts

FROM: Bob Doherty, Senior Vice President, Governmental Affairs and Public Policy

SUBJECT: ACP's views on H.R. 3200, the America's Affordable Health Choices Act of 2009, and efforts to organize opposition to it

Yesterday, the chairmen of the three House committees with jurisdiction over health care reform introduced the America's Affordable Health Choices Act of 2009, H.R. 3200. (The Senate Health, Education, Labor and Pensions Committee has introduced its bill; we are still awaiting a bill from the Senate Finance Committee, which may be released within days). I want to update you on why the American College of Physicians believes that H.R. 3200 merits internists' support, even as we continue to work for improvements through the legislative process.

I know this e-mail is long, but I encourage you to take the time to read through it. It is critical that we continue to work together as Congress moves forward on legislation so critical to patients and you, the physicians who care for them.

The bill is closely aligned and consistent with ACP policies on our top priorities for health reform as developed through our policy committees and approved by the Board of Regents (with input from the Board of Governors and ACP councils). Specifically:

Coverage: The bill creates a pluralistic framework so that all Americans will have access to affordable health insurance coverage, similar to ACP's own seven year plan. It will give eligible persons a wide choice of health plans, including the option of maintaining their current health plan. ACP supports the bill's proposals to reform the insurance industry so that coverage no longer is out of reach for people who have pre-existing conditions or who develop an illness while insured. We support sliding scale tax credits, coverage of evidence-based preventive services with no cost-sharing, and expansion of Medicaid to cover the poor.

ACP does not have policy on the bill's proposal to finance coverage through an income tax surcharge on higher income persons. I anticipate, though, that there will be major changes in the tax and financing mechanisms as legislation makes its way through the House and then has to be reconciled with the Senate, which seems disinclined to rely on an income tax surcharge. The College supports the bill's shared responsibility for funding health care reform, including requirements that employers contribute to coverage and that individuals obtain coverage once affordable options are available to them.

Workforce: The bill would establish a national health workforce policy to help set goals and policies to achieve a sufficient and optimal number and distribution of physicians and other clinicians. It includes policies, recommended in ACP's own policy paper on solutions to the primary care workforce crisis, to increase the numbers of physicians in primary care internal medicine, family medicine and geriatrics, including increased funding and creation of new pathways to provide scholarships and loan forgiveness to primary care physicians who agree to practice in areas of need and policies to facilitate increased training in office-based primary care practices. We also agree on the need to increase GME training positions for primary care specialties as the bill proposes.

Sustainable Growth Rate: The bill would eliminate the accumulated Medicare SGR payment cuts, and by doing so, pave the way for Congress to replace the annual cycle of Medicare payment cuts with a new update system. The bill provides a new framework for future updates that allow for spending on physician services to increase at a rate greater than GDP, and creates a higher spending baseline target for evaluation and management and preventive services, including those associated with primary care.

Primary Care Payment Increases: The bill provides for an additional 5% increase, beginning in 2011, for designated evaluation and management services by general internists and other primary care physicians. The primary care bonus is increased to 10% for designated services in Health Professional Shortage Areas. The bill also would increase Medicaid payments for primary care to be equivalent to Medicare.

Although ACP continues to believe that a larger primary care bonus is needed-we have asked for at least 10% in all areas the country, 15% in health professional shortage areas, we believe that the recognition of the need to increase payments for primary care is an important step forward, especially combined with other changes in the bill to support primary care.

Patient-Centered Medical Home: The bill also provides dedicated funding to pilot-test, on a national scale, the idea of paying physicians for care coordination in a qualified Patient-Centered Medical Home. ACP will continue to provide Congress with ideas on strengthening the payment and delivery system reforms to accomplish the goals of increasing the numbers of physicians in primary care fields.

Comparative Effectiveness Research (CER): The College strongly supports the proposal to fund independent, transparent and evidence-based research on the comparative effectiveness of different treatments to inform physician-patient decision-making.

In addition to its strong correlation with ACP policy and priorities, H.R. 3200 provides substantially more funding to physicians at a time when most other providers are facing deep cuts, according to preliminary estimates from the Congressional Budget Office.

