Thursday, March 11, 2010

Capuano Plays Hardball

Democratic Rep. Mike Capuano (MA-8), who voted in favor of the House's version of health-care reform in November, has released a letter raising a number of concerns with the Senate bill. Here are a few of them:

(2) DSH cuts - Currently, Medicare and Medicaid provide extra payments to hospitals that serve higher-than-average shares of people without health insurance. These hospitals are called Disproportionate Share Hospitals, or DSH. In the 8th District for example, Boston Medical Center and Cambridge Health Alliance both depend on millions of dollars a year in DSH payments. The Senate bill would cut DSH payments by $42 Billion per year, as opposed to the $20 Billion cut proposed in the House. Such cuts, made before a new health care system is allowed to fully develop, would curtail the amount and quality of health care provided by DSH hospitals and their uninsured patients, thereby driving these sick and poor persons to other hospitals that will not be equipped or paid to handle the medical and social challenges they present. I am looking into this aspect of the Senate bill as well.

(3) Value Index - The Senate bill includes a proposal to adopt a so-called "value index"; the House bill does not include this proposal. It would adjust the way payments to physicians and other non-hospital providers are calculated. Supporters suggest it would encourage practices that are more frugal by rewarding "low cost areas". Massachusetts is considered a "high cost area" due to various factors, including the regional cost of living, the relative poverty of the people served, and our financial commitment to educating America's next generation of doctors. There are no limits on how much a physician's payments could be reduced by this so-called "value index" and the method has never been tested at the physician level. Due to the probability of much lower payment rates to Massachusetts doctors, this proposal seems as though it would influence (1) where doctors practice (discouraging practice in Massachusetts), (2) how they treat patients in so-called "high cost areas", and (3) how many doctors will be trained in America. Absent a thorough study of the impact of this so-called "value index", it seems to me that it could seriously harm the quality of care in Massachusetts.

(4) Super IMAC - The Senate bill contains a proposal that would shift authority to set Medicare policies and reimbursement rates from the Congress to a board appointed by the President. This proposal has been referred to as the "Super Independent Medicare Advisory Council" by many. The House bill does not contain such a proposal, although it does require formal studies on many specific initiatives to improve the quality and cost effectiveness of the American health care system. Traditionally, reimbursement rates from Medicare are based on many factors including efficiency, complexity of the medical issues, whether the provider also bears costs associated with medical education for future doctors, whether the provider engages in research that advances medicine and the cost of living in different areas. Some argue that Medicare should focus ONLY on cost containment without regard for all the other factors that affect the cost of care and that have been traditionally considered. I am concerned that if this appointed board adopts the cost-containment only approach, Massachusetts could lose BILLIONS of dollars PER YEAR. Such a loss would hurt our world-renowned medical schools, teaching hospitals, and research programs. Those losses would undermine the quality of care we provide to our own citizens and slow progress in biomedical sciences globally. To make matters worse, I am concerned that it would quickly and inevitably result in Massachusetts losing tens of thousands of jobs and would seriously undermine one of our region's economic engines. Other regions with heavy concentrations of health care would feel a similar impact, such as New York City, Philadelphia and Los Angeles. Finally, to add insult to injury, the elected representatives of the people impacted would no longer have a say in accepting, rejecting or amending any new approaches - the entire decision would be up to Presidential appointees. Moreover, I ask people who are happy to entrust these decisions to persons appointed by President Obama to remember that there will be other Presidents, with, perhaps, very different levels of commitment to medical care.

Members of Congress have made points like this on both sides of the aisle. The last may be one of the more pressing to members of Congress; passage of Super IMAC would represent a significant blow to the power of Congress and give the executive branch even more power to intervene in the health-care of the nation.

Martha Coakley won Capuano's district in January 2009, so he might not be purely motivated by electoral concerns here. This may be an attempt to extract as many concessions from leadership as possible. It may also be a sign of principled disagreement, one from which he might not be swayed.

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