15 June 2009

Obama's talk to the AMA - Excerpts and Comments

Just a quick cut & paste of some bits from the Text of Obama’s Speech to the AMA and my own trenchant analysis.

And yet, as clear as it is that our system badly needs reform, reform is not inevitable. There’s a sense out there among some that, as bad as our current system may be, the devil we know is better than the devil we don’t. There is a fear of change – a worry that we may lose what works about our health care system while trying to fix what doesn’t.
The fear of change is all the more acute when the proposals for reform remain, even at this late date, very inchoate and vague. The process has been (reasonably) transparent, unlike in 1993, so at least the outlines and competing options have been apparent. But the fact that we still don't really know what's coming puts a lot of people, especially doctors who might favor reform, in the anxious and skeptical camp.
[Prior] efforts at comprehensive reform that covers everyone and brings down costs have largely failed. Part of the reason is because the different groups involved – physicians, insurance companies, businesses, workers, and others – simply couldn’t agree on the need for reform or what shape it would take. And another part of the reason has been the fierce opposition fueled by some interest groups and lobbyists – opposition that has used fear tactics to paint any effort to achieve reform as an attempt to socialize medicine.
Sadly, the physicians lobby -- the AMA -- has acted like any other lobby, and worse than many, in focusing its attention narrowly on the economic interests of its members. And I've seen fairly little from ACEP or the ACP or any of the other physicians' organizations speaking clearly about the reforms being considered. It's been a colossal failure of leadership on the part of the house of medicine.
We need to bundle payments so you aren’t paid for every single treatment you offer a patient with a chronic condition like diabetes, but instead are paid for how you treat the overall disease. We need to create incentives for physicians to team up – because we know that when that happens, it results in a healthier patient. We need to give doctors bonuses for good health outcomes – so that we are not promoting just more treatment, but better care.
This hasn't gotten a lot of attention, I think because nobody knows what the heck we mean by it. But I worry a lot about bundling of payments. If there's one payment to multiple providers, possibly combining a facility and professional fee, who gets what fraction of it? That looks to be a case of three wolves and a lamb voting on what to have for lunch, no? And still, we're all in favor of paying for quality, but nobody knows how to define quality let alone compensate on the basis of quality.
And we need to rethink the cost of a medical education, and do more to reward medical students who choose a career as a primary care physicians and who choose to work in underserved areas instead of a more lucrative path. That’s why we are making a substantial investment in the National Health Service Corps that will make medical training more affordable for primary care doctors and nurse practitioners so they aren’t drowning in debt when they enter the workforce.
Small beer. Nice to know that he's aware of the economic disincentives to medical students to practice in primary care fields. Pity he doesn't have any more substantial ideas to address the problem.
Each time an uninsured American steps foot into an emergency room with no way to reimburse the hospital for care, the cost is handed over to every American family as a bill of about $1,000 that is reflected in higher taxes, higher premiums, and higher health care costs; a hidden tax that will be cut as we insure all Americans.
I know there’s some concern about a public option. In particular, I understand that you are concerned that today’s Medicare rates will be applied broadly in a way that means our cost savings are coming off your backs. These are legitimate concerns, but ones, I believe, that can be overcome. As I stated earlier, the reforms we propose are to reward best practices, focus on patient care, not the current piece-work reimbursement. What we seek is more stability and a health care system on a sound financial footing. And these reforms need to take place regardless of what happens with a public option. With reform, we will ensure that you are being reimbursed in a thoughtful way tied to patient outcomes instead of relying on yearly negotiations about the Sustainable Growth Rate formula that’s based on politics and the state of the federal budget in any given year.
This is the sort of vagueness and ambiguity which hinders physician acceptance of the public plan. Yes, you have acknowledged (some of) our concerns. Great. So where does your administration stand on them? Can you tell us, clearly and distinctly, whether you think Medicare rates should be used in the public plan? Can you tell us whether participation in the public plan should be mandatory for physicians who participate in Medicare? Seriously, I'd like to know, and the fact that you're not willing to stake out a position on this, when you have on so many other policy points, implies that you think we're not going to like your answers. If you could assure us that the public plan you envision and you will lobby for is palatable, then it would be less likely that the AMA house of delegates would be voting on resolutions opposing the public plan.
[L]et me explain how we will cover the price tag. First, as part of the budget that was passed a few months ago, we’ve put aside $635 billion over ten years in what we are calling a Health Reserve Fund. Over half of that amount – more than $300 billion – will come from raising revenue by doing things like modestly limiting the tax deductions the wealthiest Americans can take to the same level it was at the end of the Reagan years. Some are concerned this will dramatically reduce charitable giving, but statistics show that’s not true, and the best thing for our charities is the stronger economy that we will build with health care reform.
Hmm? I thought that proposal died in the Senate Finance Committee.
Another way we can achieve savings is by reducing payments to hospitals for treating uninsured people. I know hospitals rely on these payments now because of the large number of uninsured patients they treat. But as the number of uninsured people goes down with our reforms, the amount we pay hospitals to treat uninsured people should go down, as well. Reducing these payments gradually as more and more people have coverage will save us over $106 billion, and we’ll make sure the difference goes to the hospitals that most need it.
I hear the hospitals are already going ape over this proposal. It's sad and it's predictable that as more and more interest groups see something they don't like in the reform package, the support for reform dwindles. I will be very interested to see if, in the end, any major groups like the AMA, AHA, AHIP, etc actually flip and come out in active opposition to the final package. Much will depend on how effective they are in neutering or averting the adverse elements of the plan.

Overall, I'm inclined to give this speech a solid "meh." He didn't speak directly to physician's concerns, and the physicians did not want to hear what he did have to say. But ultimately, this wasn't about the AMA. This was about the general public seeing Obama talk to the doctors and about creating the perception that the doctors are on board with reform. Based on the tepic and vague news conference the AMA leaders held, in which they did not stake out any major disagreements with the President, I would have to say that Obama succeeded in that objective.

1 comment:

  1. surprise, surprise, Obama manages to make an hour long speech without really saying anything.
    "High costs are bad, quality health care is good, making the evil wealthy people pay for it is good"
    Thanks for the heads up President Pelos... I mean Obama. I would have had no idea otherwise.

    Oh yeah, and this part ..."medical training more affordable for ... nurse practitioners"
    WTFFFF? already grouping in PCPs with nurse practitioners I see.

    The health insurance lobby rivals the big oil lobby so Obama better tread carefully. They will not go down without a fight.


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