Tuesday, November 24, 2009

Movin' Meat mulls Senate bill's cost controls

Ron Brownstein's roundup of expert reaction to the cost-cutting measures in the Reid health care reform bill includes this "venture capital approach" from former CBO director Robert Reischauer:
"CBO is there to score savings for which we have a high degree of confidence that they will materialize," says Reischauer, now president of the Urban Institute. "There are many promising approaches [in these reform ideas] but you...can't deposit them in the bank." In the long run, Reischauer says, it's likely "that maybe half of them, or a third of them, will prove to be successful. But that would be very important."
Seconding that reaction is a more concrete way is the ER doctor who writes the Movin' Meat blog, which offers a running practitioner's view of the health care reform process. Dr. Meat annotates Brownstein's summary of the key cost-cutting provisions; he finds some underwhelming, some of uncertain effect -- and some likely to have a powerful impact. A short sample:

"The Finance Bill proposed automatic reimbursement reductions for doctors who order up the most care for Medicare recipients with similar medical and demographic characteristics. That was meant to respond to the research showing big disparities in spending on medical services for similarly-situated patients in different communities. ... the final bill takes a less direct route toward a similar end. It requires Medicare to begin studying the utilization patterns of doctors participating in the program. And then it establishes a "values based payment modifier" that would, in a budget-neutral manner, increase reimbursements for physicians found to deliver high-quality care at lower cost, and reduce them for physicians at the other end of that spectrum."

Wow. I was unaware of this. Would it be unfair to call this the "Gawande provision?" That New Yorker article was highly influential. As someone who works in a "high quality low cost" system, I like the idea of being paid for being more efficient -- we have been penalized for many years. I like that it is budget neutral. I worry that since it does not decouple payment from volume, that the low-efficiency area practices may respond by simply further increasing volume to make up for lost revenue. When it's a revenue neutral game, there will always be someone at the bottom -- will this polarize practice patterns or reduce the disparities? I don't know.

Another Republican cost-containment priority missing from the bill is meaningful medical malpractice reform. (The bill only encourages states to think about it.)"

Yes, this is a pity. However, I blame this entirely on the Republicans. We know that the Democrats have been four-square against tort reform for time out of mind. There is no way they were going to put it in their bill on their own. If Chuck Grassley had offered five solid GOP votes for the overall package in return for real malpractice reform, I am sure that Obama would have jumped at it. Who wouldn't? There would have been no last-minute drama over whether the bill was going to pass, the compromises would have been made in committee, and both the Democrats and GOP would have been able to claim to their constituencies that they had accomplished long-standing objectives. Instead, the GOP chose immutable opposition as their strategy and as a result the bill reflects not one of their priorities. Reap the whirlwind, boys.

The conclusion bespeaks an interested party willing and able to look at issues in the round:
Overall, it's promising -- as a start. I don't think this will be the end, not by a long shot. A large number of critics claim that the health reform bills do "nothing" to control costs. This is not nothing -- not by a long shot. Whether it will work at all, or whether it will do enough are open questions. I also find it interesting that the providers who have been most concerned about the escalation of health care costs (I'm looking at you, Kevin) have not weighed in on this element of reform. As a provider, I have really mixed feelings about the potential for cost containment to (further) erode physician autonomy and to (further) reduce physician income. However, no sane person can look at the rate of medical inflation and not see the burning need for cost containment. I just worry that too much of it will fall on our shoulders, since reining in costs any other way is tricky and politically unpopular.

There, Mr President, I've done my homework. Do I get extra credit?
Extra credit is when the President circulates your analysis - as he reportedly did Brownstein's. Rahm, move this meaty response.

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