Policy & Practice Podcasting Archives

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Physicians could get a break from the monthly fee fix roller coaster. Welcome to Policy & Practice, the weekly podcast from Global Medical News. I'm Todd Zwillich.

NARR: Congressional negotiators finally agreed last week to avoid a 21 percent cut in physician fees. The cut is scheduled to take effect on June 1st. It's mandated by the Medicare fee formula, called the Sustainable Growth Rate or SGR. The lack of a permanent replacement for the SGR has roiled physicians for years and has the Obama Administration upset, as well. Alicia Ault has more.

AULT: It looks like physicians would see marginal pay increases over the next three and a half years. After that, all bets would be off and doctors would likely be looking at deep cuts. In a speech to emergency physicians, White House health reform director Nancy-Ann Deparle said that President Obama has asked for a permanent replacement for the SGR each of the last two years in his budget.

Deparle: "We know that taking on this problem won't be easy, it isn't easy, but we also know the stakes are too high to fail...there are too many Americans who are counting on us to ensure that they'll get the high quality care that they need."

AULT: The White House isn't likely to make headway any time soon. Congress is expected to vote on the three-and-a-half-year SGR fix before it leaves for its Memorial Day recess at the end of this week.

NARR: As news of the pay deal emerged, the American Medical Association issued grudging praise for the temporary solution. The AMA pushed hard for a permanent replacement to the SGR and warned that this fix won't solve the problem. But primary care groups like the American Academy of Family Physicians were more positive about the deal. It includes higher pay for primary and preventive care in 2012 and 2013. Dr. Ted Epperly, board chair of the AAFP, explained why this could be good news.

Epperly AX: "It bodes well as we see it for whatever the permanent fix will be downstream that the continuation of a differential formula that highly values what it is that primary care doctors do will be carried over."

NARR: Meanwhile, physicians got a look at a key component of health reform that will also directly affect their wallets and how they practice. There's a new effort involving 19 health systems that are taking the first steps towards forming accountable care organizations, or ACOs. It's called the Premier healthcare alliance... These networks of hospitals, physicians and other health care providers are supposed to be the backbone of the new health delivery system under health reform. But they are still loosely defined right now. At a briefing on Capitol Hill, Montana Democratic Senator Max Baucus praised the Premier collaborative, saying that it would help make health reform a reality.

NARR: Now at the same briefing, Baucus also said he met with Don Berwick, the nominee to head the Medicare and Medicaid agency. No date has been set for his confirmation hearing, however. Stay turned for more on that and for news on the SGR vote next week. And that's the Policy & Practice Podcast. I'm Todd Zwillich.

NARR: Washington tries to get serious about fraud. Welcome to Policy & Practice, the weekly podcast from Global Medical News. I'm Todd Zwillich.

NARR: The Obama Administration is redoubling efforts to combat waste and fraud. Part of the reason is to find a new revenue source for health reform. The Affordable Care Act gives the feds new tools to go after old scams as well as new scams arising from confusion about the law. Alicia Ault has more.

AULT: HHS Secretary Kathleen Sebelius and Attorney General Eric Holder briefed reporters on the record amount of money recovered from fraud investigations in 2009. 2.5 billion dollars alone went into the Medicare trust fund, a 500 million dollar increase from the previous year. 2009 saw almost 600 criminal convictions, and thousands of civil cases are pending. Ms. Sebelius said that new money and new enforcement powers in health reform mean that there will be increasing scrutiny of potential abuse.

SEBELIUS: (23 seconds) "For years, we've tolerated health care fraud. We've accepted that with any big enterprise there was going to be some waste and abuse, but those days are coming to an end. As we try to bring down skyrocketing costs across our health care system we can't afford to ignore the billions of dollars we lose to fraud and theft."

AULT: Mr. Holder said that for every dollar spent combating fraud, four dollars are returned to taxpayers.

NARR: It's only been a few months since the Affordable Care Act became law, but HHS has already issued 3 new regulations putting parts of the law into play. And while there's often less fanfare surrounding regs .... experts and lobbyists agree that these are the details that define the health reform effort. Last week, HHS, along with the Departments of Labor and Treasury, issued interim final rules requiring health plans offering dependent coverage to extend that coverage to young adults up to age 26. The rules will take effect on September 23rd, but over 65 companies are voluntarily complying early.

NARR: Meanwhile, physicians continue to wonder what Congress will do to halt the 21% Medicare pay cut slated for June 1st. Here's Mary Ellen Schneider with more:

SCHNEIDER: House and Senate leaders have been trying to negotiate some type of pay fix for doctors that could cover the next 5 years. While doctors wait, they are growing frustrated and some are talking about limiting the number of Medicare patients they see. A new poll commissioned by the American Osteopathic Association found that about a quarter of doctors would probably drop their current Medicare patients if the 21% cut goes through.

NARR: Along with Medicare payments, Congress will soon consider who should run the Centers for Medicare and Medicaid Services. The president has nominated a well-respected expert on quality-that's Dr. Don Berwick-- but he could be in for a tough fight. Republicans are already leveling charges that Berwick favors health care rationing. And that's the Policy & Practice Podcast. I'm Todd Zwillich.

NARR: Still no good news for physicians on the pay front. Welcome to Policy & Practice, the weekly podcast from Global Medical News. I'm Todd Zwillich.

NARR: Physicians are still waiting for some indication they won't face a 21% Medicare pay cut on June 1st. They're still holding out hope for a permanent replacement for Medicare's Sustainable Growth Rate formula, also known as the SGR. Bolstering their argument: A new report from the Congressional Budget Office showing that without a permanent fix, it will be even more expensive than expected for Congress to keep doing temporary fix after temporary fix. Mary Ellen Schneider has more.

SCHNEIDER: In its report, the CBO found that after taking health reform into account, the temporary fee fixes will cost an additional 9 to 10 billion dollars a year. Without a permanent fix, doctors could be looking at an eventual cut of closer to one-third--29 to 34 percent to be exact.

NARR: Meanwhile, on the health reform front... A new report from consumer advocacy group Families USA finds that more than 57 million Americans under age 65 have a diagnosed pre-existing medical condition.... of course that fact makes it harder for them to get insurance. The group's executive director Ron Pollack thinks that's a big reason why the recently passed health reform bill is so important. He said says the 57 million may even be an underestimate since it doesn't include many more whose health conditions are going undetected.

POLLACK AX: "And of course there are many people, especially those who are uninsured, those people who are underinsured, who don't go to see a doctor, who don't feel they can afford to get care, even preventive care and diagnoses, who do not have a diagnosed pre-existing condition but certainly do have a pre-existing condition, it's just that it has not yet been diagnosed."

