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The results of the November elections prompted physician organizations to predict that 2009 will be an active year for reform. They're calling on President-elect Barack Obama and Congress to expand health coverage to the 46 million uninsured and to take the lead on such issues as fostering primary care and medical homes.
"We think there's that window of opportunity next year to really accomplish something," said AMA Board of Trustees Chair Joseph M. Heyman, MD.
Ted Epperly, MD, the American Academy of Family Physicians' president, said he has never before been so excited about a new president. "I believe that under his leadership we will finally start to make significant change toward health [system reform] in this country."
It won't be long before the new Congress and White House have the chance to test out their power arrangement with a major health access issue. The State Children's Health Insurance Program will expire at the end of March, unless there is an extension or reauthorization. Attempts by Democrats this year to expand SCHIP coverage to millions of additional children were stopped by President Bush and his GOP allies.
President-elect Obama's health reform plan would cost $65 billion a year.With Obama at the helm, Democratic leaders in Congress already have set policy sights much higher. They want to cover as many of the nation's uninsured as possible.
Senate Health, Education, Labor and Pensions Committee Chair Edward Kennedy (D, Mass.) plans to build off private meetings with representatives from myriad groups to seek consensus on comprehensive reform. Sen. Max Baucus (D, Mont.), chair of the powerful Senate Finance panel, detailed some of his plans for reform on Nov. 12. House Energy & Commerce Committee Chair John Dingell (D, Mich.) wrote a Nov. 10 letter to Obama asking to work with him on comprehensive reforms, starting with an SCHIP expansion.
Such individual efforts likely will merge into a single strategy, said Michael Myers, majority staff director for the Senate HELP Committee. "There's a growing recognition that the best way, maybe even the only way, that this gets done is for Democrats to unite behind a single bill."
Obama ran on a health platform of improving the employer-sponsored health insurance system, not dismantling it to try a new approach, such as a single-payer system. Democrats don't plan to buck the next administration on that issue, Myers said.
Obama pledged to allow people who are happy with their job-based health insurance to keep it as is, but he promised that his plan would make it less expensive by creating a new national market for health insurance. He also pledged to cover more uninsured people in Medicaid and SCHIP.
At the present rate, the Medicare hospital trust fund will be exhausted by 2019.Meetings among Democratic staffers have focused on how to translate the Obama plan into compatible legislation, Myers said. "Everyone in Congress, at least on the Democratic side and certainly Sen. Kennedy, is going to be taking their cues from the Obama White House on this effort."
Obama supporters are mostly interested in getting help paying their health insurance, said Robert Blendon, ScD, a professor of health policy and political analysis at the Harvard School of Public Health. "We don't find the evidence they were thinking of new ways to reorganize the health care system."
Myers said that likely rules out legislation that would overhaul employer-sponsored health insurance, such as Sen. Ron Wyden's (D, Ore.) bill.
Wyden's bill, the Healthy Americans Act, would replace the employer tax exclusion with a standard tax deduction and an individual health insurance mandate. It would shift most Medicaid and SCHIP enrollees to new state-run insurance pools.
But Wyden said his measure shares many principles with Obama's plan, such as strong support for preventive medicine and comparative effectiveness research. The AMA has not officially endorsed Wyden's bill but has been supportive of his efforts to find a bipartisan approach to health system reform, Dr. Heyman said.
Obama's call for fostering greater care coordination through medical homes echoes physician organizations such as the AAFP and American Academy of Pediatrics. He and the AMA also agree on the need to back income-based insurance subsidies and health information technology.
"I'm sure there are more areas where we can agree than areas where we might disagree," Dr. Heyman said. Obama campaigned against ending the tax exclusion for employer-sponsored health insurance and replacing it with tax credits -- part of the AMA's uninsured proposal. The president-elect might be more supportive of expanding public health insurance programs than is the AMA, Dr. Heyman said. Still, both agree on the need for a mix of public and private solutions.
Obama gave no indication the economic recession was leading him to scale back his spending plans. Voters who backed him also have high expectations for health care change despite the financial challenges, Blendon said. "He can't say, 'I'm going to do nothing or something very small.' "
The president-elect's health system reform plan would cost at least $65 billion a year, according to estimates by his campaign staff. This figure assumes the reforms he proposes reduce health spending in other areas.
Experts said needed funding will be hard to find. The next Congress is inheriting a $10 trillion debt and has not made plans to address the more than 20% Medicare pay cut that physicians will receive in 2010. The Medicare hospital trust fund also is set to be exhausted by 2019. "This current Congress coming up needs right now to start dealing with that issue," said Phil Roe, MD, an ob-gyn and Republican newly elected to Tennessee's first congressional district.
But Dr. Epperly said the recession actually could further the cause of health system reform. People who have lost jobs and health coverage should be more apt to support new types of health legislation, he said.
Dr. Heyman said adopting comprehensive reforms is not primarily a matter of dollars. "If we have the political will to spend $700 billion in a week's time to cure the economic crisis, which is a temporary problem, we ought to have the political will to spend much, much less money on compromising and finding a solution to this long-term problem."
