Where Do Doctors Stand on Reform?

Until physicians change how they practice, "we're just tinkering at the margin" of health care reform. That's according to Steven Pearlstein, a business columnist for The Washington Post, who cites the fact that physicians' decisions drive most health care spending. Referring to the recent New Yorker article by Atul Gawande about the overutilization of healthcare in McAllen, TX, Pearlstein blames a fee-for-service system that rewards volume and treatments that aren't based on scientific evidence.

Apparently, President Obama also believes that physicians are key to reform. He plans to address the annual convention of the American Medical Association in Chicago on Monday (June 15).

So where do physicians stand on reform? In a recent letter to Obama from six healthcare trade groups, the AMA--still the largest physician society despite a decline of membership--talked about developing measures of overuse in areas like back pain, cardiac care, maternity care, and imaging tests. The AMA also said that specialty societies were developing measures to improve handoffs between hospitals and other care settings to reduce readmissions.

That's a good beginning. But how far is the AMA willing to go to reduce physicians' income in order to control runaway health spending? The answer, as revealed in a report of the AMA's Council on Medical Service, is not very far.

The report on Medicare physician payment reform, which will be discussed at the AMA convention, acknowledges that the current growth in Medicare spending is unsustainable and poses a grave threat to the solvency of the government. However, the council said, the AMA is pleased that the Obama Administration is not going to carry out the physician payment cuts that existing law calls for. It hopes that Congress will follow suit and "support adoption of a new Medicare baseline for physician payments."

The council recognizes that "Congress expects physicians to demonstrate a real commitment to change." Among the changes contemplated by policy makers, it said, are a major shift from a "volume-based payment system to one based on value and the quality of care delivered." While rejecting the premise that "fee-for-service payment policies, per se, are responsible for excessive cost growth or inefficiencies in health care delivery," the council noted that the government's scrutiny "requires the AMA to take a leadership role" in advocating for reforms that "preserve the assets of the current delivery system" while helping to make it sustainable. Translation: We'll budge a little, but don't take anything away from us.

The report also commented on several approaches to Medicare reform. It noted that some medical societies objected to "gainsharing"--the sharing of savings between hospitals and physicians--because it would give hospitals too much power and might affect patient care. The same was said about "bundling," which means giving hospitals and other providers a lump sum for covering hospital and post-discharge care. Specialty societies have expressed fears that another approach--known as the "medical home"--might create obstacles to specialty care, according to the report. And the council noted that "significant concerns remain" about pay-for-performance programs, which are already widespread.

The recommendations to the AMA delegates are vague, but certain points throw AMA positions into sharp relief: For example, the council said that Medicare payment reforms should "not require budget neutrality within Part B." For the uninitiated, this means that Congress should not require CMS to pay primary-care physicians more at the expense of specialists. Also, the reforms should "incorporate incentives large enough to merit additional investments by physicians," which probably refers to the money required to create medical homes.

The AMA delegates are expected to discuss a wide range of reform-related proposals, according to an association spokesman. But if this council report is an indication, they are unlikely to propose anything that will threaten any doctor's income.

The New York Times reported this morning that AMA opposes the inclusion of a public plan in healthcare reform. AMA President Nancy Nielsen later issued a statement saying that the AMA objects to a public plan that requires physicians to participate or that would pay them Medicare rates. But she said that the association is willing to consider other versions of a public plan and that, overall, it supports healthcare reform. "The AMA is working to achieve meaningful health reform this year and is ready to stand behind legislation that includes coverage options that work for patients and physicians," she stated.

The question is whether the the house of medicine will support reforms that require physicians to sacrifice, if other stakeholders in the system have to do the same.