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Health System Reform: What Does the Future Hold?

Aug. 25, 2009

Winter Park Memorial Hospital
Winter Park, Florida

Cecil B. Wilson, MD
President-elect
American Medical Association

Dr. Castro — thank you for that gracious introduction.

It is truly a pleasure for me to be here.

As I was thinking about being with you this evening I was recollecting back to moving to Central Florida in 1969 while in the Navy assigned to the then U.S. Naval Hospital Orlando; and of getting out of the Navy in 1971 and starting a practice in internal medicine in Winter Park.

The old adage that the more things change the more they stay the same does not really fit my journey from back then to now.

Way back then we had Winter Park Memorial Hospital, a small community hospital and Florida Hospital Orlando a single facility with two buildings rising to the magnificent height of three stories.

Now, Florida Hospital is a facility with many campuses, including Winter Park, and a main campus composed of multiple buildings. And Orlando has a new medical school and the Burnham Institute; and there's Nemours Children's Hospital and a V.A. Hospital, all of which augurs well for this community to be a center of medical excellence recognized across the country.

Tonight, my remarks will focus on the health reform debate going on across the nation. As I hope I will make clear during the course of my talk, a lot of the details are still up in the air and in some ways seem to change from day to day.

In thinking about what to say to you tonight, I am reminded of that well-known quote of Mark Twain, who said, "Everybody talks about the weather but nobody does anything about it."

Well, we have been talking about our health system for a long time. In some ways we have found a perverse delight in talking about its defects, how poorly it works, how it's really not a system at all. And, we were in agreement that something just had to be done.

I say "were," because the minute somebody started doing something about it, the agreement, at least about what to do, vanished seemingly overnight.

The town hall meetings across the country are a perfect example. The disagreement that has followed about what should be done is becoming so vehement and intense that some are even wondering if we really need reform after all.

If one takes a step back, it's really not difficult to see why passions are so high. Health care touches us all in a very personal way. The thought of change in this part of our lives is eliciting the strongest of emotions.

People are fearful of losing what they have and of getting something they do not want. This even includes physicians who as a group have been among the most outspoken about how poorly the system has been treating them.

But it is the AMA's position that change is necessary, and in the time I have with you this evening, I will talk about why that is the case.

I will also briefly describe the AMA's plan for health system reform; paint a picture of the Washington scene as it relates to health system reform, and show how the status quo is simply unacceptable.

In our testimony before Congress and our discussions with the White House, we are following a clear framework for health system reform.

Health system reform must protect the patient-physician relationship - 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.

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 — and this is key — 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 — and the long-term.

No one said that achieving meaningful health system reform this year was going to be easy.

Here's one of the reasons why it is needed.

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

We are spending $2.2 trillion annually today, and in 10 years that number will be $4.4 trillion if nothing is done.

There are some who say we cannot afford the cost of change.

To them I would pose the question, can we afford to do nothing?

There are some who say there are other problems such as the broken economy that should be fixed first.

Of them I would ask how can we expect to fix the economy if we ignore the 16 percent of the economy represented by the health care system?

And some care not one whit about health system reform and are focused solely on defeating a president.

To them I say, shame on you.

The American people deserve a better quality of leadership.

On the issue of cost.

How can we save money?

We call it "bending the curve."

The AMA recently joined with five other organizations in the health sector to outline initiatives to help decrease the health care cost growth rate by 1.5 percent, saving more than $2 trillion over the next 10 years.

Together, the AMA, the American Hospital Association, the SEIU, the Advanced Medical Technology Association, PhRMA, and America's Health Insurance Plans, are committed to action to help achieve greater value from our nation's health care spending.

Consider the health care proposals under consideration.

Most accounts put the cost at one trillion dollars — a considerable sum of money.

But remember where costs are going — they will increase more than $2.2 trillion in 10 years if we do nothing.

Now consider that we can reduce costs through making sure people get the right care at the right time in the right setting.

Through innovative approaches to reducing costs.

Through streamlining claims processing and also better management of chronic disease.

The AMA, with the help of America's specialty societies, is working to better define clinical standards of care by developing performance measures for literally hundreds of medical conditions.

The goal is the right care to the right patient at the right time.

At the AMA Annual Meeting in June, the president said to a standing ovation that "you did not enter this profession to be bean-counters and paper-pushers. You entered this profession to be healers - and that's what our health care system should let you be."