NARR: Pollack pointed out that people with undiagnosed diseases will get relief in 2014 when the Affordable Care Act bars health plans from denying coverage based on those pre-existing conditions. But some help comes even sooner. Starting as early as the summer, uninsured adults with pre-existing conditions will be able to join state-based high risk insurance pools. The pools guarantee coverage at rates that are more affordable than high risk patients can get on their own. States have the option of running their own pool or asking the federal government to do the job. At least 19 states-almost all of them with Republican governors-- have asked the feds to take the lead. The biggest barrier, they say, is money. The health reform law sets aside $5 billion to fund the pools until 2014 when health insurance exchanges open up. Republican governors say that just won't be enough.

NARR: Memorial Day is now just three weeks away. That means Congress is scrambling to get all of its work done before that break. And that's the Policy & Practice Podcast. I'm Todd Zwillich.

NARR: New numbers lead to new questions...on the cost of health reform. Welcome to Policy & Practice, the weekly podcast from Global Medical News. I'm Todd Zwillich.

NARR: The new health reform law is going to increase spending. That was the bottom line from Medicare's chief actuary in an assessment on the Affordable Care Act released last week. As Alicia Ault reports...that has riled Republicans:

AULT: The report projected that by 2019, thanks to new coverage, an additional 34 million Americans would have health insurance. The downside, however, is that expansion of Medicare and Medicaid to provide that coverage means that federal spending will rise by $828 billion over the same timeframe. The report painted a picture of rising costs despite projected savings, including a nine tenths of a percent increase in overall health spending by 2019. These estimates are greater than previous projections. That got the attention of Republicans in the House, who say that it shows that the White House underestimated health reform's costs. They want the chief actuary to testify before them, to explain his analysis.

NARR: Meanwhile, the Obama Administration shows no signs of letting up on the insurance industry. Companies have been a target since the start of the health reform debate. And last week, HHS Secretary Kathleen Sebelius commended a handful of insurance companies for moving quickly to cover young adults up to age 26 under their parents' policies. But just as quickly, she condemned another company. That was Wellpoint. Wellpoint reportedly dropped subscribers who had been diagnosed with breast cancer. The new law prohibits such coverage cancellations beginning in September. So it appeared that Wellpoint may have been trying to get in under the wire. Shortly after Sebelius issued the warning, Wellpoint backed down. UnitedHealthcare quickly followed with a similar announcement.

NARR: Now while the administration spars with insurers, doctors are wondering what their next Medicare payments will look like. The 21% Medicare physician fee cut is now scheduled to take effect on June 1st...that's unless Congress passes another short-term extension. But physicians' groups do expect to get a vote in the Senate on a permanent repeal of the problematic physician payment formula. The question is—will they have enough votes to get it passed. Robert Doherty, a lobbyist for the American College of Physicians, said doctors will have to make a convincing case.

Doherty AX: "We're going to have to work real hard to try to convince the 60 senators that failing to do a permanent fix now is just going to make the problem worse, the costs worse, the cuts worse. And if you are a fiscal conservative, kicking the can down the road again so the price tag just goes up each year to taxpayers makes absolutely no sense at all."

NARR: Expect insurance reforms to remain on Congress's agenda. Democrats are pushing a new bill that would give HHS greater authority to block insurance companies from raising their premiums. And that's the Policy & Practice Podcast. I'm Todd Zwillich.

Congress plods along on physician pay. Welcome to Policy & Practice, the weekly podcast from Global Medical News. I'm Todd Zwillich.

NARR: Physicians got a momentary reprieve this week on a scheduled 21% Medicare pay cut. But doctors and their lobbyists are again clamoring a permanent and lasting solution. Alicia Ault has more.

AULT: Congress worked right up to the deadline last week, waiting until the evening of April 15th to approve a temporary delay in the Medicare fee cut. Medicare indicated that it was set to reduce physician pay by 21% on April 16th. But the Senate debated the temporary fix for almost a week, finally voting to grant only a six-week extension of the current pay rate. The House approved it and then President Obama quickly signed the bill. But just that short delay alone will cost the federal government 2 billion dollars. Physician organizations point to that expense as one reason why Congress should just find a permanent replacement for the SGR formula. And, they said, the uncertainty is leading some physicians to stop taking new Medicare patients.

NARR: Meanwhile the administration has released details on the massive Medicaid expansion set to begin in 2014 under the health reform bill. Congress is letting states know they can start adding new types of enrollees to their programs now and still get their regular federal matching rates. Much more generous matching funds will kick in starting in 2014. But insurance giant UnitedHealth Group says access may be a problem because of low Medicaid reimbursement rates. The health reform law boosts Medicaid payment rates to Medicare levels temporarily in 2013 and 2014. But what happens after that? United executive vice president Simon Stevens says the temporary nature of the increase could cause some problems.

Stevens AX: "What we think needs to be avoided is a new Medicaid doc fix problem where the federal government or states are temporarily making adjustments after the 2014 federal funding runs out in the same way as is currently happening with the Medicare doc fix problem, which itself is yet to be resolved."

NARR: The Obama administration is continuing its sales job on health reform. They're highlighting opportunities to improve quality. The Department of Health and Human Services released national data showing slow improvements in health care quality. The quality of preventive care is the slowest to get better. The nation struggles with disparities in care for low income and minority groups. But HHS Secretary Kathleen Sebelius sees a silver lining. She said this week health reform will expand research efforts into disparities and increase diversity in the health care workforce. Most important, according to the administration...the new law expands coverage for millions of uninsured Americans, potentially eliminating many gaps in care.

The podcast will take a break next week, but we'll be back in May with the latest on reform implementation and efforts to fix Medicare payments. And that's the Policy & Practice Podcast. I'm Todd Zwillich.

Growing legal challenges and some potentially good news for doctors. Welcome to Policy & Practice, the weekly podcast from Global Medical News. I'm Todd Zwillich.

NARR: The Obama Administration continues to promote the benefits of its health reform law, with top officials like HHS Secretary Kathleen Sebelius hosting web chats and meeting with consumers around the country. But at the same time, opinion is still running strongly against the reform law in many places. Last week, another five states joined a suit filed in late March by the Florida attorney general. And that brings to 18 the number of states that say that health reform is unconstitutional because it violates states' sovereignty. In a speech at the National Press Club, Secretary Sebelius said she has doubts about the litigators' motivation.

Sebelius AX: "I think that the vast majority of lawsuits have been filed by attorneys general in states where they have also some interest in higher office and...We're confident that the legal standing of the law is solid and that this has more to do with politics than with policy."

NARR: Meanwhile, doctors are looking to put some political pressure on Congress to fix the Medicare physician payment formula. Here's Mary Ellen Schneider with more.

SCHNEIDER: The Texas Medical Association has launched a petition drive urging Congress to repeal the Sustainable Growth Rate formula-- or SGR-- and replace it with a more stable plan for Medicare physician fees. The goal is to get 1 million signatures from patients and their doctors by the end of May. The campaign appears to be gaining momentum. In the first week, the association collected more than 15,000 signatures online and more than 50 state and specialty medical societies joined the effort. But this campaign is focused on a long-term, permanent fix. Congress still needs to act this week to keep physicians from feeling the effects of a 21% Medicare pay cut.

