'Doc fix' collapses, Reid tells colleagues AMA led him astray - TheHill.com

'Doc fix' collapses, Reid tells colleagues AMA led him astray - TheHill.com

Doctor on-Call? Cell-Phone Cameras Can Diagnose Disease

Doctor on-Call? Cell-Phone Cameras Can Diagnose Disease

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S. 1776 Update

U.S. Majority Leader Senator Harry Reid (D-NV) and U.S. Minority Leader Senator Mitch McConnell (R-KY) have reached an agreement that will allow the Senate to proceed to S. 1776 next week.

As such, the cloture vote on the motion to proceed to the bill that had been scheduled for Monday, October 19th is no longer necessary and has been cancelled.

Senators Reid and McConnell will negotiate an agreement which will permit a very limited number of amendments to S. 1776 to be offered and voted upon. We expect that there will be one or more votes on S. 1776 next week, including a critical vote on a motion to waive the budget act with respect to the bill.

While the vote is no longer on Monday, the legislation will still move very quickly. It is critical that you continue to reach out to to your senators and ask them to support of this legislation. Use our hotline at (800) 833-6354 and call your senators or email them here.

Senate to vote on SGR Monday

On Oct. 13, Sen. Debbie Stabenow (D-Mich.) introduced S. 1776, the "Medicare Physicians Fairness Act of 2009," which the Senate leadership announced yesterday will serve as the Senate legislative vehicle for eliminating Medicare's sustainable growth rate (SGR) formula and laying the foundation for establishing a new Medicare physician payment update system.

S. 1776 will be the subject of a cloture vote on Monday, Oct 19. The Senate needs 60 votes to invoke cloture to allow formal consideration of the bill. A vote on final passage is expected to occur late next week, either on Oct. 22 or 23. Senate Majority Leader Harry Reid (D-Nev.), Senate Finance Committee chairman Max Baucus (D-Mont.), and Sen. Chris Dodd (D-Conn.), along with President Barack Obama, are all strongly supporting passage of S. 1776.

Sen. Stabenow's 18-line bill repeals the SGR formula and eliminates all debt that has been accumulated under the current payment system, setting future physician payment updates at zero. Importantly, the Senate leadership made it very clear yesterday that Congress does not intend to implement a permanent physician payment freeze and call it Medicare payment reform.

Rather, by passing a separate bill that repeals the SGR and eliminates the accumulated spending target debt, budget constraints will be eased, allowing a new physician payment update system to be incorporated into a broader health system reform bill. The details of that future update system have not yet been worked out, although certainly the two spending targets that would be created by the U.S. House of Representatives health system reform legislation, H.R. 3200, could be viewed as a starting point.

The procedural path for passing S. 1776 will be complicated, requiring the support of 60 senators on several procedural motions over the next few days. Furthermore, because the legislation is not offset by other spending cuts or revenue increases it will add to the federal budget deficit, raising its controversy and making supporting votes difficult for some senators.

Repealing the SGR is one policy objective that is a common goal for all physicians. Sen. Stabenow's bill creates the pathway the AMA has been seeking to finally achieve that goal. Grassroots activism will be absolutely critical to the success of this strategy.

The AMA has activated its physician and patient grassroots networks, and will be running television advertisements in key states. A unified and concentrated effort by the entire house of medicine will be essential to the AMA's success.

Visit the AMA's grassroots action center to send an e-mail to your senator. Also, the AMA grassroots hotline at (800) 833-6354 can connect you directly to your senator's office.

Sanofi says children under 10 likely to need two H1N1 vaccine doses.

The CBS Evening News (10/14, story 4, 1:20, Couric) reported that "the first injections of the H1N1 flu vaccine were given to the public today, but for children under ten, one shot will not be enough. The vaccine's maker says they'll need two injections to be fully protected."

The AP (10/15, Marchione) reports that vaccine maker Sanofi Pasteur said that tests of its H1N1 "vaccine suggest that children under 10 are likely to need two shots to be fully protected." According to federal officials, these results are "not surprising, since this age group needs two doses of regular seasonal flu vaccine the very first time they ever are given a flu vaccine for full immunity to develop." Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases confirmed that Sanofi's "results back up what government tests are showing."

Bloomberg News (10/14, Serafino) reported that the clinical trials also "showed the vaccine triggered an immune response" that "was well tolerated," and patients experienced no serious side effects. The "Booster Shots" blog of the Los Angeles Times (10/14, Maugh) also covered the story.

College H1N1 cases said to be increasing slowly. In its "Booster Shots" blog, the Los Angeles Times (10/14, Maugh) reported that the American College Health Association said that "influenza-like illnesses, generally assumed to be pandemic H1N1 influenza, continued their slow growth on college campuses with a two percent increase last week." While "regional outbreaks of swine flu appear to have peaked already in the Southeast, Northeast and Mid-Atlantic regions...the Midwest, Rocky Mountain area and Southwest are experiencing increases." Dr. James C. Turner, president of the organization, said, "Many outbreaks will have waned significantly by the time H1N1 vaccine becomes widely available," so the next few months are "a critical period for achieving high rates of immunization among college students before the next wave starts this winter."