When I went to medical school, I knew there would be challenges. But I expected them to be the challenges of diagnosing and caring for patients.

I now know about other challenges, not as rewarding.

I know from experience how regulations and administrative hassles can bog doctors down, taking time away from caring for our patients.

I know from experience how government bureaucracy can interfere with the practice of medicine and come between the patient and physician.

I know from experience how a tort system run amok can force physicians to practice defensive medicine for fear of lawsuits adding increased costs to our health care system.

Over 30 years of practice have taught me how to navigate the system.

I've seen presidents try — and fail — to achieve health system reform.

But there are a number of things different today than in the past.

For one, the AMA has a prime seat at the table where we continue to play a constructive role

It ensures that the voice of medicine is heard.

It ensures that reforms reflect what physicians and patients need.

So, why is it so important to have a seat at the table?

That's simple, because it is at a table where decisions are made that will affect all of our lives.

And, as someone has said, if you are not at the table when they carve the bird, you may well end up being the turkey.

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.

Here's what is happening right now.

On July 16, we announced our support for House Resolution 3200 - "America's Affordable Health Choices Act of 2009."

House Ways and Means, and Education and Labor approved the bill July 17.

On August 1, the House Energy and Commerce Committee worked late into the night — and ultimately voted 31 to 28 to approve H.R. 3200.

This bill includes provisions that are key to effective, comprehensive health system reform.

It is important to note, however, that this is just the latest step, not the final step — in a long process of passing a health reform bill.

The following are some of the reasons the AMA decided to support H.R.3200.
The nonpartisan Congressional Budget Office — the CBO — 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 who do not have it now.

There also are key insurance reforms in the bill.

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.

H.R. 3200 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;

It also improves coverage for preventive services

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

First is the repeal of the flawed Medicare physician payment formula.

Under the current Medicare payment system — seniors' access to care is threatened because Medicare year after year reimburses less and less for care that grows more costly to provide.

H.R. 3200 fixes that problem.

It also erases the SGR debt and provides a formula that accurately reflects the increased cost of providing care.

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 also are insurance reforms and provisions concerning Medicaid and SCHIP.

This still is a work in progress.

The House Energy and Commerce Committee was the third committee to vote on the bill. And they still have 50-60 amendments to consider after Labor Day.

All three versions will need to be combined into a single bill for consideration before the entire House of Representatives.

The Senate is a slightly different story, but the negotiations between the key senators are ongoing.

It's a long road. We're making good progress.

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

The AMA believes that if there is a public plan in the final bill - physician participation should be voluntary.

Patients should have the freedom to choose their doctor.

The public plan should be subject to same regulations as private plans.

And the public plan should be self-sustaining.

The public plan as detailed in H.R. 3200 is not mandatory.

The Secretary of Health and Human Services will be required to negotiate payment rates at no lower than current Medicare rates

Physicians and other health care providers can opt out.

Patients enrolled in a public plan will be able to receive care from the physician of their choice.

And H.R. 3200 does not affect the ability of physicians to engage in private contracting arrangements with patients.

H.R. 3200 also requires a public plan to be self-sustaining and independent of the federal treasury.

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

So at the end of the day, here's what I know.

When Congress returns after the August recess, we need to focus on the
common ground we share to reach the end goal.

We need to continue to work for affordable, high-quality health care for all.

We need to continue to emphasize an even better health care system for patients-and the physicians who care for them.

To try and counteract the misinformation — and provide the AMA view to the public, the AMA has been more vocal than probably at any time in my memory.

On a regular basis, our president, Dr. Jim Rohack, has been appearing on major national news programs, writing posts on important blogs, and doing numerous newspaper interviews.

In addition to numerous print media and radio interviews I have been on national TV programs eight times in the past two months.

It's essential we clarify two things:

One — what's actually at stake for patients and physicians; and

Two — what the facts are.

And although I didn't go to medical school to be interviewed by The New York Times,

To quote the time-honored Robert Frost poem, sometimes you have to take the road less traveled to make sure the job gets done right.

Despite the progress we've made, we have a tremendous amount of work remaining.

So who are the key players we're working with to get to the finish line?

In other words, who's on first?

  • President Obama, HHS Secretary Sebelius, Nancy-Ann DeParle, Rahm and Zeke Emanuel
  • Tom Daschle
  • House: Pelosi, Stark, Waxman, Rangel
  • Senate: Baucus, Grassley, Kennedy, Conrad, Nelson
  • AMA, unions, health plans, pharma, device manufacturers, big business, small business
  • Patients, those with employer-based insurance

Our own Senator Bill Nelson is one of the major players who we continue to work closely with, and we look forward to his continued support.

