Wednesday, November 25, 2009

The Reid bill in the Senate

It's true, dear Blog, I have been neglecting you. I think of it as a fallow period. After all, before just signing in and blogging away, it's good to think first. So I guess I have been.

I have read most of the Reid bill in the Senate, and earlier this year I read the two house bills, especially HR 3962. All I can say is, deficient as I think the bills are, and I think they are grossly deficient, at least they will break the logjam in health and get change moving. I'm trying to be optimistic. My essential pessimism comes from realizing that the powers that be, are the powers that will be. It's not only the rules of the Senate, it's the makeup of the Senate with over-representation of the West, the South, and the rural, and the lack of electoral reform that makes money talk. None of this is going to be fixed in my lifetime, and perhaps in yours. And this situation conditions events strongly.

But, given that, here are some observations on the Reid bill.

The problem of primary care, that there are a diminishing number of primary care physicians and the field is economically uninviting, remains unaddressed. The House bill had a 5% primary care bonus, and it had more people on Medicaid (150% of the poverty line), but increases of Medicaid payments over 3 years to 100% of Medicare. That's all gone in the Reid bill. What remains is nothing to make primary care a more attractive destination, but to make entry more attractive by loan forgiveness and more residency places - not an ideal solution to my mind. In fact, pretty poor.

There is a chance that the changes envisioned for MEDPAC, the body that recommends payment levels in Medicare, would change that. I do think that separating MEDPAC from the special interests, which is what insulation from Congress means, is very good. But I still doubt that they will go ahead and pull compensation for primary care up. So, I think the primary care issue, grounding the system in primary care, is very poorly addressed.

I think the hospitals are going to make out like bandits, because their uncompensated care will now be compensated and they will have given up nothing. The quality measures under Medicare (not getting paid for patients who are readmitted, not paying for hospitalizations for infections acquired in the hospital, etc.) is something they should do anyway, and can do, and in the end it will cost little. Most of them, for all their complaining, do very well with local monopolies, pay SEIU very well (for all their complaining), pay nurses far too much (for all their complaining), pay the administrators phenomenally well, and don't do basic management well (clearing OR's so the next case can follow, etc.) Instead of being efficient and kicking some butt they just raise their rates. Can't see that changing. Hospital rates are so unbelievable, it is surprising there is not more focus on that. This is such a core problem, and it is very poorly addressed.

Pharma will do just fine, thank you, as has been well documented. They will sell more than ever and not much competition will ensue. This issue, festering since the Kefauver investigations, remains poorly addressed.

Insurance companies still will have little oligopolies and no ceiling on rates. Yes, they will get rid of exclusion and rescissions, but they will reduce their underwriting expenses, have many more people enrolled, government money, and yes they will have to report their medical loss ratio, but what games will they play? They will still torture us, the doctors with their contracted rates and quibbling over bills we send in, etc. This problem is better addressed than hospitals and pharma, but where will the competition come from? The Public Option has withered on the legislative vine. They will all still probably retain their monopolies.

So, where will the savings occur? Can't really see it, despite the optimism of the economists. Some will come from us (physicians, especially primary care), where we don't need it. There are the beginnings of ACO's (Accountable Care Organizations), of course, but they will take a while to work if they do. Of course care has to be organized and coordinated, it's a scandal that it isn't. But the major story with ACO's will be political control. Will this further the corporatization of medicine? Almost inevitably. Who will be in control, hospitals? Dunno. This will be the story to follow, I guess.

Some tidbits from the bill: nurses do well, as they will now be empowered to run medical home practices with them in charge, no doctors, just a back up institution like a medical center or FQHC. Nurses are getting their autonomy! Plus the academics get more training money. What they should do is resurrect the hospital nurse schools, get more LVN's, and break the RN strangle hold on the hospitals. Not going to happen.

I think there is further movement to separate and unequal health systems, as the FQHC's get billions, from $1B to $4B over 5 years, I think, while their colleagues in private practice get squeezed instead, and FQHC's already get 2-3 times as much payment per visit. An inevitably high cost and low customer service solution.

There's also $50 million for school health centers - great jobs! No nights, no weekends, just hang out around the school without anyone checking your productivity - a county job! Sorry I can't be enthusiastic, because on paper it's a good idea. In practice? Not so much. Without productivity measures, people just don't work so hard, they just don't.

Then there's this: "The Primary Care Extension Program shall provide support and assistance to primary care providers to educate providers about pre-ventive medicine, health promotion, chronic disease management, mental and behavioral health services including substance abuse prevention and treatment services), and evidence-based and evidence-informed therapies and techniques, in order to enable providers to incorporate such matters into their practice and to improve community health by working with community-based health connectors (referred to in this section as ‘Health Extension Agents’)."

I can't wait until I meet the little MPH graduate who comes around to my office telling me how to practice medicine!! On the positive side, maybe we could capture this program and become the "hub" and the "agents," but I've been around long enough to be able to spot a disaster in the making. "What are you doing now, Barbara?" "I'm a Health Extension Agent. I get to tell stupid doctors what they should be doing." "Oh, that must be fun! Are any of them cute?"

Well, take away my misogyny, and you get the picture.

Budd Shenkin

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