Schools, hospitals throughout US deal with H1N1 virus. The AP (10/14) reported, "The largest hospitals in central Indiana are putting more restrictions on visitors as they try to stem the spread of swine flu." Marion County Health Department director Virginia Caine said that "every major hospital in the city has agreed to tougher visitation rules." Methodist Hospital, Indiana University Hospital, and Riley Hospital for Children in Indianapolis will only allow parents, spouses, domestic partners, and clergy to visit patients.

The Washington Post (10/15, Goodman) reports, "Schools and hospitals in Southern Maryland have reported several cases of swine flu, and health and school officials are continuing to battle the virus." The Post adds, "Southern Maryland's three county health departments and school systems are planning to host flu clinics for residents and students." William Leebel, a spokesman for the Charles County Health Department, said that people with "flulike symptoms probably have the H1N1 strain," as "the seasonal influenza usually hits during the winter holidays and in January."

Health-Care Bill May Not Get Single GOP Vote in the House

By Ben Pershing

Washington Post Staff Writer
Saturday, October 10, 2009

The House is inching closer to voting on a comprehensive health-care bill, even as the chamber appears so divided that the measure may not attract a single Republican supporter.

The final vote, likely in late October, is impossible to predict, but lawmakers and aides from both parties said this week that there is a strong chance the GOP will be unanimous in its opposition. Such a result would mark the second time -- the first came on the economic stimulus package in February -- that the entire House minority rejected one of President Obama's top domestic initiatives.

"We're still hoping that some of them will come on board, but we see no sign of it," said Rep. Chris Van Hollen (Md.), a member of the Democratic leadership.

Even the most moderate Republicans, who might be inclined to vote with Democrats on big-ticket legislation, say they don't expect to do so on health care.

"I don't think I would, and I don't sense much support from any Republicans," said Rep. Peter T. King(N.Y.), predicting that the GOP support would be either zero or "no significant number."

The effort at bipartisanship has been difficult on Capitol Hill. The two parties have traded blame for that, with Republicans alleging that they've been shut out of the process and Democrats arguing that GOP members were never interested in a constructive discussion -- only in a chance to deal a defeat to Obama.

Sen. Max Baucus (D-Mont.) spent weeks huddling with Republican senators on health care through the "Gang of Six" but had modest results: The White House's only hope for a Republican nod when the Senate Finance Committee votes Tuesday is Sen. Olympia J. Snowe (Maine).

And the House's 177 Republicans have played almost no substantive role in moving health care through the chamber, as Speaker Nancy Pelosi (D-Calif.) has summoned to her office Democrats of every stripe to build a health-care bill that will appeal to the majority of her members.

This week there were some new, largely symbolic attempts at consensus: Health and Human Services Secretary Kathleen Sebelius met with conservative House Republicans in a closed-door session, and House Majority Leader Steny H. Hoyer(D-Md.) and House Minority Whip Eric Cantor (R-Va.) met. "We could have got something done in July," Cantor lamented afterward. But now, he said, Republicans "are opposed to it to a person."

Rep. Steven C. LaTourette (Ohio) said he and his fellow moderate Republicans will oppose the bill because there "haven't been any substantive attempts" to reach across the aisle. "If they want it to be bipartisan, there have to be some discussions," he said.

Some big-name Republicans off the Hill, such as California Gov. Arnold Schwarzenegger and former Senate majority leader Bill Frist (Tenn.), have voiced support for the general idea of health-care reform, but none has endorsed a measure like the one expected to emerge from the House, which may include a government-sponsored insurance program, or public option.

LaTourette singled out the public option as what most concerned him and others in the GOP. A public-option provision in the Senate bill is far less likely.

This week there were some new, largely symbolic attempts at consensus: Health and Human Services Secretary Kathleen Sebelius met with conservative House Republicans in a closed-door session, and House Majority Leader Steny H. Hoyer(D-Md.) and House Minority Whip Eric Cantor (R-Va.) met. "We could have got something done in July," Cantor lamented afterward. But now, he said, Republicans "are opposed to it to a person."

Rep. Steven C. LaTourette (Ohio) said he and his fellow moderate Republicans will oppose the bill because there "haven't been any substantive attempts" to reach across the aisle. "If they want it to be bipartisan, there have to be some discussions," he said.

Some big-name Republicans off the Hill, such as California Gov. Arnold Schwarzenegger and former Senate majority leader Bill Frist (Tenn.), have voiced support for the general idea of health-care reform, but none has endorsed a measure like the one expected to emerge from the House, which may include a government-sponsored insurance program, or public option.

