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Health System Reform: What Does the Future Hold?

Aug. 11, 2009

Rotary Club of Gainesville
Gainesville, Florida

Cecil B. Wilson, MD
American Medical Association

Thank you for that kind introduction.

It is a pleasure for me to be here today for two reasons.

First, I am a former Rotarian.

And I remember with pleasure the years being a part of this fellowship when I was a member of the Winter Park Monday Noon Chapter.

It is good feeling attending Rotary meetings and being reminded of the genius of the Four Way Test with its values of truth, fairness, being beneficial to all and building good will and better friendships.

So, thank you for that reminder.

Speaking of reminders, the sports season is about to start &151; "the" sport being football.

Having attended Emory University, a school noted for not having major intercollegiate athletics, I have had the luxury over the years of being relatively agnostic about sports teams.

Usually I watch the first quarter and then root for the team that is behind.

I say relatively agnostic since I have to confess my daughter attended that school out West of here, a school that shall go un-named.

In fact someone told me the other day that there is a city ordinance in Gainesville prohibiting voicing out loud the name of that school.

I want you to know I stood up for you. I told that person he must be wrong.

No one would be that rabid about their football team.

The second reason for appreciating the opportunity to be here is to talk about health system reform, clearly the hot topic in our country today and a topic the AMA feels is critical to our future.

As community leaders, you know how health care is central to the health of your community.

There is an incredible infrastructure here to provide care &151; ranging from SHANDS to the North Florida Regional Medical Center to the research being done at the University's state-of-the-art facility.

I've been told that the research center, noted for its success in obtaining externally funded studies, continues even in the face of the downturn of the economy to increase research grants obtained each year.

There is clearly a connection between the health of the community &151; and the community's ability to provide quality health care; that connection is critical &151; and it's also very fragile. It deserves our care, our support, and our constant attention.

I have the privilege of giving many talks for the AMA.

It is a special privilege to talk those who are patients like many in my practice.

Business owners. Mothers. Fathers. Doctors. Lawyers.

You know firsthand how health care costs affect your family and your business.

You know how much costs have increased, and many of you have probably struggled with the decision of whether you'll be able to afford to provide care for your employees.

It's not an easy choice, and one that I wish no one had to make.

That's one of the key reasons why the AMA is so engaged in what's happening up in our nation's capitol.

What happens there matters here.

And, when you or someone you know or love needs medical care, it doesn't matter whether they, you or your doctor is a Democrat or a Republican.

You just want the right care at the right time in the right place.

And you don't want it to break the bank.

Now, that's a whole lot of "wants," which is why health system reform is so tough.

We believe any meaningful reform effort in this country must begin with covering the uninsured.

The AMA remains committed to this cause.

Over the past few years, we spent more than 15 million dollars on our Voice for the Uninsured Campaign to highlight the issue.

It's not that 46 million uninsured Americans were a secret, but we wanted to ensure that they received attention from the presidential candidates.

About 57 million Americans were in families that had problems paying medical bills in 2007.

That's 2007.

Slightly more than half of Americans say their household cut back on health care due to cost concerns in the past 12 months.

Working mothers and fathers are putting off seeing the doctor and going to the dentist.

Parents are being forced to decide between paying bills or filling prescriptions &151;

Seniors are cutting pills in half or skipping doses to make a prescription last longer.

In short, they live sicker and die younger.

That's not health care.

That's a prescription for disaster.

And that's just the reality.

I say "at least" 46 million uninsured because since the recession began in December 2007, more than 5 million jobs have been lost.

According to the Kaiser Family Foundation, job losses since 2007 have led to an estimated 9 million fewer Americans receiving health coverage through their employer.

Where do they go?

Medicaid accounts for an extra 3 point 6 million people?

And there are another 4 million who become uninsured.

Here is another, very compelling reason why we need reform now.

The current system is unsustainable and is bankrupting our nation's future.

Costs today are $2.4 trillion headed for $4.4 trillion in ten years

It's complicated, however, because sometimes we forget that this is hard, complex stuff we do every day.

Think about it &151; there are more than 60,000 diagnoses; 11,000 surgical procedures; and at least 4,000 drugs.

The pressures on physicians are intense, and we welcome that responsibility.

But we also have to recognize that we can do better.

The medical profession must continue and intensify efforts to develop evidence-based guidance for quality improvement.