I'd like to go into a little more detail about what the AMA is for.

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

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.

That was one key part of our strategy.

Today, you're seeing the other key — efforts to cover the uninsured.

Consider the consequences of being uninsured:

  • Fewer preventive, therapeutic and screening services
  • Sicker when diagnosed
  • Poorer health outcomes
  • Higher mortality and disability rates
  • Lower annual earnings

In short, if you are uninsured, you live sicker and die younger.

In this — the wealthiest nation on the earth — that is not just a national tragedy, it is a national disgrace; a prescription for disaster; and without reform — that's just the reality.

The critics of reform say we can't afford it.

But to those who can't afford health care now, consider their daily consequences and decisions.

Self-treatment.

Delaying or skipping necessary care altogether.

Cutting pills in half, or not taking necessary medicine altogether.

Or not being able to afford mental health care

As American patriot Thomas Paine wrote in "The Crisis": "These are the times that try men's souls."

Today, you frequently hear the figure "46 million uninsured."

But I say "at least" 46 million uninsured because since the recession began in December 2007, according to the Kaiser Family Foundation, job losses since 2007 have caused an estimated 11 million fewer Americans receiving health coverage through their employer.

Eleven million is truly a sobering number.

So where do the newly uninsured go?

4.6 million become eligible for Medicaid

And the 5 million who don't qualify for Medicaid are added to the uninsured rolls.

Let me reiterate a few key points on where the AMA is.

First, medical decisions should be made by patients and their doctors, using the best possible information.

Second, no one should be denied health insurance because of pre-existing conditions.

Ideally, we want patients to own their health insurance even if it's financed through their employer, so if they leave that job, the insurance isn't lost, just paid for differently.

And third, if we reform the health insurance market, we can make this happen.

Reform is complex, but we are accustomed to complexity.

Think about it — 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.

We also have to recognize that we can do better.

The medical profession — and the AMA — must continue and intensify efforts to develop evidenced-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 reform government programs such as Medicare.

When you consider the wide disparity between what Medicare pays and actual medical costs, it's like the open jaws of an alligator

I mentioned earlier the need to reform the reimbursement system, but there's more to Medicare reform.

To improve and modernize Medicare, we need new approaches to physician payment that focus on care coordination and quality.

Teamwork among physicians, hospitals, nurses, technicians, patient advocates and others can help prevent costly hospital readmissions and keep patients from cycling between nursing homes, hospitals and other post-acute care settings.

Medicare payment methods should promote better care coordination and disease management, which is particularly important for vulnerable seniors with chronic conditions who need access to high-quality, cost-effective care.

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 —

Even when we work to reduce unnecessary care —

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 — 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.

Reforms such as health courts, administrative compensation systems, early offer models, and "safe harbors" for physicians who follow best practice guidelines, and to adopt other proven medical liability reforms.

Along the way — when we see the opportunity to remind people of the millions of dollars spent on the wasteful medical liability system — including the cost of defensive medicine, we will do so.

This letter in the July 15 Hartford Courant was in response to a trial lawyer suggesting there is no such thing as defensive medicine.

Oh really?

Let me just say this — the AMA continues to advocate for liability reforms that help physicians implement best practices in patient care and reduce unnecessary health costs.

We will continue to work with the president and Congress on reducing the burden of medical liability.

Incidentally, I hope you saw my letter to the editor I the Orlando Sentinel Saturday taking Congressman Grayson to task for saying during his town hall meeting last week that there is no medical liability problem.

Looking forward, let's remember that multiple committees in the U.S. House of Representatives have completed versions of health care legislation.

But more amendments will be considered in September.

In the Senate, more work remains.

It's too soon to tell when that work will be completed, or whether a health care bill will be advanced through the reconciliation process.

It might seem strange to say that health system reform is still in the early stages.

But that's the reality.

It's also the reality to say that we'll see provisions we don't like at various stages of the legislative process.

But the AMA is working with key Members of Congress and the Administration to influence the critical end-game negotiations when the different approaches and ideas are reconciled

The key is to stay in the game and we're doing just that

I'd like to finish with a few words about involvement.

For physicians, nurses 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.

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.

And, 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.

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