LaTourette singled out the public option as what most concerned him and others in the GOP. A public-option provision in the Senate bill is far less likely.

Democratic strategists say that at least a few GOP lawmakers would feel compelled to vote for such a bill.

Unanimous party opposition to major bills is rare. President George W. Bush's first major tax-cut package got 28 House Democratic votes in 2001. Nine Democrats broke ranks with their party to support the Medicare prescription-drug bill in 2003. Even this year's climate-change bill, which was heavily criticized by conservatives, drew eight Republican votes as it passed the House.

Surveys suggest that the public does care about the final tally. A Quinnipiac University poll released this week found that 57 percent of respondents think Congress should not approve a reform bill with only Democratic votes.

But for Republicans, "there's very little reward in voting for this," said former Virginia congressman Tom Davis, the head of the moderate Republican Main Street Partnership. He added that he thought there would not be any political price to pay for a no vote.

Polls have shown broad support for the general idea of health-care reform, but opinion is more mixed for specific proposals such as the public option. Democrats say voters want the public option, and they are sure to use the health-care vote to bludgeon vulnerable Republicans.

"I think they run a huge risk," Van Hollen, the chairman of the Democratic Congressional Campaign Committee, said of the GOP. "I think they've placed themselves firmly on the side of the insurance industry and the status quo."

The White Coat

One of the privileges of being the GLMS President is to be able to take part in the annual University of Louisville Medical School's White Coat Ceremony. I thought I might be suffering from early onset cognitive decline when I could not recall my own white coat ceremony until I discovered that this is a relatively new tradition, started in 1993 at Columbia University. Students are welcomed into the practice of medicine with the official donning of their white coats, while receiving comments from their dean and others (including the president of the medical society). Having to speak to this new group of physicians to-be made me wonder, why is it a white coat? Before the turn of the 20th century, medicine and the "healing arts" were practiced by many quacks and charlatans. In an effort to improve the image of physicians, the lab coat was adopted as a sign of scientific credibility. Although the traditional lab coat was beige, doctors adopted the white color to symbolize life and purity. In the early days of hospitals, caretakers used to wear black robes as patients in those times typically did not survive their hospital stays. Students in the 1920s also apparently wore black lab coats while examining cadavers. The change to white lab coats signaled the change of medicine to a healing art and a sign for hope. The white coat, however, is more than just a symbol of science. It is the principal object used to depict the physician. The media use it to depict knowledge and authority. While advertisers also use this to sell their pills or devices, the white coat should remind us of the responsibility bestowed upon us as physicians. Some would argue that white coats should not be utilized (do white coats actually cause "white coat syndrome"?). The Mayo Clinic's physicians do not wear them. They only wear business attire, and there is some evidence that white coats can contribute to the spread of infections. However, some studies suggest that patients prefer their physicians to wear them. The white coat helps define the relationship between the physicians and their patients. It helps to demonstrate that the interaction is purposeful and serious, providing confidence that a patient's complaints will be handled competently and compassionately. The white coat (whether we choose to be wear it or not) is a symbol, and symbols can affect and reflect certain behaviors. This symbol is a reminder of the awesome privilege and responsibility that we have as physicians. We are not only allowed respectful access to patients' bodies, but also to their innermost feelings and secrets. It is a symbol of trust that reminds us of our professional duties. It is also a visual reminder of our commitment to "do no harm." Seeing the frightened look in the eyes of many of the incoming students (maybe it didn't help that I also reminded them of the symbolism of the white coat - the awesome privilege and responsibility they will have as a physician) reminded me of the immense commitment that they have made and that we all made many years ago. Fortunately, a few very thoughtful physicians many years ago developed a resource to help medical students navigate these challenging years. Dr. Leah Dickstein originated the Health Awareness Workshop (now called Med School Matters, overseen by Dr. Toni Ganzel). It emphasizes the risk factors involved in being a medical student and the importance of maintaining proper nutrition, sleep, exercise and relationships. It provides students a resource for depression, substance abuse or other problems that might threaten a successful education. The GLMS Foundation helps support this very important program. Having a few moments to speak at this year's white coat ceremony was a special moment. Thank you for the opportunity to do this as the GMLS president.

Sincerely, Lynn T. Simon, MD GLMS President

Democrats Try to Balance Cost and Coverage in Health Plan

WASHINGTON — As Democrats prepare to take up health care legislation on the floor of the Senate and the House, they are facing tough choices about two competing priorities. They want people to pay affordable prices for health insurance policies, but they want those policies to offer comprehensive health benefits.

These goals collide in the bills moving through Congress. The different versions of the legislation would all require insurance companies to provide coverage more generous than many policies sold in the individual market today. That is good for consumers, Democrats say.

