President Barack Obama, groping for a strategy to pass healthcare reform now that Sen. Scott Brown (R-Mass.) has been sworn in, has invited congressional Republicans to discuss the issue at the White House with their Democratic counterparts with the TV cameras rolling.
Getting them onboard
Tort reform, Medicare pay fix will draw patients, doctors to support reform
Patients and doctors are still waiting for their invitations. Moreover, Congress has given the back of its hand to two of their top priorities: medical malpractice reform and physician pay. Although Congress is listening to neither, doctors and patients are listening to each other. And what they are saying, Congress would not like.
Last fall, the Congressional Budget Office released its estimate of the cost of averting the 27% cut in Medicare payments to doctors, scheduled for 2011: $210 billion over 10 years. Neither the House nor Senate reform bills now propose to foot that cost. So, despite promises that Congress made to doctors, we are preparing to abandon Medicare. As one of the few members of the Bush administration who has persistently and personally (pro bono, on behalf of no institution or agency) urged Congress to work toward health reform, I take some blame that its cure could prove worse than the disease.
Now is the time to resurrect tort reform and to dedicate those savings to avoid the planned 27% cuts in Medicare reimbursement for doctors.
These “narrow” issues are put in perspective in the four studies John Zogby and I conducted last year of U.S. opinions on healthcare reform. In June, when the major papers were still enthusiastically reading their own polls as supporting health reform, we noted that—when shown the actual provisions of the bills—fewer than 50% of Americans were supportive.
We pointed out what they did support: insuring regardless of pre-existing conditions, insurance exchanges (for online comparison shopping and to pool risks to reduce premiums), requiring large employers to offer insurance, administrative simplification and transparency and a host of quality incentives. These include incentives to reduce fraud, unnecessary tests, surgeries and errors; and to reward patients for taking better care of themselves and doctors for better outcomes—paying for quality, not just quantity, of care.
Americans oppose more taxes for themselves (or their children, by deficit spending) except on cigarettes or those making more than $280,000 a year. And they oppose federal support for elective abortion, for care of illegal immigrants and any type of rationing or cuts in services that are not plainly wasteful or abusive. We also reported—before and after the outcry about “pulling the plug on Grandma”—that they support advance directives.
It was gratifying to see most of these provisions in the bills that passed committees of the House and Senate, and especially to see the rebound in interest in tort reform and in a public option when we showed congressional leaders our Sept. 30, 2009 data: only 27% supported (and 59% opposed) the Senate Finance bill, but when offered a choice of amendments, most chose tort reform, and it made it too close to call. Adding in a public option put the bill over the top with 52% in favor and 41% opposed.
Tort reform and the Medicare physician pay problem can be corrected together: defensive medicine costs $60 billion to $110 billion per year, according to published estimates by university and HHS analysts, but even if only some tort reforms can be put in place, the CBO projects $54 billion in savings over a decade. This cautious estimate (twentyfold less than some others) could nevertheless provide the funds to avert the doctor cut until the pay-for-performance programs are rolled out in 2013.
There are two alternatives: a one-time “doc-fix” bill that the CBO estimates would cost $210 billion over 10 years and would provide no further incentive for doctors to focus on quality rather than quantity of services. The other is to do nothing, and doctors will stop taking new Medicare patients and spend even less time with their current Medicare patients (yet order more tests).
For our part, doctors must embrace pay-for-performance. Legislation may foster—but cannot ensure—compassion, courtesy and cost-effectiveness. To do that, reform must win the hearts and minds of physicians, but a survey published last September by Investor's Business Daily showed that two-thirds of physicians had turned against the reform bills being considered in Congress.
I now wish Zogby and I had underlined one finding of our surveys: Americans strongly oppose cuts in physician reimbursement. They know doctors aren't poor, but also that they work 70 hours a week, and don't pay off their medical school debt until age 40. Most don't want to change doctors, but want that choice to remain theirs. And they trust their doctor more than they trust Congress or the president. So, if their doctor drops Medicare, or just retires, they will not soon forget President Obama's promise: “You will not have to change your doctor.”
I caution my students that there is no such thing as “my patient,” only “my doctor.” The latter is earned. Quietly, patients vote with their feet, and more conspicuously, they vote in elections. Congress and the president should listen to them and their doctors, and respect their choices. They can start by adding tort reform and using those savings to save Medicare.
S. Ward Casscells is a professor of medicine and public health at the University of Texas Health Science Center at Houston and was assistant secretary of defense for health affairs from 2007 to 2009.
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