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Shall we dance?

November 10, 2007

61st Interim Meeting
American Medical Association House of Delegates
Hawaii Convention Center
Honolulu, Hawaii

Ronald M. Davis, MD
American Medical Association

Aloha, and mahalo nui loa, thank you very much.  I hope you’re all enjoying our location.  I know I am.  The beauty of these islands is simply unsurpassed.  And the people are so warm and friendly. I think I feel healthier just breathing in the air here, or smelling the flowers.  I wish we could write prescriptions for that.

Another reason why I have a deep affection for Hawaii is because my very first AMA meeting was here, back in December 1979.  Also, my father was stationed here during World War II, from 1942 to 1945.

Hawaii is still a crucial strategic location in the world.  Did you know that this is the only place with all five U.S. armed services on one small island?  Soldiers at Schofield Barracks, sailors at Pearl Harbor, airmen at Hickam Air Force Base, Marines at Kaneohe Bay, and the Coast Guard patrolling the waters as well?

Wherever they are, and whenever they served, I want to acknowledge all those who put themselves in harm's way to protect our freedom, and this country, and a way of life that embraces peace and friendship among all people.  And that includes the selfless physicians here with us from the Defense Department and the Veterans Administration.

My brother returned from Iraq two months ago, and like others returning from the front lines, he’s going through a challenging transition.  As physicians, we’ll be dealing for years to come with highly visible physical injuries suffered by service members returning from Iraq and Afghanistan, and also post-traumatic stress disorders and other emotional wounds that afflict our returning troops.  Let’s be ready for them.  They deserve it.

Getting back to my father, who passed away in 1997 … he was in the 113th Radio Intelligence Corps, just a few miles from here.  And in his free time, believe it or not, he taught ballroom dancing to his fellow GI’s.

Watching a film clip a few weeks ago of him teaching dancing in Hawaii got me thinking about the dancing we do at the AMA, and the partners with whom we dance.  We engage in a very special form of dancing.  It’s not the Hula.  It’s not Tahitian dancing.  It’s not nearly as pretty, or graceful, or enjoyable to watch.  Sometimes it’s more like a limbo at a luau.

Thirty years ago, a Rhodes Scholar named Eric Redman wrote about “The Dance of Legislation.”

That was actually the title of his book, about the drafting and passage of legislation to establish the National Health Service Corps.  The NHSC, through scholarship and loan repayment programs, has recruited more than 27,000 health professionals to deliver primary care in underserved communities.

Many of you have no doubt read “The Dance of Legislation.”  Redman published an updated version of it a few years ago.  This dance is one of both triumph and frustration, and includes some strange moves and countermoves.  But most of all, it involves one hell of a lot of work.  And it’s a very slow dance.  Legislative change usually occurs incrementally rather than revolutionarily.

Take a look at the State Children’s Heath Insurance Program, or SCHIP.  The original legislation passes 10 years ago, but with a 10-year sunset.  This year, Congress passes a bill to reauthorize the program, but it’s vetoed by President Bush, and the House fails to override his veto.

So now we have a new bill, stewing in the most partisan environment I’ve ever seen.  Yet it’s over something that we, the members of the House of Delegates of the AMA, had no problem with last summer.  We were virtually all on board when we adopted our position.  It’s clearly in the best interests of everyone.

I’ve been disappointed in hearing a lot of uninformed criticisms of the SCHIP legislation.  Let’s separate fact from fiction.

Myth No. 1 is that the SCHIP compromise is a major step toward “government-run,” “socialized” health care.  In fact, SCHIP is a public-private partnership, with 77 percent of kids in the program getting their coverage through private health plans.  Let me ask you this:  If the SCHIP legislation is socialized medicine, why is Senator Orrin Hatch supporting it? 

Myth No. 2 is that the SCHIP compromise vastly expands program eligibility.  In fact, there is no provision in the bill to expand income eligibility for children, and the compromise will limit program eligibility more than current law.

Myth No. 3 is that the SCHIP compromise bill will cover illegal immigrants.  In fact, the SCHIP bill does not change current law prohibiting coverage for illegal immigrants.  Health coverage is only available for U.S. citizens and legal immigrants who have been in the United States for at least five years.

Myth No. 4 is that the SCHIP legislation will cover adults.  In fact, the bill phases out non-pregnant adults from the program.

I don’t know about you, but I can no longer stomach rollercoaster rides.  So let’s get SCHIP off Washington’s rollercoaster, so children from low-income families will have secure and reliable access to health care.

The first version of the SCHIP legislation in the House included Medicare physician payment reform.  Unfortunately, the Medicare provisions were not included in legislation passed by the Senate, and did not make it into subsequent compromise bills.  So now it’s likely we’ll be dancing with that one all the way to December, down to the wire, once again.

Recent Congresses seem to want to wait until a crisis occurs, or until the last possible moment before it would almost assuredly occur, before taking definitive action.  And this pathetic yearly tourniquet approach to the SGR cuts is a perfect example of management by crisis.