NARR: The Senate voted early this week to proceed to a bill including a temporary delay to that 21% cut. The uncertainty over payments aside, physicians may soon have something to celebrate. Under the health care overhaul law, doctors can now use quality reporting mechanisms built into their licensing systems...that's instead of the Physician Quality Reporting Initiative. The so-called PQRI is used by Medicare to collect quality data, but it annoys many doctors. They see it as redundant...because they already collect similar data for other payment or to maintain their licenses. Details still have to be worked out with Medicare, but the new law probably means that physicians will have less bureaucracy and a more familiar way to report quality data. That's according to Dr. Christine Cassel, president of the American Board of Internal Medicine.

NARR: Stay tuned for more developments on these and other aspects of health reform now that it's the law of the land. And that's the Policy & Practice Podcast. I'm Todd Zwillich.

How will the health overhaul affect access to care...this year? Welcome to Policy & Practice, the weekly podcast from Global Medical News. I'm Todd Zwillich.

NARR: The federal government is planning to issue new regulations clarifying coverage for children with pre-existing conditions. The move comes after reports that the reform law, as written, didn't live up to lawmakers' promises guaranteeing broad access for kids. There was some concern that insurers might capitalize on what appeared to be a loophole. The Obama Administration said it would issue new rules making it clear that children with pre-existing conditions must have access to their parents' health insurance starting in September. Health plans also can't deny coverage once those kids are insured. America's Health Insurance Plans, the industry's main lobbying arm, quickly promised to follow the new rules.

NARR: Meanwhile ADULTS with pre-existing conditions are also getting some relief this year. Help comes in the form of temporary state-based high risk insurance pools required under the reform law. The pools cover uninsured people with pre-existing conditions at standard individual-market premium rates. Last week, HHS asked states how they plan to work with the feds to set up those new rules. The program is expected to be up and running in less than 90 days. HHS Secretary Kathleen Sebelius said pools will act as a bridge until pre-existing exclusions are lifted for adults in 2014.

Sebelius AX: "When it's up and running the new high risk pool program provides immediate relief for potentially millions of Americans with pre-existing conditions like diabetes or high blood pressure who have been shut out of the insurance system."

NARR: The Obama Administration is not alone trying to convince Americans that health reform was a good move. One big fear . .. the law will add to the deficit because it doesn't do enough to control costs. At a forum last week in Washington, House Majority Leader Steny Hoyer of Maryland said he believed in the Congressional Budget Office estimates saying reform could indeed cut the deficit. But, he also said, it would take strong political will to make sure health spending does not outrun those estimates.

Hoyer AX: "Those savings, however, in part, are contingent on Congress keeping its pledge and taking hard votes to control health care costs in the years ahead. The Congress does not have a good track record on that objective."

NARR: Hoyer and his Democratic colleagues have a big sales job ahead of them...including winning over physicians aggravated about a 21% cut in Medicare fees. Those cuts technically went into effect April 1st. The Medicare program is holding all payments through April 14th in hopes that Congress will reverse the cuts when they return to Washington next week. And that's the Policy & Practice Podcast. I'm Todd Zwillich.

NARR: A new chapter in health reform.... implementation. Welcome to Policy & Practice, the weekly podcast from Global Medical News. I'm Todd Zwillich.

NARR: The bulk of the health care overhaul that Democrats proposed more than a year ago is now law. The President is expected to sign the bill making final corrections to the package this week. Mary Ellen Schneider has more:

Mary Ellen: After the political heavy lifting it took to get the Senate-passed health reform bill through the House, the effort to move a corrections bill through both chambers was almost anti-climactic. The 153-page bill won a majority in the Senate in just three days and then was passed by the House within hours. But this smaller bill has real significance for physicians, especially those in primary care. It will bring Medicaid rates up to at least the same levels as Medicare for primary care in 2013 and 2014. That's essential, physicians say, as more people join Medicaid under the new law.

NARR: With the health reform deal now done, supporters and opponents are looking ahead to its implementation. There are definitely efforts afoot to try to overturn the bill entirely. But at least one group of opponents will be working to make the law a success. Health insurance companies were painted as the enemy by the Obama Administration. But they're now part of a coalition working to get people benefits under the new law. A group called Enroll America will try to make sure the sign up process is easier for people...who could otherwise fall through the cracks. Families USA is part of the coalition with the insurance companies. President Ron Pollack said he expects broad support for the effort because insurers and others stand to benefit.

Pollack AX: "You know, you can get 30-40 million people newly enrolled, that's 30 to 40 million more people with whom they're doing business. That's true of the pharmaceutical companies, and the hospitals, and the doctors. So I don't think this is a stretch at all. Quite the contrary, it makes absolute and abundant sense for this to be a very cooperative effort."

NARR: Physicians lent their cooperation throughout the health reform debate. But now they're feeling...kind of snubbed. Congress left town for a two week recess without addressing the Medicare physician fee fix. As a result, a 21% cut in pay goes into effect this week. The American Medical Association called that unconscionable and it said a recent poll indicated that a majority of doctors may now limit the number of Medicare patients they see. Medicare, meanwhile, said it would hold claims for the first 10 days of April. They are anticipating that Congress will return and reverse the fee cut.

NARR: Now Congress may have another health reform priority when it comes back from the Easter break. President Obama is expected to name a new chief for the Medicare and Medicaid program this week. That nominee has a big job. Many of the details of implementation will fall heavily on that office. And that's the Policy & Practice Podcast. I'm Todd Zwillich.

NARR: Health reform heads to the President's desk. Welcome to Policy & Practice, the weekly podcast from Global Medical News. I'm Todd Zwillich.

NARR: The House approved two pieces of health reform legislation in a marathon Sunday session. No Republicans voted in favor making it a narrowly won victory for Democrats. House members first passed the reform bill approved by the Senate in December. The president plans on signing that on Tuesday. Next, the House approved a set of changes that removed some controversial political deals and added increased subsidies for buying insurance. That fix-it measure, called reconciliation, must now be approved by the Senate.

NARR: Physicians' groups praised the House passage of what they called an imperfect but important piece of legislation. Dr. Lori Heim, president of the American Academy of Family Physicians, said her group will continue lobbying for improvements, including tort reform and larger bonus payments for primary care.

Heim AX: "This is a start. This is the beginning of changes that we have fought for for over 20 years as an academy, to increase access to high-quality, affordable health care. Our role as family physicians will be to help explain to the American public what is and is not in this bill."

NARR: Abortion was an issue that threatened to derail the bill at several turns. In a last-minute compromise that won over several pro-life Democrats, the president said he would address the issue by executive order. The Department of Health and Human Services would be directed to issue guidelines ensuring that federal money is not used for abortion under the new insurance programs created by the health overhaul.

NARR: Meanwhile, a permanent fix to the Medicare payment formula was not included in the final reform bill. But physicians are not giving up. AMA President Dr. James Rohack said he wants to see Congress approve a permanent fix to the flawed formula before they adjourn this session.

