AMA Conference Call on HC Reform

The AMA is doing regional conference calls on health care reform. The one for my region (PA, NY, MA, maybe others) was tonight. I gather it was the first one they've done so far, but they indicated they would be doing more.

On the call for the AMA were Immediate Pat president Nancy Nielsen, Jim Wilson, Political Education Programs Manager, and Richard Deem, Senior VP for Advocacy.

I was pretty pleased with the call and the positions that the AMA seems to be taking, so you may be pleasantly surprised.

The call started with some comments by Dr. Nielsen, then questions from the group (transcribed for the AMA reps, who read them to us), and a brief closing statement.

Dr. Nielsen opened with a discussion of HR 3200, presumably because of the push back the AMA has gotten from its more conservative members. HR 3200, in its original release addressed in positive ways, many of the AMA's highest priority goals. These included extended coverage for the uninsured, preserved choice of health insurance plans, fundamental Medicare reform including elimination of the SGR, encourages mangament of chronic diseases and coordination of care, increased payment to Primary Care Physicians with no reduction in fees to specialists.

The things in 3200 the AMA wants changed: addition of Medical liability reform; change in plan for public option fees to be 5% above medicare; and restrictions on physician ownership of hospitals.

Ammendments introduced so far include "modest" liability reforms (AMA speak for anything that is not "caps" on damage awards), including encouraging states to give incentive payments for certificate of merit and "early offer" programs, and she reaffirmed, essentially, that we're all about caps at the AMA. Also ammended, public plan participation by physicians will not be mandatory and public plan fees will be negotiable and not fixed to medicare rates.

Compromises still being sought include, in the Senate HELP committee: Public Plan similar to HB 3200; negotiated payments; the plan must be self sustaining, and compete on a "level playing field."

In the Senate Finance Committee, the bipartisan "Gang of 6" are seeking compromise legislation, but we have not seen an actual bill yet. But all indications are that this bill will NOT fix SGR (only another one year fix, then replay the annual ritual of rganized medicine fightinng to fix this again. The AMA wants to fix this with Senate FLOOR VOTE. Also concerning are possible penalties for PQRI non participation and that we may end up with co-ops rather than PO/PP. Dr. Nielsen preemptively addressed the question of why the AMA has postioned itself where it has re: HB 3200: We need insurance market reform because insurance is tenuous to the public, it is tied to jobs, it is limited by preexisting conditions and because we all pay for care given to uninsured anyway. Getting rid of SGR is a big deal for the AMA as is avoiding other financial penalties (such as with PQRI) and we do all have to be worried about costs.

She also points out that we physicians are being dealt with very fairly in HB 3200: Hospitals are going to get cuts, home health gets cuts, as do others while physicians get $230 Billion (erasing SGR debt is part of this number, but also includes higher fees for PCPs including incentives for coordinating care and dealing with chronic care patients)

Why did AMA support HB 3200 so quickly? Dr. Nielsen said that early support means something and gives us more influence; we are working with leaders in both houses and they understand Medicare must be strong(!). The AMA did not "give away" support; it was negotiated and we got things: No mandatory participation in a public plan, more money.

She points out that ranting is not useful, quiet negotiation does and is working.

QUESTIONS FROM AUDIENCE:

Q: Socialized medicine!!! Slippery Slope!!!! (I paraphrased here.)
A: NO: Americans will not tolerate it. Expanding coverage is not socialism.

Q: Will there be rationing under Medicare or under any public option.
A: NO NO NO

Q: Wwhy support anything without "significant" liabilty reform?
A: We're still fighting!

Q: How does AMA support 3200: It's awful.
A: No, it isn't. SGR!

Q: Can we have physician council to guide HC?
A: AMA may be filling this role in guiding legislation, but not clear if tere would be a way to do some far reaching council.