$228.5 billion to eliminate accumulated SGR cuts
$1.6 billion for the PQRI (positive incentives only, no penalties for non-reporting)
$1.3 billion to make the geographic floor on Medicare payment permanent
$5 billion for the primary care bonus
$1.8 billion for medical home demonstrations

No bill is perfect, but the House bill delivers on our major priorities in a way that is remarkably consistent with ACP policies, policies that were developed by the College's leadership over many years and always guide how we-leadership, Key Contacts and staff-advocate for ACP's internal medicine physicians and your patients.

Despite all of the positive elements in H.R. 3200, there is an effort being made in many states to persuade physicians to oppose the bill. You should be aware of the arguments being made by opponents and how I respond to them:

• Opponents argue that the "public plan option" included in H.R. 3200 would lead to the destruction of private insurance and government-run health care.
This is an issue that has elicited strong but divided opinion among ACP members. Some internists have expressed practical and philosophical concerns about the public plan, while others have said that they believe a public plan is essential.

ACP policy says: a public plan could appropriately be offered, along with qualified private plans, if participation in the public plan is voluntary, if it competes on a level playing field with private insurers, and if it is not locked into Medicare's payment rates. Under H.R. 3200, physician and patient participation in the public plan would be voluntary. The public plan would have to pay for itself through premiums collected, rather than being funded from the U.S. Treasury, to help place it on a level playing field with private insurers.

ACP has advised the House that we are concerned that the House bill would have a public plan use Medicare rates (Medicare plus 5% for physicians who accept both Medicare and the public plan) for its first three years. The College will continue to strongly advocate that the public plan be required to pay competitively with private insurers. (The Senate HELP bill, for instance, would benchmark the public plan's rate to the average offered by qualified private plans, so there will be opportunities to address how the public plan sets its rates later in the legislative process).

Opponents also suggest that H.R. 3200 would prohibit private contracting and balance billing, but there is nothing in the law that prohibit existing rights for physicians and patients to enter into voluntary contracts. Like Medicare, however, physicians who choose to take care of patients in the public plan would have to accept limits on charges, similar to the Medicare participating and non-participating physician agreements. No physician would be mandated to accept the public plan and its rates.

The idea that the public plan would destroy private insurance is also not supported by expert analysis. The Congressional Budget Office notes that because physician participation in the public plan is voluntary, and payments are likely to be lower than payments under private insurance plans, it is difficult to estimate how many people would enroll in the public plan. The CBO suggests that enrollment in a public plan, at full implementation, could be as many as 8 or 9 million people out of the estimated 30 million who would get coverage through the exchange, many of whom though are currently uninsured, but even so, this would mean that most people in the exchange would be covered under private insurance. CBO also estimates that the vast majority of persons-164 million, an increase of two million persons compared to current law-would be covered by employers.

• Opponents argue that CER would lead to rationing of care by government bureaucrats.
Actually, the bill's CER provisions are completely consistent with ACP's support for an independent, transparent and evidence-based process to conduct research on the clinical effectiveness of different treatments to inform clinical decision making. There is nothing in the bill that allows costs to be used to deny care. The research would be conducted by physicians and other scientists in agencies, like the National Institutes of Health and the Agency for Health Care Research and Quality, not by government bureaucrats. Coverage decisions would still be made as they are today, but instead would be informed by the best available clinical evidence instead of by criteria that often is not guided by science.

Now it's time to think politics.

To try to influence Congress to consider our ideas to improve the bill, we will be far more effective if internists support all of the positive policies in the bill. We want to continue to be invited to the table and not to have to fight to be there. Destructive opposition will effectively remove us from being invited and place at great risk all of the positive changes that the bill would bring about -including the coverage, workforce, elimination of Medicare SGR cuts, and payment reforms to support primary care.

To this point, the overwhelming majority of physicians have supported health care reform. Let's stay together and let other stakeholders bloody themselves. We still have the senate bills to work through, votes to seek and a Senate-House conference committee to work with. We need, and hope for, your active participation throughout.