Rohack AX: "Repeated, short-term actions to delay this year's 21% cut, do not inspire confidence in physicians struggling to keep their practice doors open to Medicare patients. A new, informal online poll of physicians found that 68% will limit the number of Medicare patients they can care for this year if the cuts go through."

NARR: Physicians are still waiting for a temporary fix to forestall that that 21% cut. As of now, it's scheduled to go into effect April first. We'll be watching that and action in the Senate, which aims to finish reconciliation by Saturday. And that's the Policy & Practice Podcast. I'm Todd Zwillich.

NARR: Democrats mount a final push on health reform. Welcome to Policy & Practice, the weekly podcast from Global Medical News. I'm Todd Zwillich.

NARR: Months of uncertainty and maneuvering - and a changing political landscape - it's all putting Democrats in must-pass mode on health reform this week. But cost is a continuing concern for the bill. The Congressional Budget Office says the bill, passed by the Senate in December, will shrink the federal deficit by 118 billion dollars over the next decade. That's a somewhat cloudier outlook than when the bill first passed. At that time, around Christmas, CBO said the bill would save around 132 billion dollars. Republicans continue to say the reform package is full of budget gimmicks that will actually add to the deficit. Henry Aaron, a senior fellow at the moderate Brookings Institution, disagrees and says the bill lays the groundwork for containing costs.

Aaron AX: "Judging this bill as the be all and end all is a mistake. It is a first step on a long journey to reign in uncontrolled growth in a 2.6 trillion dollar industry. It's not an easy job, a lot of interests are involved, and care has to be exercised."

NARR: Meanwhile, in a move that is sure to add to the deficit, the Senate passed yet another temporary delay in the scheduled 21 percent pay cut to physicians' fees. The delay was part of a larger bill that extends COBRA insurance subsidies and unemployment benefits. If the bill passes the House, the Medicare fee cut would not go into effect until October first. But physicians are still fuming at Congress and its inability to permanently fix the Medicare fee formula. The American Medical Association called the Senate's action a band-aid. And as the years tick by, the cost for a permanent solution is mounting, according to the AMA.

NARR: Meanwhile the battle between insurance companies...and the White House has many chapters. The latest is being written right now as President Obama pushes for a health bill this week. Here's Mary Ellen Schneider with more:

Schneider: It's been going on for weeks-but the temperature started to rise as the President got more vocal. He's been hitting health plans hard over rate hikes as he delivers a series of campaign-style speeches promoting health reform. Now America's Health Insurance Plans-the industry's lobbying arm-- is fighting back with a million-dollar TV ad campaign. One ad says that health plans account for only about 4 percent of health costs...and that doctors, hospitals, medicines, and tests make up the bulk of the health care spending pie. If politicians want to bring down costs, they should focus on the real drivers, the ad says.

NARR: President Obama has delayed a scheduled trip to Indonesia and Australia to concentrate efforts on health reform. The House could cast votes at the end of the week. And that's the Policy & Practice Podcast. I'm Todd Zwillich.

NARR: New deadlines and new ideas energize the health reform debate. Welcome to Policy & Practice, the weekly podcast from Global Medical News. I'm Todd Zwillich.

NARR: Health reform is back on the top of the agenda. Last week President Obama urged lawmakers to schedule an up or down vote on comprehensive reform in a matter of weeks. With the new deadline, House and Senate leaders are scrambling to line up votes. To get it done it appears they will use a procedure known as reconciliation...to pass portions of the reform package with only 51 votes in the Senate. The President appears undeterred by passing the package by a simple majority.

Obama AX: "Now it deserves the same kind of up or down vote that was cast on welfare reform, that was cast on the children's health insurance program, that was used for COBRA health coverage for the unemployed, and by the way for both Bush tax cuts, all of which had to pass Congress with nothing more than a simple majority."

NARR: The President also signaled he wants to include a few more Republican ideas in the final bill, including more money to test malpractice reform ideas.

NARR: Showing interest in liability reform is likely to win the president a few points with physicians. HHS Secretary Kathleen Sebelius tried to entice a gathering of the American Medical Association by telling physicians that the Administration is looking into how malpractice insurers do business. Sebelius said payouts for malpractice claims are continuing to fall while the premiums doctors pay keep rising. She vowed a thorough examination of loss ratios at the big malpractice insurance companies. Her idea was met with muted applause. Many of those companies are owned by physicians who share not only in the losses, but also in the profits.

NARR: Doctors were only slightly happier that Congress finally found a way last week to delay the 21 percent cut in Medicare fees. Mary Ellen Schneider has more.

SCHNEIDER: Congress missed the March first deadline, but came together a day later to approve a bill that extended current pay rates until April 1. President Obama signed the bill into law the same night it passed. But physicians are not satisfied. They are still looking for a permanent replacement for the Medicare's sustainable growth rate, or SGR. Some physicians have started to be more vocal in their protests, suggesting that they will stop seeing Medicare patients if there is no fix soon. The AMA, has been more measured and continues to urge the Senate to come up with a replacement for the SGR within the next month.

NARR: But the pay fix may get put off again. Given the President's health care deadline, the Congress will likely be consumed with that effort over the next few weeks. And that's the Policy & Practice Podcast. I'm Todd Zwillich.

NARR: A missed deadline and a big fee cut. Welcome to Policy & Practice, the weekly podcast from Global Medical News. I'm Todd Zwillich.

NARR: Physicians are looking at a temporary stop in Medicare payments for the next two weeks, thanks to a failure in Congress to act by a March 1st deadline. Medicare fees were due to be cut 21% on that day. Lawmakers have tried several times to change the formula dictating the cuts, that formula is called the sustainable growth rate. The House came close again before the weekend, passing a bill that would put the cuts on hold for one month. But Republican Senator Jim Bunning of Kentucky blocked that proposal. Legislators now have to find another way to fix the reimbursement problem.

NARR: Meanwhile, physicians are angry that they've been left again with an uncertain pay rate. Dr. Joseph Stubbs, president of the American College of Physicians, said the consequences may be dire.

STUBBS AX: "Physicians are for the most part, I think, tired of having to deal with this inconsistency and lack of a solution year after year after year and I think what you're going to be seeing is a number of physicians are simply going to say that until Congress fixes the situation they will not be accepting new Medicare patients."

NARR: Anger was also on display at President Obama's long-awaited health summit last week. The president didn't appear to convince any Republicans to join Democrats in supporting the current health reform bills. Here's Joyce Frieden with more.

JOYCE: The 7-hour session began with the President urging the participants to listen and not just try to score political points. But the 36 House and Senate leaders still spent much of their time playing to their bases. Tennessee Republican Senator Lamar Alexander asked Democrats to start over and to forsake reconciliation. North Dakota Democratic Senator Kent Conrad tried to stir up enthusiasm for his side, saying that if Congress did nothing, it would endanger Medicare. One glimmer of compromise appeared when Republican Senator Mike Enzi of Wyoming said that although no health plan offered in a health insurance exchange should be required to meet any coverage standards, the federal government could still develop suggested minimum standards and then designate which plans met them. But by the end of the day, President Obama was forced to admit that there was no agreement on a central tenet: how to cover the 30 million uninsured, as well as the insured who have preexisting conditions but are gradually being priced out of the market.