Q: Anything restricting physician patient relationship?
A: The AMA is FIRM in that there can be no interference in care decisions. CER will never mandate what a doctor may offer to a patient. MC is easier to deal with than PHIs(!!!), she said, from her perspective as a primary are physician. Less hoops with MC! We also want best evidence! Mr. Deem: No penalties on PQRI in HB 3200

Q: How can we support bill we haven't seen? Aren't we being used/abused?
A: Physicinas are necessary in this debate. Congress has brought actors together and said we are all in this together and we have to do this. NN thinks we are participating, not being used and we believe we have influenced the process significantly, but perhaps not on CAPS.

Q: HB 3200 better PCP fees?
A: Yes; also increased coordination of care fees.

Q: Did you read 3200?
A: Yes. We have a team that does that and they analyzed it. I have read it as well.

BIG POINT HERE: She calls out the BS email about he facts of HB 3200 as "outrageous," and notes that the AMA has reviewed, and agrees with the rebuttal provided by politifact.com.

Q: Massachusetts seems to be working well except cost controls, what now?
A: We need to learn from MA; getting people in system but costs are big issue; bigger question is how do we come to grips with our responsibility as citizens and patients and physicians and insurers? MA has shortages in work force, nursing and derm and gen. surgeons; We don't need to wait for workforce to be online before we reform HC; lead time too long for physicinas in particular. Choice of doctors and insurers key.

Q: 70-83% of peopple are satisfied with coverage; maybe they won't be if we change things; maybe Congress will lower reimbursement after the bill passes?
A: We are all nervous; but we are also the unhappiest MDs in the world. Prez says you can keep what you have; AMA is concerned about this and we want to preserve choice.

Q: Will Public Plan crowd out private insurers?
A: Bill is written so choice to join PP is limited (to the uninsured, small businesses and some others) but this could change and we must be vigilant.

Q: Why should we trust this administration?
A: Trust but verify. This is about influence and we are critical to change. It is important for us to pay attention and focus on what we agree on, and not on divisive issues.
Mr Deem: Adminstration trying to fix/improve payment formula and did something about MD administered drugs that AMA has been asking for for 8 years and we are just now getting it.

Dr. Nielsen made the point here that Obama's example of non-indicated tonsillectomy example. She thinks that was Really Bad; we know it is not like that; they got big push back.
[CMHMD: I actually agree that he really mangled this one; "inartful" was the kind way to put it, I thought.]

Q: Will there be an independent body, such as an uber-MEDPAC or IMAC, that will rule the roost?
A: Dr. Nielsen expressed concern that there seem to be expenditure targets for physicians, but not for any of the othr big players. She indicated the many if not all of these issues are "in process," and the AMA is expressing our concerns.

Dr. Nielsen added that she thought a view expressed what she called a "minority view" of physicians is that an independent council would be better than dealing with congress. [CMHMD: I don't think this is a minority view. Many health policy big wigs think having Congress function as the "Board" for Medicare is a bad thing that needs fixed.]

Q: CBO score for Senate Bills?
A: We don't know when we'll get them.

Q: Other countries physicians' have less financial pressure coming out of training.
A: We agree and are working on it.

Q: What should physicians be doing now?
A: AMA is happy to help and reach out. Like this call. Hard to say what to do; gives example of tea baggersand cautions that physicians need to be rational and let people know we want to take care of patients without government interference and make sure uninsured get in system and don't saddle kids with crushing debt. Don't fall for labels and rhetoric.

Q: What happens to HSAs?
A: Mr. Deem: HSAs stay in so far. And we will push for that.

Q: Geographic variation?
A: AMA pushing for money for IOM study. Gypsy payment floor (?)

Closing, Dr. Neilsen: This is moving target. What's the difference between an echanges and a co-ops? Exchanges are like a mall to shop; co-op like a single store where owners are also customers.
[CMHMD: I'd call this mutual insurance, and it could be a good thing if well regulated.]

CMHMD final comments: I fouund this very encouraging. There was the expected conservative push back, but that's OK, Dr. Nielsen did a great job of keeping things focused on what are truly high goals for physicians: universal access and fairness in the system. She also stuck to the markers she must or get pummelled by the membeship on tort reform and "choice," but, hey, pretty good from where I'm sitting!

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