SHARON FITZGERALD

Calling passage of the Medicare Improvements for Patients and Providers Act of 2008 “a long and winding road,” AMA President Nancy H. Nielsen, MD, applauded the U.S. Congress’ move on July 15 to override President Bush’s veto of the legislation. It is now law, averting a 10.6 percent Medicare physician payment cut.

On June 24, the U.S. House of Representatives approved the bill by an overwhelming, veto-proof majority of 355-59. The Senate’s initial ballot fell one vote short on June 26, and then Congress adjourned for a long Fourth of July holiday recess. That vacation was particularly long for Republican U.S. senators who voted against the bill. The American Medical Association, joined by other agencies such as AARP, barraged those senators’ districts for days with advertisements accusing the lawmakers of siding with insurance companies over America’s seniors. The blitz worked.

On July 9, the Senate approved the bill, which replaces the payment cut with a 0.5 percent update extension through Dec. 31; additionally, the legislation provides a 1.1 percent update for 2009. In a dramatic turn of events, U.S. Sen. Edward Kennedy, absent from the Senate because of treatment for a brain tumor, returned to the upper chamber to cast the deciding 60th vote and gain cloture. In the end, 69 senators voted “yes.” To override the veto, the House voted 383-41, and the Senate followed suit with a 70-26 vote.

Many Republicans and the White House objected to provisions in the bill that would decrease payments to Medicare Advantage plans, and that’s why Bush vetoed the legislation. This vote marks only the third time that Congress has successfully overridden a Bush veto.


Putting Up a Fight

The AMA backlash against the first Senate vote was swift and decisive.

“Physicians across the country are outraged, because we go through this every year. Now Congress makes us do it every six months,” Nielsen told Medical News Inc. “To come down to the wire like that, when it was very clear that the cuts needed to be stopped and physicians and Medicare beneficiaries needed to be treated fairly, to let this happen and to go home for the Fourth of July recess has just sent people over the edge.”

The AMA rallied its members, who also called their federal lawmakers to express their dismay. “What’s clear is that physicians are, in fact, outraged, and they have begun to contact the people who voted ‘nay,’ both in the Senate and in the House. There were only a few in the House, but they’re going to be hearing from us as well, and we are going to put the pressure on, not only from physicians, but from everybody who’s on Medicare and everybody who cares about them,” Nielsen said at the time. “This is just not a political issue, and it’s become partisan. It’s not fair to hold Medicare recipients and their physicians as pawns in this partisan game. It’s just not fair, and we’re tired of it.”

Nielsen said the Medicare funding formula for physicians is “flawed,” and added, “Everybody knows it’s wrong. There’s not a member of Congress who doesn’t know it’s wrong.”


What’s Next?

Paul H. Keckley certainly agrees that Medicare is in dire straits, and he sees this latest payment flap as a harbinger of more serious debate. “There is no scenario in which Medicare in its current payment structure is sustainable. Where I think this is going to take us is a couple of really, really interesting and potentially disruptive discussions,” he said. Keckley is executive director of the Deloitte Center for Health Solutions and boasts 30 years of experience in academic medicine and private-sector healthcare ventures.

Keckley rightly predicted immediately after the June 26 vote that the 10.6 percent slash in Medicare fees wouldn’t materialize and that the Senate would acquiesce. “In a political season, there is a lot of posturing that goes on. That’s the result of Medicare exceeding the thresholds that Congress enacted that put a force mechanism in place,” he said.

Keckley explained that a likely route for the Medicare of the future would be a “comparative effectiveness platform,” using evidence-based medicine and outcome studies to determine logical steps in patient care. “Which types of medications are working best and in what order, when is surgery essential as the next step versus others that are not surgical, when are certain types of diagnostic tests appropriate and when are they not?” he asked, noting that, according to the Congressional Budget Office, 30 percent of the nation’s healthcare spending could be reduced by applying comparative effectiveness to care.

Keckley added that physicians’ liability concerns would certainly be part of any comparative-effectiveness discussion. “What doctors would say is, ‘I do a lot of things because I’ll be sued if I don’t.’ Well, sometimes that’s true and sometimes it’s not, but it’s a valid discussion to have,” he said. “The second one is that we do a lot of things that we shouldn’t be doing, and that’s also something that needs to be addressed. Addressing both of those will be a pretty interesting policy discussion over the next really two years. I think it’s likely we’ll have a comparative effectiveness platform in place in the system before the presidential campaign in 2012.”

Yet another point of Medicare debate, Keckley predicted, will be how much enrollees themselves should be paying. “You’ll hear discussions around means testing,” he said. “If Medicare enrollees have annuities and big dividends coming in in addition to Social Security, should they be paying a higher premium than those who don’t?”

In closing, Keckley said, “In my career, this is the first time all sides of this discussion know that something has to happen. The difficult part of that is that there are going to be some losers.”



August 2008