The challenge and opportunity for health system reform

Four times in recent weeks, I've been in the White House on your behalf. This unprecedented access will cause some of you to rejoice and others to worry about why and what's the goal of your AMA leadership.

The first trip to the East Room was for the signing of the CHIP reauthorization, ensuring continuation of health coverage for 7 million children, and its expansion to 4 million more. It was, as President Obama said, "a down payment on the promise of health insurance for all Americans."

This should be viewed as a real victory. It will enable states to extend health coverage to more children whose parents cannot afford it, but earn too much to qualify for Medicaid. We are particularly pleased that the law will provide more flexibility to states to allow better coordination and partnership with existing employer-provided private health insurance. Enhanced premium assistance provisions should also help ease budgetary pressures on the CHIP program.

The second trip, to the "fiscal responsibility summit," began in the East Room, then moved to breakout sessions in the Eisenhower Executive Office Building.

The opening plenary session began with the vice president, two economists of differing political stripes, and Peter Orszag, director of the Office of Management and Budget, describing the current dire economic situation and noting the rising health care costs affecting our global competitiveness.

The president then spoke, noting the effect of unaffordable health insurance on many working Americans and the worsening problems when losing a job also means losing one's health insurance.

Since medical costs are the No. 1 cause of personal bankruptcy, even insured Americans are having a tough time, and we all know that those without insurance delay care, including preventive measures.

By the time the "parade of horribles" was finished, I felt a great sense of unease and wondered if the breakout session on health care would have medicine not "at the table," but "on the menu."

However, that wasn't the case. The meeting was chaired by Melody Barnes, director of the White House Domestic Policy Council, who skillfully asked each participant, beginning with members of Congress from both sides of the aisle, to describe briefly what they hoped for as we approach health system reform.

The comments were pretty predictable, but what was interesting was the respectful tone of all comments and the listening that occurred. Listening hasn't always been a hallmark of conversations around these issues, as those of you who've met with members of Congress and government officials know full well. It helped that there was press in each breakout session.

I can't comment on how things went in the other four breakout sessions, but the one on health care was polite and somewhat informative, at least in terms of "beginning positions." Two members of Congress favored a single-payer system, but they were a distinct minority. It was clear that building on the current system was the approach that will be taken.

After congressional members spoke, the rest of us around the table were asked for brief comments. I said that our AMA wanted all Americans to have access to affordable, high-quality health care. I also noted that there has to be personal responsibility involved as well as some tough decisions, since our country cannot afford everything for everybody.

I described the bedrock of our profession as the patient-physician relationship, and our ethical responsibility to do the very best we can for our patients. I also referenced the need for physicians and scientific evidence, not government or health plans, to guide decisions about treatment options. At the same time, our profession has acknowledged the need to be just stewards of finite resources.

AMA members should know that our policy emphasizes that physicians play a central role in efforts to contain costs and improve value, both because of the impact of our behavior on costs and outcomes, and because our involvement is essential to the development of successful initiatives. And while physicians play a central role, confronting endemic problems like obesity, tobacco use, and violence will require coalitions of stakeholders from within and outside the health care system, as well as major societal change.

In my talks across the country, I highlight four broad strategies that we believe can be used to manage health care costs and improve value in the health care system: reduce the burden of preventable disease; make health care delivery more efficient; reduce nonclinical health system costs that do not contribute to patient care; and promote "value-based decision-making" at all levels.

And at the summit, I made sure that I said we want a strong private sector, not government-run health care. We will be constructively engaged, I said, because it is physicians and their patients, along with other clinicians who help deliver care and services, who have to live with the results of reform efforts.

The closing plenary for that day was televised and respectful, and it had a few interesting back-and-forths between members of Congress and the president. You may have seen clips from that on news broadcasts.

My overall impression was that this will be a serious effort to engage stakeholders in improving health care and addressing the impending insolvency of Medicare if there's not a "bending of the curve" of rising health care costs.

At no point did anyone talk about cutting payment to "providers" (I hate that word!), but restructuring payment was clearly on the horizon.

The view from the summit

On March 5, the "health care summit" occurred, again beginning in the East Room with a 24-year-old firefighter from Dublin, Ind., who presented President Obama with a report of the regional listening sessions attended by more than 30,000 people across the United States.

The president then spoke, saying he wanted and expected significant health reform this year. The three pillars of concern were access (meaning coverage as well), quality and cost. He challenged those who defeated health reform last time and said that this time they would not prevail.

My breakout session was moderated by Nancy-Ann DeParle, newly appointed head of the White House Office for Health Reform. She deftly called on members of Congress -- Sens. Max Baucus (D, Mont.); Charles Grassley (R, Iowa); and Reps. Henry Waxman (D, Calif.) and Joe Barton (R, Texas) to state their hopes/plans for reform.

After Baucus mentioned a concern about geographic variation in practice patterns and the costs associated with that, I was asked to comment on what our profession will do about practice variations. I responded that when the Dartmouth statistics on this subject were first released, we thought the variations could be explained by differing patient characteristics ("some patients are sicker"), but now we know that patient risk factors and co-morbidities do not explain the variation in practice.

I added that most practice variations occur when a clear-cut, evidence-based "right thing to do" has not been established. I called for investment to enhance that evidence base. I also stated that physicians will not trust either the government or health plans to decide the strength of the evidence, but they do trust their specialty societies.

I cited the example of the American College of Cardiology and the American College of Radiology, who jointly developed "appropriateness criteria." I said that it was really important to stick to the principles of doing the right thing for an individual patient, and that framing the issue as what's "appropriate" for the patient, with that patient's unique set of circumstances, was pivotal in gaining physician and patient buy-in. Douglas Weaver, MD, of the American College of Cardiology was in the room, and he articulately elaborated on this point and the efforts of the two specialty societies.

Waxman talked about high costs of care at the end of life and wondered if a reduced insurance premium might be available to patients who have at least considered advance directives -- no matter what decision the patients make. Grassley was very concerned that we not "ration" care at the end of life -- that was agreed to by all.

A clear message was that payment systems will be different -- perhaps bundling, perhaps "accountable care organizations," perhaps medical homes. Cognitive services will be valued more, and quality measures and outcomes will, at least in part, replace fee-for-service as the only payment methodology.

At the closing session, Sen. Edward Kennedy (D, Mass.) entered to thunderous applause and a standing ovation.

Obama called on a few members of Congress and signaled that the ball was in their court to press forward. He also signaled a willingness to consider options different from his campaign approach. The president called on Karen Ignagni, president and CEO of America's Health Insurance Plans, and her response was a significant change from the past: "You have our commitment to play, to contribute and to help pass health care reform this year."

There is, at least for now, an apparent willingness of all sectors to engage constructively. As the country hurtles toward health care reform, we have to help lawmakers get it right, since doctors and their patients will be the ones who live with the results. Let's stay tuned, stay focused and stay vigilant.