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Congress needs to rewrite script for fixing payment system

From the January ACP Internist, copyright © 2008 by the American College of Physicians.

By Robert B. Doherty

Washington, D.C. is once again playing its own version of the film “Groundhog Day,” in which an ill-fated newscaster repeats the same day over and over again. The original 1993 film placed the newscaster, played by comedian Bill Murray, in Punxsutawney, Pa. Had the film been based in Washington, D.C., the script would go like this: Well-meaning members of Congress start out the legislative year full of promises to deal with the perennial Medicare physician payment cuts in a comprehensive and expedient way that will lead to a long-term solution. Months go by, other issues take priority, members of the House and Senate can’t agree, and they postpone action until the closing days of the legislative year. It isn’t until right before the December holidays that anything gets done. Even then, Congress might decide (as it did in 2006 and 2003) to wait until after the cuts have gone into effect to enact legislation to reverse them.

When Congress does “fix” the problem, it enacts a short-term measure (such as a one- or two-year freeze or small positive update) that doesn’t replace the flawed Medicare Sustainable Growth Rate (SGR) formula that created the problem in the first place. It pays for the short-term fix by making the cuts deeper in future years. With deeper cuts, the price tag for Congress to enact a permanent solution goes up annually by tens of billions of dollars, making it more difficult for Congress the next time to agree on budget offsets (tax increases or cuts in other programs or providers) to pay for positive payment updates to replace the SGR cuts. And in this script, instead of Bill Murray trying to repeatedly and endlessly file a news report on Groundhog Day, the lead role is played by physicians trying to care for Medicare patients.

Rewriting the script

In December, physicians were waking up to the reality that Congress still hadn’t enacted legislation to avert a 10.1% cut, with only a few weeks left before the winter recess. Although the House of Representatives had passed a bill earlier in 2007 that would replace the cuts in 2008 and 2009 with positive updates, the Senate was only starting to address the issue. It was unclear what the Senate would decide to do, how anything it decided would be reconciled with the House of Representatives’ actions, or even whether action would be completed before Congress adjourned for the year and the cuts went into effect.

In the film version of Groundhog Day, Bill Murray’s character broke out of his endless cycle of repeated days by changing his own actions, so that the outcome for each subsequent Groundhog Day became subtly (and eventually entirely) different than the ones before. ACP is trying to do the same through a series of position papers. We have proposed:

  • physician payment models that support the value of the relationship between patients and their primary care providers,
  • care organized around the patient-centered medical home,
  • a national workforce policy that ensures a sufficient supply of well-trained physicians and, more specifically, attracts more physicians into general internal medicine and other primary care career paths,
  • policies that reduce health care disparities,
  • positive incentives for continuous and measurable quality improvement, and
  • expanded access for the uninsured.

The latest addition to ACP’s policies is a three-part article, which I co-authored: “Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries,” published in the Jan. 1, 2008 issue of Annals of Internal Medicine. Unlike previous, highly focused policy papers, this paper takes a broad view, describing health care in the U.S., comparing our system to other countries, and then proposing lessons that the U.S. can learn from these countries and recommendations for achieving a high-performance health care system. It is a thoughtful, evidence-based and provocative statement of what the U.S. needs to improve to provide all residents with affordable, efficient and high quality care. While individual readers may not reach the same conclusions on how best to reform health care, I hope that the paper succeeds at least in making a compelling case that the status quo is unacceptable.

This new policy paper re-writes the script from “How do we get Congress to halt the Medicare cuts” to “How do we get Congress to create a high-performing health care system,” including changes in Medicare payment policies. ACP’s policies will not allow us to escape from this year’s version of Groundhog Day—we still need to do everything possible to stop the Medicare cuts. But the College’s policies would re-write how health care is financed, reimbursed and delivered in the U.S. We plan to challenge the Presidential candidates to play off our script, instead of replaying their same old tired show.

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