NARR: Democrats and Republicans in the House did then put aside some differences to deal blow to the health insurance industry. In a 406 to 19 vote, the chamber stripped health plans of their exemption from antitrust laws. The bill's supporters said the move made good common sense and would make health plans more accountable. But America's Health Insurance Plans, the lobbying arm of the health insurance industry, said the bill is aimed at stopping abuses like price fixing, that are already prohibited. The group also said the bill could have unintended consequences like preventing health plans from working together to reduce paperwork and improve quality. The antitrust issue has yet to be addressed in the Senate.

NARR: Insurance companies meanwhile will be on the hot seat again this week. The administration has invited CEOs from five large health plans to come to Washington on March 3 to talk about insurance premiums and health reform. And that's the Policy & Practice Podcast. I'm Todd Zwillich.

NARR: It's the deadline for Medicare payments to physicians. Welcome to Policy & Practice, the weekly podcast from Global Medical News. I'm Todd Zwillich.

NARR: Physicians are anxiously awaiting congressional action this week. Unless the House and Senate act, doctors will be hit with a 21% reduction in Medicare fees on March 1st. The American College of Physicians says Capitol Hill staffers have guaranteed that something will be done this week to avoid the cuts . But that promise rings hollow for ACP president Joseph Stubbs. He says doctors see Medicare's payment system as flawed, and they've given up trying to run their businesses based on temporary fixes to it.

STUBBS AX: (32:07 to 32:16, or 9 seconds) "What are we supposed to do if we're sitting there with maybe or maybe not a twenty-one percent cut and if we don't have a twenty-one percent cut for how long will we not have a twenty-one percent cut?"

NARR: Stubbs says a congressional reprieve won't make up for years of declining rates.

STUBBS AX: (32:28 to 32:41, or 12 seconds) "At best we're hoping a victory is a freeze. A freeze is zero percent increase over four or five years. It's simply untenable for the practicing physicians out there who are trying to do a good job of taking care of patients."

NARR: In the meantime, health insurers may be wishing Congress and the administration would pay a little less attention to them. The Obama administration released a report drawing attention to some of the double-digit rate increases recently sought by health plans and the massive profit those same plans are earning. Health and Human Services Secretary Kathleen Sebelius has taken the lead in hammering health plans. She said the plans' practices are just another reason the country needs reform.

Sebelius AX (18 sec.): "This kind of rate increase gives a highlight to why the President said a year ago we need to address health reform, comprehensive health reform, as part of addressing the economy. We won't fix the economy without fixing our health care system."

NARR: But America's Health Insurance Plans, the industry's main lobbying group, says that Democrats are just playing politics and that they should stop vilifying the industry. And while all of this is going on, President Obama is trying - once again -- to re-energize the push for health reform. The White House is hosting a summit on Thursday with Congressional leaders. The president released his own plan calling for health reform. His plan has a lot in common with the reform measures passed already in the House and in the Senate -- but also some changes. The president's plan throws out a special Medicaid deal for the state of Nebraska negotiated by Democratic Senator Ben Nelson in exchange for his "yes" vote on the bill. It closes the so-called "donut hole" in the Medicare prescription drug benefit, and it raises the level at which high-cost plans, or so-called "Cadillac" health plans, will be taxed. But it does not include a public option, and makes little mention of well-known proposals offered by Republicans, such as tort reform.

NARR: The half-day summit will be televised, but some critics are saying it will be little more than a chance for members of Congress to put on a show for their constitutents - that means not an opportunity to get any actual work done. Stay tuned. And that's the Policy & Practice Podcast. I'm Todd Zwillich.

NARR: President Obama seeks compromise, not capitulation on health reform. Welcome to Policy & Practice, the weekly podcast from Global Medical News. I'm Todd Zwillich.

NARR: President Obama is looking to gin up some enthusiasm for the health reform summit he's having with members of Congress later this month. In a surprise press briefing with reporters, the president said that agreeing on a basic set of facts will be step one... to reaching bipartisan compromise on a health bill.

AX Obama (36 secs.): "If it's established that by working seriously on medical malpractice and tort reform that we can reduce some of those costs, I've said from the beginning of this debate, I'd be willing to work on that. On the other hand, if I'm told that that is only a fraction of the problem and that is not the biggest driver of health care costs, then I'm also going to insist, okay, let's look at that as one aspect of it, but what else are we willing to do?.

NARR: As the administration repackages its health reform message, insurance companies are once again the target. Here's Mary Ellen Schneider with more:

Mary Ellen: It started last week when Health and Human Services Secretary Kathleen Sebelius sent a strongly worded and well publicized letter to Anthem Blue Cross demanding to know why the California health plan was raising its premiums by as much as 39%. The health plan responded by saying that healthy people are opting out of coverage leaving Anthem to cover a sicker pool of people. They added that the increases are in line with state law and affect only individuals and not group plans. Apparently, that wasn't good enough for Secretary Sebelius, who responded that Anthem's decision to raise its rates demonstrates "the urgent need for real reforms."

NARR: The House Energy and Commerce Committee is scheduled to examine Anthem's rate hike at a February 24th hearing. In the meantime, Congress has to find a way to prevent...or at least stall...a scheduled 21% cut to doctors Medicare payments. And that's the Policy & Practice Podcast. I'm Todd Zwillich.

NARR: The president's vision for health care...while reform waits in the wings. Welcome to Policy & Practice, the weekly podcast from Global Medical News. I'm Todd Zwillich.

NARR: President Obama has released his proposed budget for 2011, requesting hundreds of billions of dollars for federal health programs, like Medicare, Medicaid, and the Children's Health Insurance Program. What's missing is any kind of focus on health reform. This is in stark contrast to last year, when his proposal centered on a 600 billion-dollar-plus set aside to get health reform done. This year's proposal still contains many elements that are consistent with reform and are good for doctors, says Dr. Lori Heim, president of the American Academy of Family Physicians. She praised a proposal to increase funding for the National Health Service Corps.

Heim AX: "That opens up an additional 449 opportunities for new physicians. And we know that those physicians provide care in rural and underserved areas. So I think that that's been an important part of encouraging medical students to go into primary care."

NARR: The HHS budget was also the main topic on Capitol Hill last week. Senate Finance Committee Chairman Max Baucus said that he was pleased that President Obama's proposal assumed passage of health reform. Baucus sees another plus: the budget assumes reform could cut the deficit by $150 billion over the next ten years. Baucus urged his colleagues to continue their reform efforts. HHS Secretary Kathleen Sebelius -- emphasized that the budget did not cut Medicare payments to physicians. And she said, HHS supports an overhaul of the Medicare physician payment formula so that the yearly debate over how much to pay doctors could end.