Providing physicians and patients with real time data for decision-making at the point of care should be the driving force for quality improvement.

This can also help reduce the rate of growth in health care spending.

We also need to improve and modernize Medicare, work for new approaches to physician payment that focus on care coordination and quality.

This graph is like an alligator's jaws, and it shows the wide disparity between what Medicare pays and actual medical costs.

The reality is if it costs me 10 dollars to provide care, and Medicare only reimburses me 5 dollars, pretty soon I have to close my doors, and that hurts all my patients.

A better approach is for Medicare payment methods to provide incentives for better care coordination and disease management.

This is particularly important for vulnerable seniors with chronic conditions who need access to high-quality, cost-effective care.

A better approach for Medicare is to encourage teamwork among physicians, hospitals and other providers.

Working as a team can help prevent costly hospital readmissions and keep patients from cycling between nursing homes, hospitals and other post-acute care settings.

Working as a team helps reduce cost, improve value &151; and most important, it helps improve the care you receive.

There's a lot of controversy over whether the government is going to tell doctors what we can do to treat you and your loved ones.

The truth is that the current legislation in Congress does not tell doctors what to do.

The patient-physician relationship is critical to good health care.

And the current legislation in Congress doesn't change that.

Now, let me say a few words about the AMA framework &151; our foundation for whether we'll support or oppose any legislation in Congress.

Health system reform must protect the sacred relationship between patients and their physicians &151; without interference by insurance companies or the government.

Our vision for effective reform is a system that provides affordable health insurance for all through a choice of plans and eliminates denials for pre-existing conditions.

Effective reform should focus on promoting quality, prevention and wellness initiatives.

Effective reform will repeal the Medicare physician payment system that harms seniors' access to care.

And it should ease the crushing weight of medical liability and insurance company bureaucracy.

Through it all &151; and this is key &151; we have to keep in mind that the reforms we seek today must be fiscally responsible for our nation.

That means they have to be sustainable for today &151; and the long-term.

I think we all know that the road to the White House has many avenues.

Sometimes it might seem like there are too many U-turns, dead-ends and one-way streets.

A little patience will help.

Now might be a good time to remember those words written by Paul McCartney and made famous by the Beatles.

The long winding road that leads to your door will never disappear. I've seen that road before.

It is a long winding road to the White House and each step must be traversed.

It is also good to know "who's on first".

Here are some of the players:

  • President Obama, HHS Secretary Sebelius, Nancy-Ann Min DeParle, Rahm and Zeke Emanuel, Tom Daschle.
  • In Congress, Representatives Pelosi, Stark and Waxman; and in the Senate, Senators Baucus, Grassley, Kennedy, Nelson
  • We're also working with the unions, small business, patient groups, big business; everyone with employer-based insurance; physicians, medical students, patients; health plans, big pharma, device manufacturers, and others.

You should know that our own Senator Bill Nelson is one of the major players, and several other members of Florida's congressional delegation are helping.

One of the points I want to stress here is that the American Medical Association is deeply involved.

If you're not involved, you're not at the table, which reminds of the old Mark Twain quote, "Everyone complains about the weather, but no one does anything about it."

Given the cacophony of activity the health reform debate has generated over the past week and likely throughout this month, there may be also a reason people have generally mainly talked about health reform rather than do anything about it.

The AMA is doing something about it.

On July 16, we announced our support for House H.R. 3200 &151; "America's Affordable Health Choices Act of 2009."

On July 17, House Ways & Means and Education & Labor approved H.R.3200.

On July 31, the House Energy and Commerce Committee approved it by a vote of 31 to 28.

But keep in mind &151; this is just the latest step, not the final step &151; in a long process of passing a health reform bill.

There is a lot in this bill important to health reform.

For starters, the nonpartisan Congressional Budget Office &151; the CBO &151; has estimated that the bill will ensure that 97 percent of the legal, non-elderly population will have health insurance.

In other words, 37 million uninsured Americans will have health insurance coverage that do not have it now.

H.R. 3200 also has key insurance reforms.

Insurers will no longer be able to deny coverage for so-called pre-existing conditions.

H.R. 3200 expands Medicaid eligibility to non-elderly adults and families up to 133 percent of the federal poverty level.

It increases payments for primary care services.

And it sets up a health insurance exchange to provide choice of plans to uninsured, self-insured and small business employees;

As well as improving coverage for preventive services.