We in medicine know a lot about crises through our work in disaster preparedness.  We plan for, and respond to, terrorism, tsunamis, hurricanes, and many other mass-casualty events. 

The latest are the fires in southern California, which were on everyone’s minds when I was at the California Medical Association’s annual meeting in Los Angeles a few weeks ago.  Our hearts go out to our colleagues and their patients who have been affected by the fires, and we’ve offered assistance through our AMA Center for Public Health Preparedness and Disaster Response. 

Speaking of fires, I share a birthday with the late Red Adair.  You’ll remember that he was the world-famous oil field fire fighter, who successfully battled more than 2,000 fires in oil and natural gas wells.  Adair’s well control company, which continues its work today, divides its services into three categories:  prevention, response, and restoration.

Let’s apply those approaches to the looming SGR disaster.

Let’s begin with prevention.  Prevention involves safety inspections.  We’ve already done safety inspections, and we already see weak points in our system of care for seniors.  According to the Medicare Payment Advisory Commission, or MedPAC, about a quarter of seniors seeking a new primary care physician are already having difficulty in finding one to take care to them.

Prevention also includes conducting a risk assessment.  We’ve done that too.  And we see huge risks if Medicare cuts go through as projected. 

According to our MemberConnect survey, if the 10 percent cut goes through in January, almost a third of physicians will reduce the number of new Medicare patients they accept, and almost 30 percent will stop accepting new Medicare patients altogether.  Even more disturbing is that almost a third of physicians will reduce the number of established Medicare patients in their practice, if the 2008 cut goes through.  And another eight percent will stop seeing any Medicare patients in their practice.

And ladies and gentlemen, 10 days after Halloween, this is not the type of scare I want.  Before the U.S. Capitol becomes a haunted house, Congress needs to listen to MedPAC, its own advisory committee, and scrap the SGR.  Listen to MedPAC, and tie physician payment to the Medicare Economic Index, the government’s own index for the costs of running a physician practice. 

A few years ago, the Congressional Budget Office estimated that a permanent SGR fix would cost $90 billion.  Now the CBO says that deep-sixing the SGR in favor of the MEI will cost us $262 billion.  As Congress continues to kick the can down the road, effective remedies become more and more costly.

But Congress seems to ignore the benefits of preventing an SGR disaster. It seems willing to rely on disaster response and restoration.

Well, we need to tell Congress that if this imminent melt-down occurs, response and restoration will be slow in repairing the damage, will be expensive, and may ultimately fail.  If physicians across the country are forced out of the Medicare program, and lose trust in the program, they may become wholly resistant to any last-ditch effort by the federal government to respond to the crisis, and to restore the program to “business as usual.”

Unless Congress has a “Medicare Red Adair” to put out brush fires in every one of the 3,066 counties in the United States, a lot of seniors are going to get burned.

I’m pleased that my own senator, Debbie Stabenow, is showing leadership on this issue.  You’ll recall that she spoke at our National Advocacy Conference in February, wearing her AMA purple.

Two days ago, she spoke passionately about the SGR problem on the floor of the Senate.  She called on Congress to “pass legislation this year that provides physicians with two years of positive Medicare payment updates … in a way that does not add to the cost of eliminating the SGR.”

Senator Stabenow endorsed a repeal of the SGR and the establishment of “a Medicare physician payment system that will provide stable, positive payment updates to preserve Medicare beneficiaries’ access to high-quality care for the long-term.”  She said, “It defies common sense to think that payment rates that are lower today than they were six years ago will be enough to maintain the access to care that our seniors need.”

Many physicians have told me that they doubt Congress will solve this problem unless a melt-down actually occurs.  Thus, some have suggested that we acquiesce to the 10 percent cut for 2008 -- just let it go through, they say -- so Congress will see that our concerns and predictions are not a poker-style bluff.

A few have even suggested to me a physician boycott of the Medicare program.  Well, boycotts raise serious legal and ethical issues.  But I know where those suggestions come from.  Many or most physicians are mad as hell and are in no mood to take it any longer.  Lest you have any doubt, there’s as much anger on this stage as there is on the floor of this House and in physician offices across this country. 

So let me highlight several courses of action that are available to physicians.

First, we can do what TV news anchor Howard Beale suggested in that 1976 movie “Network” -- get up out of your chairs, go to the window, open it, and stick your head out, and yell, “I’m as mad as hell, and I’m not going to take this anymore!”

Unfortunately we don’t have any windows in this room, so you’ll have to save your best Halloween scream for later.

For our second course of action, we must continue, and intensify, our advocacy efforts, talking to our Congressmen, and our patients, and the media, about the looming melt-down.

And third, we must remind physicians, in the face of these huge cuts, that they may wish to review their Medicare participation options.

As explained in the fact sheet that’s available on the tables at the back of this room, physicians who wish to change their current Medicare participation or non-participation status for next year, must do so between November 15th and December 31st.

They have three options:

One, they may sign a PAR agreement and accept Medicare’s allowed charge as payment in full for all of their Medicare patients.