Legislation enacted in July reversed a 10.6% cut that took effect at the beginning of that month. Starting in January 2009, a 1.1% across-the-board increase will replace an additional roughly 5% cut that would have gone into effect if lawmakers had not acted, the Centers for Medicare & Medicaid Services said in the final pay rule issued Oct. 30. Because the rule applies payment changes related to the most recent five-year adjustment in Medicare relative values for certain services, some physician specialties might see updates slightly larger than or smaller than 1.1%.
"Medicare's new rule confirms that physicians caring for seniors would have faced a harsh payment cut of 15.1% next year if Congress had not stepped in," said American Medical Association President-elect J. James Rohack, MD.
The upcoming 1.1% boost will fall short of the CMS-projected 1.6% increase in the cost to physicians of providing care next year. Payment freezes and increases in recent years also have come in under the rise in costs. But the agency stressed that two bonus opportunities exist to more than quadruple the raise that doctors will get for the year.
Physicians who successfully participate in the Physician Quality Reporting Initiative will receive a 2% bonus on all of their Medicare payments for the year. Also, the program for the first time will award a separate 2% bonus to physicians who successfully prescribe medications electronically for their Medicare patients. Although the sums will not be paid out until sometime in 2010, after Medicare has processed all of next year's claims, this means the maximum effective raise for 2009 will be 5.1%.
The rule gives more detail on how a doctor can secure an e-prescribing bonus. For example, he or she would need to have a qualified system that can adequately communicate with the patient's pharmacy, identify appropriate drugs and lower-cost alternatives, provide formulary information, and generate adverse event alerts. A physician must report one of three special e-prescribing codes at least half of the times they are applicable. Claims containing the codes must represent at least 10% of all the services for which the physician bills Medicare for the year.
CMS envisions that the e-prescribing bonus will provide the "tipping point" for the health care industry as a whole to move to widespread adoption of the technology, the agency said in the final rule. The effects would go well beyond physician pay.
"E-prescribing can greatly reduce the number of medication errors that jeopardize the health and safety of Medicare patients and waste precious health care dollars treating conditions that never should have happened," said CMS Acting Administrator Kerry Weems.
Despite the prospect of more money on the table, physicians worry that more restrictive policies in other areas of the rule could increase the number of doctors who see their payments -- or their ability to see Medicare patients -- stop altogether.
"We are reviewing the 1,500-page rule now to determine how it addresses AMA concerns with proposals that would exacerbate already significant administrative hassles that take physicians away from patient care," Dr. Rohack said Nov. 10.
Earlier this year, for example, the AMA and others strongly opposed a provision in the proposed 2009 fee schedule rule to clamp down on retroactive Medicare billing. Doctors cannot bill until they are officially enrolled in Medicare, but afterward they can bill for services provided as far back as 27 months from when their enrollment takes effect. CMS proposed limiting that retroactive billing to only 30 days before the date the enrollment application was successfully filed or the date a doctor started providing services at a new practice location, whichever comes later.
The organizations argued that the process of enrolling or re-enrolling in Medicare has turned into a complex process that often takes much longer than a month to complete. Backlogs on the part of Medicare contractors often make the process even longer, and the prospect that this could lead to a denial of retroactive payments means that a doctor waiting to enroll or re-enroll might be unable to see Medicare patients until the contractors resolve the problems, they said.
"Simply adding another 'gotcha' regulation to the mix will only make matters worse," AMA Executive Vice President and CEO Michael D. Maves, MD, MBA, wrote in a comment letter on the proposed rule.
But CMS rejected the comments and adopted the new retroactive billing restrictions in the final rule. Agency officials insisted that they cannot know whether a newly enrolled physician met Medicare requirements prior to the date that the enrollment actually takes effect.
CMS in this case appears to be fixed on a solution in search of a problem, said Lisa Goldstein, government affairs representative with the Medical Group Management Assn. A practice taking on a new physician who needs to be enrolled in Medicare, for instance, would never risk the liability of having that doctor see Medicare patients if he or she were not in compliance with program rules, she said.
Goldstein said even more physicians could experience enrollment-related payment problems once the new restrictions take effect Jan. 1, 2009. Doctors are already citing widespread enrollment delays and payment stoppages related to this year's Medicare contracting reforms and the move to the National Provider Identifier.
Some of the physician comments on the proposed rule did have a positive impact. CMS had planned to ban the use of computer-generated faxes to order Medicare drug prescriptions starting next year, but a strong response from the AMA and others caused the agency to push off that effective date until 2012.
Many doctors who have electronic medical records systems rely on computer-generated faxes for drug orders. A Medicare ban in 2009 likely would have driven a large number of them to revert to paper prescriptions rather than having the intended effect of moving them toward true e-prescribing, said Steven E. Waldren, MD, the director of the American Academy of Family Physicians' Center for Health Information Technology.