NARR: Health reform may reduce the deficit, but it's not clear how it will affect the ever-increasing rate of health spending. The latest projections were released last week. For more on the estimates, here's Alicia Ault.

AULT: Medicare's actuaries are projecting that, barring any change, spending on health care will outpace the annual growth in the economy over the next 10 years. By 2019, the nation's $4.5 trillion health bill will make up 19% of the gross domestic product. Last year, spending took a big jump, as the recession drove growth in Medicaid enrollment. Spending also rose as more people took advantage of the government's health insurance subsidy for the unemployed. If the Congress votes to keep Medicare physician pay at 2009 levels, total health spending will grow just under 5% this year, or about a percentage point less than last year. But that outlook could change - with the passage of a reform plan, or with any change to the Medicare physician pay formula.

NARR: Health reform, or at least a piece of it, will likely be front and center on Capitol Hill next week. The House looks at repealing the anti-trust exemption for health insurance companies and medical malpractice providers. It's part of a strategy to pass smaller-and Democrats hope-more popular parts of the health reform bill to avoid losing all their momentum. And that's the Policy & Practice Podcast. I'm Todd Zwillich.

NARR: The President shifts his focus from health reform...to health INSURANCE reform. Welcome to Policy & Practice, the weekly podcast from Global Medical News. I'm Todd Zwillich.

NARR: As expected, health care did come up during President Obama's State of the Union address last week....but not until about 32 minutes into the speech. Although jobs and the economy were his early focus, the President said that America still needed what he called "health insurance reform." He refrained from giving Democrats any specific direction on how to pass a bill in the wake of their recent loss of a 60-seat majority in Congress. Instead, he simply urged everyone to press on:

AX OBAMA (16 secs.): "Here's what I ask Congress, though. Don't walk away from reform. Not now. Not when we are so close. Let us find a way to come together and finish the job for the American people. Let's get it done."

NARR: In his opposition response, Virginia governor Bob McDonnell said Republicans had already offered ideas for reform, including letting families and businesses buy health insurance across state lines and reforming the tort laws. He chided the Democrats, saying the huge bill was been fully read by anyone, and that was crafted behind closed doors with special interests.

NARR: A broad coalition of unions, patient advocates, and physician organizations gathered the day of the speech...urging the President and Congress to keep working. They proposed several pathways for passing a reform bill. One was for the House and Senate should finish negotiations on the Senate-passed measure and find enough compromises to win approval in the House. Or, legislators could use reconciliation, they said. That process would include reform provisions that affect the budget, but would leave out many other policy changes. Congress should find a way to bring lawmakers together, even if it takes awhile, said Dr. Jack Lewin. He's president of the American College of Cardiology.

Lewin AX: "Let's get it done this year. Let's take this year in the congress and really have...and fix and develop a greater consensus. And maybe even more of a bipartisan consensus. Certainly between the democratic party constituencies, let's get the Blue Dogs and the rest of the democratic party together on the issues."

NARR: Physicians aren't willing to wait a year, however, to fix the Medicare payment formula, known as the sustainable growth rate, or SGR. In raising the national borrowing limit last week, the Senate made a promise to set aside enough money to avoid physician fee cuts for five years. But that promise still has to gain approval in the House and then...Congress has to agree to actually spend the money. This year's 21 percent cut will go into effect March 1 unless Congress acts. And that may not happen until late February.

NARR: House Speaker Nancy Pelosi said last week that she might break off some bits of the House and Senate bills and bring them to the floor by mid-February. But she said she was not giving up on a bigger reform package. There's guaranteed to be more maneuvering this coming week. That's the Policy & Practice Podcast, I'm Todd Zwillich.

NARR: The urgency for health reform gives way...to urgency for Medicare reform. Welcome to Policy & Practice, the weekly podcast from Global Medical News. I'm Todd Zwillich.

NARR: Last week began with the news that Massachusetts State Senator Scott Brown had pulled off an upset victory over the Democratic candidate for Ted Kennedy's vacant Senate seat. Alicia Ault has more on the chaos that followed.

AULT: Democrats found themselves blind sided - unprepared for what might happen if they lost their filibuster-proof majority. Now, with one less Democrat to vote in favor of health reform, party leaders are frantically weighing options to get a package passed. Defections began fast, with some Senate Democrats suggesting scaling back the already-passed bill. Others suggested the House quickly pass the Senate bill wholesale before the new senator was sworn in. But House Speaker Nancy Pelosi said that her Democratic colleagues would not vote for the Senate-approved plan. President Obama told an interviewer that he might accept a less-sweeping package, but that he preferred the broad plan. And perhaps slowing down the process.

NARR: While Congress considers what to do about the long term, the American Medical Association is more concerned about the short term -- specifically, an imminent 21% cut in Medicare payment rates. Under the current formula, known as the SGR, or Sustainable Growth Rate, the cut was supposed to take effect January 1st. But Congress delayed it until March 1st. Last week, in a multi-city press conference held jointly with the AARP and the Military Officers Association of America, the AMA called on Congress to permanently repeal the SGR at a cost of $200 billion. The AMA's Dr. Nancy Nielsen said the formula should be changed now before fixing it gets even more expensive.

NIELSEN: And so it's time now that Congress work with us and try hard to figure out how we're going to permanently repeal this, because to not do it now is fiscally irresponsible.

NARR: If Democrats do try to revamp their plans on health reform, they may want to pay more attention to nurses. At least that's what a new Gallup poll commissioned by the Robert Wood Johnson Foundation suggests. Gallup asked more than fifteen hundred leaders in government, health care, the insurance industry, and academia if they'd like to see nurses have more influence over health policy. More than eighty-five percent said nurses should have more clout when it comes to reducing medical errors, increasing quality, and promoting wellness and prevention. When asked what kept nurses from taking on an expanded role, sixty-nine percent said nurses aren't seen as decision-makers the way doctors are.

NARR: Well, the Massachusetts election seems to have reset at least part of the process in Washington, even though it appeared to be near its end just a couple weeks a go. We'll be following all of the agreements ... and the controversy ...including the President's State of the Union speech this week. And that's the Policy & Practice Podcast. I'm Todd Zwillich.

NARR: Crunch time for the Democrats health care plans. Welcome to Policy & Practice, the weekly podcast from Global Medical News. I'm Todd Zwillich.

NARR: Time seems to be running out for Democrats to iron out their differences and get a final health reform bill to President Obama. The President called Democratic leaders to the White House last week to reach a consensus. And labor union leaders went there too to protest the tax on high-cost health plans included in the Senate's bill. Congressional leaders agreed to delay the so-called Cadillac tax until unions can renegotiate their health benefits. That delay lasts until 2017. They also agreed to exempt more people from the tax and to shelter plans with larger numbers of women and seniors. Matt Coffina [Co-FEENA], a health insurance industry analyst at Morningstar, says the tax likely won't be a big problem for health plans' bottom lines.

AX Coffina (14 seconds): "So probably it's going to have a relatively small impact on health plans. The threshold above which the tax takes effect is going to be I think almost two times the average premium in the country."