Or, two, they may elect to be a non-PAR physician, which permits them to make assignment decisions on a case-by-case basis and to bill patients 9.25 percent above the PAR-approved payment rates.

Or, three, they may become private contracting physicians, agreeing to bill patients directly and to forego any payments from Medicare to their patients or themselves.

For folks who are fatigued by these endless machinations in policy, Eric Redman explains our current reality:  “… the dance of legislation never really ends, and … a law may [even] intensify rather than terminate the perpetual struggle over policy.”

At the AMA, it’s our job to continue this dance until the music stops.  Fortunately, we’ve had some nice recent victories in the smaller dance contests, such as getting the Department of Education to extend eligibility for deferring repayment of student loans, so that medical student and resident debt burdens don’t get worse than they already are.  Yet that, too, is a short-term fix.  We still need a long-term legislative solution to that problem.

Have you seen either of the current reality television shows, “So You Think You Can Dance” or “Dancing with the Stars”?  To win these competitions, you need to be more than just the best dancer.  There’s song selection.  There’s how well you’re trained by a randomly chosen choreographer.  And there’s your popularity with the viewers, who vote off the contestants.  Thus, winning the dance contest involves talent, training, and a tendency to be liked.

Well, physicians have a lot of talent.  Are we’re certainly well trained.  And I’d like to think we’re popular among our patients.  So we must show Congress that we’re in this for the long haul.  We aim to win our dance marathon, and not get voted off.

Now, to accomplish this, I believe the key is to always keep patients as our main focus, and to ensure that their access to care is the basic harmonic running through everything we do.

Which is why we’ve been pushing so hard to be the Voice for the Uninsured.

I’m very proud of our campaign.  We’ve joined forces with some of the most influential groups in America.  And we’ve joined forces with our patients. What we’re doing, we’ve done before, but never with as much strategic and tactical focus.

So this is probably a good time to show you one of our 30-second spots.  These will go national in January.  And those of you in Iowa, South Carolina, and New Hampshire have most likely already seen it.

I’d really like to thank the Medical Societies of those states for their superb partnership with us on this campaign.  When I was out on the road for four days last week in Iowa, I personally heard several sad stories about the devastating impact that lack of insurance can have on people who experience serious illness or injury.

I heard something else, too.  Leaders of the Iowa Medical Society and I met with Gov. Chet Culver for an hour, to talk about covering the uninsured, Medicare physician payment reform, and a few other important issues.  Moments after we walked into his office, the Governor mentioned that he had seen our AMA billboards about covering the uninsured all over the place.

I’m glad the Governor saw our signs.  Because for two days before our meeting with him, I was out driving our mobile billboard around the state capitol in Des Moines.

So we need to do whatever it takes to get the message out in this campaign, to important decision-makers but also to our patients and to voters, to convince them to consider this issue when they decide which presidential candidate to support.

Politicians everywhere, but especially in Congress, need to be told by us that we’re going to do our damnedest to win these contests; that we’re going to lead the charge to provide the best health care for all Americans, but especially the most vulnerable:  our children, the elderly, and the uninsured.

As we work toward covering all Americans, we need to remind our patients, and all citizens, that they play a critically important role in determining how healthy they are and how long they will live.  More than one-third of all deaths in this country are due to four unhealthy lifestyles:  tobacco use, alcohol abuse, poor diet, and physical inactivity.

That’s why I’m very pleased that earlier this week, our AMA and the American College of Sports Medicine launched a new initiative to assist physicians in helping their patients get more physical activity.  The theme of the campaign is “Exercise is Medicine,” and we encourage you to prescribe exercise for all of your patients.  Please check out the campaign website at www.exerciseismedicine.org.

Incidentally, one way to get exercise is through dancing.  In fact, the state of West Virginia is combating the epidemic of youth obesity by placing the videogame “Dance Dance Revolution” in all 765 public schools in the Mountain State.

I sometimes wish I had inherited my father’s dancing skills.  I did not.

But when we do the “Dance of Legislation,” whether for SCHIP or Medicare or another important issue, it really doesn’t matter if we occasionally step on our partner’s toes.  It might even prove a point.  What matters is, when the music stops, who wins the dance?

I hope you get the chance to catch the evening show at the Hilton Hawaiian Village or out at the Polynesian Cultural Center.  You’ll be amazed at all the dancing.  And the climax is a dancer who juggles flaming torches.  It’s like combining Red Adair with Fred Astaire.

Sometimes, we have to juggle a little fire in our dance.  That just comes with the territory.  And when we have partners, we’re not always going to be in sync.  And we may have to switch partners when we find one who has better moves.  And we may need to stay on the dance floor longer than we thought we should.

So bring your Dr. Scholl’s.

Because we need to fight for physicians everywhere.

We need to prevail for patients everywhere.

And we need to win, not to get a trophy, but because it’s the right thing to do.

There is no one in this country who has more expertise in health care than we do.  So in this dance, we need to take the lead.