But Republicans say the new requirements would mean added costs for some consumers and for the government, which would help pay premiums for millions of low- and middle-income people.

That tension between keeping costs low and improving coverage is just one of many challenges facing Congress and the Obama administration as they head toward the final stages of the effort to pass health care legislation.

Under the legislation, the government would not only require insurers to accept all applicants. It would also define the acceptable levels of coverage.

Senator Jeff Bingaman, Democrat of New Mexico, said the federal government had to specify coverage levels because the benefits under many existing insurance policies were inadequate.

“We have more than 46 million people who are uninsured,” Mr. Bingaman said. “We also have a substantial number who are underinsured. Although they have coverage, it is so bad or so inadequate that if they really get sick, they find they cannot afford the health care they need.”

But the No. 2 Republican in the Senate, Jon Kyl of Arizona, said it was “an act of hubris” for Congress to prescribe the permissible coverage.

“For the life of me,” Mr. Kyl said, “I don’t see why Washington has to dictate what kind of insurance you get to buy. Why not let the consumer decide?”

The Senate Finance Committee had been scheduled to meet Tuesday to finish work on a sweeping health care bill that it put together over the last two weeks. But it postponed the session while it waits for a cost estimate from the Congressional Budget Office.

Under the committee’s bill, there would be four levels of benefits — bronze, silver, gold and platinum — and all insurers would be required to offer, at a minimum, coverage in the silver and gold categories.

Most employer-sponsored health plans already meet the proposed federal standards. But insurers and actuaries say that one-third to one-half of policies bought by individuals and families fall short. About 17 million people buy insurance on their own, in this individual market.

Senator Kent Conrad, Democrat of North Dakota, who helped write the Finance Committee bill, acknowledged that the federal standards were “high in relation to what is selling in the marketplace in some parts of the country.”

The Senate health committee and three House committees have approved bills that would set even higher standards, meaning that insurers would pick up more of the costs.

In comparing the overall benefit levels of different health plans, federal officials often use a yardstick known as actuarial value. This statistic measures the share of health care spending for a given population that is covered by a plan. Consumers pay the remainder, in deductibles, co-payments and other charges.

The four levels of coverage allowed by the Finance Committee have actuarial values ranging from 65 percent for the bronze plan to 90 percent for the platinum plan.

The Senate health committee prescribes three levels of coverage, with actuarial values from 76 percent to 93 percent.

The House bill also calls for three levels of coverage — basic, enhanced and premium — with values from 70 percent to 95 percent.

By contrast, the Congressional Budget Office says, the actuarial value of policies bought in the individual insurance market now averages 55 percent to 60 percent.

For insurance plans provided by employers, it said, the average value is 80 percent to 85 percent. And according to the Congressional Research Service, the value is slightly higher, 87 percent, for the standard Blue Cross and Blue Shield plan available to federal employees, including members of Congress.

Senator Michael B. Enzi, Republican of Wyoming, said Congress was being “too prescriptive.”

“We are about to tell the nation, every person in the nation, what the minimum insurance is that they can have,” Mr. Enzi said. “And then we will institute a penalty if they don’t buy the minimum insurance we say they ought to have. If they want less, we say no.”

While higher-value plans may provide greater protection for many people, they may also cost more.

“In many states, the average actuarial value is way below the 65 percent proposed in this legislation,” said Senator Charles E. Grassley of Iowa, the senior Republican on the Finance Committee. “So if health care reform passes and our constituents go to buy new coverage, many will end up seeing higher prices than they would have under current law.”

But Senator Debbie Stabenow, Democrat of Michigan, said the whole point was to improve the protection of consumers.

“The more we lower the actuarial value, the more the individual or the family will have to shoulder the costs of their plan,” Ms. Stabenow said. If a plan has a value of 60 percent, she said, policyholders as a group would be expected to pay 40 percent of their medical expenses.

Senator Olympia J. Snowe, Republican of Maine, said she shared that concern. Under the bronze plan, she said, “you could be consumed by cost-sharing unless you were very healthy.”

The major bills would set annual caps on out-of-pocket spending, but the limits could be as high as $5,950 for individuals and $11,900 for families.

Roland D. McDevitt, director of health research at Watson Wyatt Worldwide, a benefits consulting concern, said it was a huge challenge to make insurance “affordable for families and affordable for the government” at the same time. Under the major legislative proposals, Mr. McDevitt said, insurance is likely to be more expensive for many young healthy people, but less expensive for a 60-year-old with diabetes and a heart condition.

The chairman of the Finance Committee, Senator Max Baucus, Democrat of Montana, said he was trying to “strike a balance between affordability and proper coverage.”

If the government does not set minimum coverage levels, he said, insurers will continue to offer low-value policies that leave consumers exposed to exorbitant costs and the risk of bankruptcy.

Such policies amount to “pseudo coverage,” Mr. Baucus said.