Additional reasons we support H.R. 3200 include some common sense reforms that will help physicians, help patients, and overall &151; help our health care system.

In addition, H.R. 3200 repeals the flawed Medicare physician payment formula.

I mentioned a few minutes ago that if it costs 10 dollars to provide a service, but Medicare only reimburses 5 dollars, pretty soon you're closing the doors and shutting off the lights for good.

H.R. 3200 fixes that problem.

And it increases Medicare primary care payments without offsetting cuts in reimbursement for other physician services.

H.R. 3200 also moves in the right direction on medical liability reform.

It offers the states financial incentives for enacting medical liability reforms, such as certificate of merit requirements and early offer programs.

There's certainly been a lot of talk about the "public plan."

And like so many other things in Washington, you'll get different answers for "What is the public plan?" depending on who you talk to.

So let me tell you what the public plan actually is in H.R. 3200 &151; and what the AMA believes the public plan should be.

First, it's not mandatory.

The Secretary of Health and Human Services will be required to negotiate payment raters.

Physicians and other health care providers can opt out.

Choice is a bedrock principle to the AMA, and we fought hard to ensure it would be included in H.R. 3200.

Choice is about more than physicians, however,

We believed that patients enrolled in a public plan should be able to receive care from the physician of their choice.

Under H.R. 3200, they can.

Second, the public plan should be subject to the same regulations as private plans.

We call that leveling the playing field.

And third, the public plan should be self-sustaining &151;

Which to the AMA means that the public plan should not rely on federal subsidies.

I might add that Florida's own Representative Cliff Stearns successfully offered an amendment that would prohibit taxpayer bailouts to subsidize the public plan.

I've mentioned, "being at the table" a few times already, and it's not just an expression.

On the left side of this slide, you can see the AMA President, Jim Rohack, who just explained to the president that the AMA is committed to improving quality.

But Jim also emphasized that even when physicians follow best practices &151;

Even when we work to reduce unnecessary care &151;

Those efforts do not necessarily provide us with any protection in the courtroom.

Jim stressed the need for liability reforms, such as safe harbors when we do adhere to guidelines.

In response, even though President Obama has said he does not support caps on damages, he publicly told us that he is willing to consider ways to reform the system so we do not have to practice while looking over our shoulder.

He told us &151; and I quote "I recognize that it will be hard to [reform the health care system] if doctors feel like they are constantly looking over their shoulder for fear of lawsuits."

The AMA believes that medical liability reforms will reduce costs by reducing the practice of defensive medicine.

The president has said he understands the concerns we have.

And we look forward to working with him on reducing the burden of medical liability.

Congress has adjourned until after Labor Day

In the House this is the status/timelines:

  • Tri-committee versions completed
  • Energy & Commerce have approximately 50 to 60 amendments pending to be sent in September as a separate bill
  • Leadership and Rules Committees and three chairs will negotiate the bills
  • Bill to House for debate (likely September)
  • Separate vote on a single payer alternative
  • Bill to conference committee with Senate

In the Senate

  • H.E.L.P. Committee bill approved
  • More than 180 amendments still to be inserted
  • Finance Committee still working - goal Sept. 15
  • Meld H.E.L.P. and Finance into one bill for action by Senate or
  • Separate Finance bill to Senate
  • If no action by October 15 may consider reconciliation process
  • Bill to conference committee with House

During the recess, we'll be working closely with members of Congress and their aides to keep the process of reform moving.

We'll be emphasizing the importance of health reform to patients and physicians.

We'll be stressing the need to work together.

Before I take your questions, I want to come back to one of the themes I've discussed &151; involvement.

For physicians and other health care professionals, there's no apathy when it comes to providing high quality patient care.

It's a challenge we face every day to care for the healthy, the sick, the injured, young, old and everyone in between.

As Rotarians, you know what it means to be involved and how important that is.

These are incredibly difficult times.

And the challenge is likely to be increasingly how to avoid allowing controversial pundits, others political agendas and headlines to shape our thoughts in absence of the truth.

And, at the end of the day, a question we're all going to ask is "How will this affect me?"

That's only natural.

But let me suggest that our nation's effort to reform the health care system is not just about us.

It's about helping patients.

It's about securing the future of our nation.

Thank you for your time and generosity in having me speak with you today.

I'd be happy to answer your questions.