NARR: With final deals seeming to fall into place, physicians and other health providers are looking to shore up their payments under Medicaid. A coalition of provider groups recently sent a letter to congressional leaders urging them to boost Medicaid rates for primary care in the final health reform bill. Higher rates are vital, they said, if Congress plans to dramatically expand Medicaid. The House bill increases Medicaid rates for primary care to Medicare levels over a four-year period. But the Senate bill would leave Medicaid rates as they are-and that's just not acceptable, say doctors. Dr. Joseph Stubbs, the president of the American College of Physicians:

AX Stubbs (9 seconds): "Physicians are anxious to take care of patients but the rates have to be something that does not actually cost us money to do so."

NARR: Doctors' wishes may go unfulfilled, however. In fact, the entire health reform effort is threatened by Tuesday's Senate election in Massachusetts. Voters are choosing a successor to the late Ted Kennedy, a Democrat and staunch health reform supporter. After early leads of as much as 30 points in the polls for Democrat Martha Coakley, the race is now a dead heat with GOP state Sen. Scott Brown. Brown has said that if he's elected, he'll vote against health reform. That has Democrats scrambling to get the work done before the Massachusetts winner is certified and sworn in to the Senate.

NARR: In Washington, Democrats want to have health reform done in time for the President's State of the Union address. But here's a sign of just how fluid the situation is. The annual speech usually takes place in late January. But with health reform still undone, Congressional leaders STILL haven't scheduled the speech. And that's the Policy & Practice Podcast. I'm Todd Zwillich.

It's a new year but an old issue. Congress is trying to wrap up health reform. Welcome to Policy & Practice, the weekly podcast of Global Medical News. I'm Todd Zwillich.

NARR: It appears that Republicans are running out of time in their fight against health reform legislation. Mary Ellen Schneider has more.

MARY ELLEN (30 sec): President Obama and Democratic congressional leaders announced last week that they agreed to forego a bipartisan formal House-Senate conference to reconcile the two reform bills. Instead, Democrats are informally going to negotiate amongst themselves. They'll then send the bill to the Senate for a final vote. Not surprisingly, Republicans objected, saying that the public would be left out of witnessing the process on this historic piece of legislation. But Democrats plowed ahead.

NARR: Democrats got some new ammunition for health reform...from a new government report. It showed that the overall rate of growth in health spending slowed in 2008 from the year before. But still health care costs far outpaced the economy's ability to support them. The report found that it's a bad economy...and some of the slowdown was simply because...a million fewer people have health coverage. Visits to physicians also dropped. Susan Dentzer is editor of the journal Health Affairs. She says reforms like the proposed employer mandate and a new health insurance exchanges are designed to tackle health care's vulnerability to the economy.

DENTZER AX (12 sec): "In the future, we wouldn't necessarily get into a situation where because there was a recession and because people lost coverage, the health sector would be hit and people would not be getting the health care they needed."

NARR: The health reform debate appears close to being finished...at least for now. So now experts are trying to decide just how proposed health exchanges would work. Both the House and Senate want to allow for some policies to be sold outside of the exchange, where regulation is much lighter. Insurance companies could still game the system by going outside the exchange and offering bare-bones policies that cater to healthier people...and THAT could leave sicker people inside the exchange, so says Timothy Jost [Yost] of Washington and Lee University. Jon Kingsdale, who runs the health exchange in Massachusetts, said some states don't want exchanges in the first place and will do everything they can to see them fail. And THAT could make the SENATE's plan of having states run the exchanges...problematic.

NARR: Democrats are once again battling the calendar as they seek to complete health reform before the President's State of the Union speech in just a few weeks. Stay tuned to see if they meet this goal and what compromises are struck along the way. And that's the Policy & Practice Podcast. I'm Todd Zwillich.

NARR: The President gets an early Christmas present....from the Senate. Welcome to Policy & Practice, the weekly podcast from Global Medical News. I'm Todd Zwillich.

NARR: In an early-morning session on Christmas Eve, the Senate passed its version of a health reform bill by a party-line vote - that was 60-39. One Republican was absent, and while Democrats hailed the bill's passage as historic, Republicans vowed to continue fighting the measure as it now moves on to a conference with the House.

NARR: Reactions from physician groups varied; Dr. Jack Lewin, CEO of the American College of Cardiology, said his group didn't take a position on the bill, but that it's glad that something is being done

AX Lewin (15 seconds): "The nation is going to bankrupt itself with health care unless we do something. Families won't be able to afford insurance premiums, businesses are finding insurance costs to be unaffordable, and Medicare will be bankrupted."

NARR: The final vote was a foregone conclusion by Christmas Eve. Still, Republicans tried until the final moments to derail the bill. Republican Senator John Ensign of Nevada made a last-ditch attempt to stop the measure, arguing the bill was unconstitutional. That's because of the requirement that all Americans purchase health insurance. Such a mandate is not authorized by any of the limited powers granted to the federal government, Ensign said. That was before the challenge failed.

NARR: But there's still plenty work to be done to get health reform to the President's desk. Here's Mary Ellen Schneider with more:

Mary Ellen: (42 seconds) The next stop for health reform is a House-Senate conference committee, where a select group of senators and representatives will have to reconcile the differences between the bills passed by the two chambers. Among the key sticking points -- what to do about the public plan and the abortion issue. Once the conference committee finds common ground, the bill must be approved again in both the House and Senate. But this time around there is no chance for amendment. Many Capitol Hill insiders have been speculating that the Senate version is likely to win out, given the fragile coalition formed there to pass it. But liberals in the House have been holding out hope that they can use the conference committee to tilt the bill back to the left.

The 111^th Congress returns for its second session in a couple of weeks. And that's the Policy & Practice Podcast. I'm Todd Zwillich. Our team -- Alicia, Joyce, Mary Ellen, Keith, Denise, and myself -- wish you a happy and healthy holidays. We look forward to bringing you the best in health reform news when we return on January 11th.

The Christmas rush is on for Democrats and their health reform plans. Welcome to Policy & Practice, the weekly podcast from Global Medical News. I'm Todd Zwillich.

NARR: As a self-imposed Christmas deadline crept ever closer, Senate Democrats were scrambling over the weekend to get their version of a health reform bill passed. After overcoming objections from Connecticut Independent Joe Lieberman and Nebraska Democrat Ben Nelson, Senate Majority Leader Harry Reid of Nevada managed to pull together his 60 votes. Now that allowed him to pass a motion to end debate on the bill without prolonging a Republican filibuster. The vote was taken at around 1:30 a.m. on Monday, an hour noted by Republican National Committee Chairman Michael Steele.

AX Steele (19 seconds): "The fact that they would have this vote at the dead of night to me speaks to a cowardice -- a cowardice that's reflected in this leadership in the Senate and quite frankly Democrats across the country."

NARR: Democrats, of course, responded that the early morning vote was the earliest possible time allowed by Republican delaying tactics. But Republicans weren't alone in their chagrin. It also became apparent that public support for the Democrats and their plan was slipping. Alicia Ault has more.

