ACC President Bove and ACC leadership have asked staff to get in the weeds a little bit more around some of the controversies swirling around health care reform, such as the public option, the "MedPAC on steroids notion," what the minimum benefits should be, how quality will be incentivized, and so on. We have very little time to get such ideas agreed upon and on the table, but we are committed to doing so. A few of the ideas that we believe ought to be incorporated could include:

• Payment and delivery system reform. While this critical need is a minefield of extraordinary complexity, we believe at least one new provision must be added that would create significant resources to fund pilot projects and experimental demonstrations around payment reform, bundled payments, accountable care organization concepts, the patient-centered medical home and other such ideas that will never come to fruition without significant funding and experimentation. We believe that new funding approximating 1.5 to 2 percent of Medicare spending for hospital, physician and other provider reimbursement should be made available to the secretary of HHS for such payment reform experimentation -- and with new dollars. That would provide about $4 billion out of a $450 Medicare billion overall program -- not even 1 percent of total spending. That money could not only fund a broad array of pilots that could extend to smaller practices and hospitals, but it would allow the CMS (Centers for Medicare and Medicaid Services) to expeditiously hire the kind of expertise and capacity-building resources it will need to help the nation make these transitions gracefully and effectively, and to work with the profession to make it happen sensibly.
  
  
• The SGRrrr needs to be obliterated. HR 3200 wipes it out for 10 years, but not completely. I think Mr. Baucus will just fund a one year fix -- that’s unacceptable. Let’s move on.
  
  
• Tort reform has to be included. The cost of defensive medicine is widely argued. HHS estimates it at $126 billion per year including almost $60 billion in Medicare and Medicaid, but Pricewaterhouse Coopers estimates it at $210 billion (I trust them more than HHS), and others claim it may even be higher. So, what’s to argue? It’s a lot of wasted money, not to mention the legal costs and hassles! What if we cut the defensive medicine estimates by 75% to, say, an estimate of $50 billion a year? Saving $50 billion annually would result in a $500 billion savings over the 10-year budget period for which expanded access to care is estimated to cost $1 trillion -- the cosmically sized number Congress has not yet decided how to pay for. Dang! Why not fund half the cost of reform by reducing the hemorrhaging of health care dollars into the legal system? While we know the U.S. Senate won’t vote for the most comprehensive reforms we would like to see, we believe the current pressure for bipartisan action could open the door for significant tort reform progress that would save that $50 billion of defensive medicine target I referred to. ACC is working on convening specialties, states, consumer groups and others to get this issue back on the table!
  
  
• Primary care: Nobody would disagree that primary care is more devastated than the rest of medicine, even though workforce shortages in cardiology, CT surgery and other specialties will also impair the system in the future in significant ways. But primary care really is a disaster in terms of supply. So, why not fund a renaissance of primary care as part of the $1 trillion investment, rather than the “robbing Peter to pay Paul,” nickel-and-dime approach currently before us? These approaches won’t work in terms of saving primary care; they divide the House of Medicine, and they will further impair access to specialty care. HR 3200 puts some new funding in for primary care, but it will be insufficient to even persuade one medical student to move in that direction.
  
  
• Benefits: If the cost of universal access exceeds what Congress is willing to spend, why not consider having the minimum benefits consist of USPHS-approved prevention services and high deductible coverage (perhaps over $2000) at minimum? People would still have to pay for some outpatient care, but nobody would be bankrupted by health care anymore, and any serious condition would be covered. This isn’t perfect, but it is so much better than we have now.

Weighing in on Other Controversies
We probably do need to help Congress find its way to work around the public option dilemma, the MedPAC on steroids idea, and other divisive issues. But if we were to succeed in getting the previously mentioned objectives moving, these controversial provisions might iron themselves out on their own, given the lack of consensus about them in the Congress. In other words, we might do better to be emphatic and clear about what we want to happen than to spend all of our energy on what we don’t want.

Regarding an empowered MedPAC, Sen. Rockefeller (D-W.V.) has introduced a separate bill on this topic. We will need to think about what we agree with. His bill would:

• Reform MedPAC as Executive Agency Modeled After the Federal Reserve Board
  
  
• Elevate MedPAC to be an independent, executive branch entity, like the Federal Reserve, with the power to implement recommendations that are more insulated from special interests, and more accountable to the American people
  
  
• Inform new research in health services to adequately address deficiencies in the evidence
  
  
• Test new and innovative payment models for provider reimbursement, and
  
  
• Expand the capacity to evaluate basic and health services research for reimbursement. 

President Obama tonight will address Congress on health care reform "in understandable, clear terms [with] what our administration wants to happen with regard to health care, and what we are going to push for specifically," according to Vice President Biden. Let's see if he addresses any of the items I've outlined here.

*** Image from Flickr (WilWheaton). ***

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