As the Senate debate over healthcare reform ends its first week, the house of medicine is speaking with many voices, but they're all basically saying the same thing. While the AMA supports the broad outlines of the Senate bill, medical societies in California, Florida, Georgia, and Texas oppose the measure. So does a coalition of 19 surgical specialty societies, although it says it is amenable to reversing its position if the Senate makes the changes it wants in the bill. The AMA wants many of the same changes.
What physicians object to the most is the failure of the Senate bill to permanently reverse Medicare payment cuts required under current law. Although the measure would knock out this year's 21 percent cut, it does nothing to prevent payment reductions in future years. The AMA also opposes other changes that could affect physician reimbursement, including shifting money from specialists to primary-care doctors, basing a small part of Medicare payments on physician performance on quality measures, and creating a new Medicare commission that, theoretically, could make binding recommendations on reimbursement with limited Congressional oversight.
Physicians, like hospitals, would be outside the jurisdiction of this commission for the next decade. But the AMA and other medical societies are probably worried that somewhere down the road, they would lose the ability to lobby Congress for ever-greater payments.
So what else are physicians worried about? The AMA and the surgeons are upset because the bill places a 5 percent tax on cosmetic procedures. While these are not usually covered by insurance and are primarily provided by plastic surgeons, the concern is that other "non-medically necessary" procedures could be taxed in future.
The California Medical Association also notes that while the bill would greatly expand Medicaid coverage, the rates paid by Medicaid would not increase. MediCal rates are already so low, the CMA notes, that only a third of California physicians take Medicaid patients. "If the doctors can't see you, the only choice you have is the emergency room, which is a very bad way to get healthcare," said Dr. Dev GnanaDev of San Bernadino, a member of the CMA's executive committee.
The surgeons oppose provisions of the bill that would penalize them financially if they failed to report quality data to Medicare, although they currently are eligible to receive a 2 percent bonus if they do report the data. Also, the surgical coalition is against "creation of a budget-neutral value-based payment modifier which CMS does not have the capability to implement and places the provision on an unrealistic and unachievable timeline." Beyond the posturing about CMS' supposed inability to implement this measure, what this really means is that the surgeons do not believe that any of their Medicare reimbursement should be based on the quality of their care. Ditto for the AMA objection to the same provision, mainly on the basis that risk-adjustment methods are not yet up to the job.
Overall, physicians seem mainly concerned about how reform will affect their incomes. Even the provisions they favor, such as expanding coverage and banning pre-existing condition exclusions by health plans, would increase their business.
Of course, the self-interest of physicians is no different from the self-interest of every other healthcare sector. But if everybody pushes their own interest to the detriment of the commonweal, we will never solve our healthcare dilemma.