The Senate Committee on Health, Education, Labor and Pensions (HELP) last week outlined its broad goals for reforming the American health care system. Among the top goals: improving the delivery system; enhancing prevention and wellness; reducing fraud and abuse in public and private health systems; and establishing shared responsibility for financing of reform efforts. Nobody can argue with the goals, but how the heck do we get there? We’ll need more details and some HELP.

The Committee appropriately suggests that health care reform legislation should encourage adoption and use of health IT; promote evidence-based medicine; facilitate health literacy; and include strategies for tackling preventable medical errors and hospital readmissions. It also proposes better managing chronic conditions through care coordination, medical homes and community health teams. Again—we agree. I mean, duh.  But, how do we systematically do that? ACC is working with leaders in the Senate and House as they continue to flesh out these and other proposals and develop overarching health reform legislation. For the latest information on health reform, visit http://qualityfirst.acc.org.

Meanwhile, President Obama met this week with key Democratic Senators Baucus and Kennedy and reaffirmed his support for the creation of a government-sponsored “public plan” health insurance option — the issue that invokes the most angst and opposition from Republicans who might otherwise support some kind of overarching health reform legislation (as an alternative to national bankruptcy?). Read more in the New York Times and The Washington Post. 

For me, it’s what is not in these articles and stories that is most concerning. Consider the following:

IF the SGRrr payments are flat for ten years as projected, how do we prevent tens of thousands of doctors from just throwing in the towel, exacerbating the access problem? If we move the delivery system toward integrated groups, and transform payment from fee-for-service to bundling or episodes of care (or capitation) to align payment incentives with quality improvement, who receives and distributes the payment bundles?  Hospitals? New entities?  If the money goes to hospitals to dole out to doctors, should doctors all be employees of hospitals to be able to share in the huge profits hospitals make from? Or could bundles go directly to doctor groups? If so, how would they be organized if not already in integrated systems? And, if any of this is going to work in terms of payment incentives, gainsharing, and new potential relationships between physician specialties and hospitals, isn’t some anti-trust relief going to be needed? Is that part of the reform plan?

And, where is the med-mal relief plan that we will need to reduce defensive medicine costs? And, what if a new public plan is created that pays less than what it costs for some doctors to produce the required care? In the current Medicare program, it is illegal to balance bill patients to cover costs. Will a future potential Medicare-for-all concept of Medicaid, the new ‘public plan,’ and Medicare allow doctors to opt out--or will we be forced into a kind of pseudo-public employment? If the new public system were to become untenable and unfair in terms of reimbursement (let’s say the government has some budgetary problems in the future?), would doctors be prohibited from opting out of the program and still seeing patients who were willing to pay them directly?

And what about EMTALA? If health reform achieves universality, is EMTALA to be sunsetted? Do on-call stipends go away? Why or why not?

None of these ‘details,’ among many, many others, are currently included in the emerging principles of reform discussions. It’s a little scary. We really need to think about these details. It seems to me that after we pass whatever we pass this year, we’re going to have a year or two of very messy details and divisive issues to deal with.   

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