AULT: Both a Wall Street Journal/NBC News and a Washington Post/ABC News poll found that Americans were losing faith in Congress, President Obama and health reform. Fifty-one percent in the Post poll said they disapproved of the changes being proposed, up from 48 percent in October. Respondents also said they worried about costs going up and quality going down. In the Wall Street Journal poll, 44 percent said that it was better not to pass a plan at all.

NARR: With time winding down, Congress gave physicians relief from a 21 percent Medicare pay cut originally scheduled for January 1st. But that reprieve is only for two months-- theoretically buying lawmakers a little more time to work out a permanent fix. Doctors have been making the case that a permanent repeal of the Medicare physician payment formula is needed to provide predictability. Here's Dr. Lori Heim, she's president of the American Academy of Family Physicians.

Heim AX: "It's very difficult to do a business plan when you don't know what your payment's going to be. We need to have a stable planning process. That's how you get innovation."

NARR: Health reform has been far from stable so far this year. Things may get a little more predictable now that the Senate appears headed for a vote on Christmas Eve. After the holiday break, the action moves to a joint House-Senate conference where lawmakers will try to work out differences between the two bills. And that's the Policy & Practice Podcast. I'm Todd Zwillich.

NARR: Drugs from Canada...and Medicare for more. Welcome to Policy & Practice, the weekly podcast from Global Medical News. I'm Todd Zwillich.

NARR: Drug reimportation was a big topic last week as the Senate continued its debate on health reform. Senator Byron Dorgan, the North Dakota Democrat, wants to allow reimportation of less-expensive prescription drugs from other countries. Some lawmakers had praise for the bill for its cost-cutting potential, but FDA Commissioner Margaret Hamburg repeated what the agency said during the Bush Administration - that reimportation raises safety concerns. Others questioned whether the measure would undercut a deal between the Obama administration and drugmakers worth 80 billion dollars on the health reform bill. At a press briefing, Michigan senator Debbie Stabenow said that while she would like to see Dorgan's reimportation measure in the final bill, for her, it was not a deal-breaker.

AX Stabenow [17 secs.]: "I think all of us in the caucus are united to make sure that even if there are things we need to come back and work on later, such as has been done with every other major reform that has ever passed, we can't let anything get in the way of the larger goal."

NARR: Meanwhile, the debate over the public option continued, but with a new wrinkle: a proposal to drop a publicly run health plan in favor of several non-profit nationwide health plans administered by the federal government. The proposal opens up Medicare to adults 55 to 64. Some senators say they won't vote for a bill that doesn't keep a public option, but others seem willing to trade off that provision for the Medicare buy-in. At the same time, more conservative members of the Democratic caucus, including Connecticut senator Joe Lieberman, spent the weekend tossing cold water on the idea of that Medicare buy-in.

NARR: And while some lawmakers discussed opening up Medicare to more people, one issue was notably absent from the debate this week: how much Medicare will pay doctors. Alicia Ault has more:
ALICIA: Without congressional action, physician fees will be reduced by 21% starting January 1st. Efforts to eliminate the fee formula have passed the House but have gone nowhere in the Senate. Bob Doherty, a lobbyist for the American College of Physicians, says it's looking more likely that Congress will pass a short-term stop-gap solution to prevent the cut. He predicts that Congress will extend the 2009 pay rate into the first few weeks of the new year. Then, in late January, Congress will revisit the fee formula. But organized medicine is not giving up. It still hopes to put a stake in the heart of the formula, sooner rather than later.

NARR: The Senate is awaiting Congressional Budget Office estimates on the costs of the reimportation and Medicare buy-in proposals. Democratic leaders are sticking by their goal of wrapping up everything by Christmas. And that's the Policy & Practice podcast; I'm Todd Zwillich.

NARR: The health care reform debate plods along. Welcome to Policy & Practice, the weekly podcast of Global Medical News. I'm Todd Zwillich.

NARR: It took Senators nearly four days to cast their first votes to amend the health reform bill. As expected, Republicans are trying mightily to slow down the process while Democrats are working hard to speed it up.

NARR: One of the first amendments to pass requires all health plans to cover preventive services for women. It was a response to a controversial set of recommendations by a federally appointed task force, which said that screening mammograms should not be routinely done in women age 40 to 49. Republicans seized on the recommendations as evidence of the kind of rationing that would be commonplace under reform.

NARR: At a House hearing on the task force controversy, GOP members repeated the accusation. But Michigan Democrat John Dingell called their assertions fairy tales and said he wanted to set the record straight.

DINGELL AX: (58:00 to 58:22) "The bill does NOT in its provisions behave as my Republican colleagues would have us believe. It does NOT use these kinds of recommendations to suppress treatment or interfere with the relationship between the patients and the doctors."

NARR: The White House, meanwhile, was doing some defensive maneuvering of its own. Joyce Frieden has more.

JOYCE: White House Budget Director Peter Orszag argued that the Senate bill does a lot more to reform health care than some people think. For example, having a Medicare commission constantly proposing cost-cutting ideas will counterbalance efforts by Congress to get around the rules as it has repeatedly with Medicare physician fee updates. And the bill would allow more innovation because it lets Medicare roll out successful test projects nationwide without Congressional approval.

NARR: Orszag's former employer, the Congressional Budget Office, weighed in last week with some fresh cost estimates for the Senate bill. Essentially, CBO said, health insurance premiums would be slightly higher for individuals than if the status quo was maintained. But a BlueCross BlueShield study claimed that premiums could rise as much as 54% for individual buyers. That's because the bill doesn't do enough to attract all comers, and thus spread the risk. Alissa Fox, a top lobbyist for the Blues plans, explained:
FOX AX: (0:58 to 1:12) "The penalties to purchase and obtain coverage are very weak and because of that, young healthy people we estimate, many of them, are likely to forego coverage."

NARR: Fox said that the Blues believed there was still time to change the bill on the Senate floor. That's possible, since Majority Leader Harry Reid of Nevada is forcing his colleagues to work weekends in hopes of passing a final bill by a Christmas deadline. But Illinois Senator Dick Durbin, also a member of the Democratic leadership, predicts that abortion and the public option will be major obstacles to passage. And that's the Policy & Practice Podcast. I'm Todd Zwillich.

NARR: In the Senate, health reform has finally jumped out of the starting gate. Welcome to Policy & Practice, the weekly podcast from Global Medical News. I'm Todd Zwillich.

Up until a couple of hours before the vote on Saturday...it still wasn't clear whether Harry Reid would have the 60 Democratic caucus members he needed to put the health reform bill on the floor. He got his 60, and now...health reform is set for a full debate right after Thanksgiving.

The bill is on the floor. But it's not coming off unless it changes. A lot. That's the promise from conservative and moderate Democrats and Independents who say they won't vote again for the bill...until the public option goes away or is changed, until abortion language is tightened, and until the cost comes down. .

Nebraska Democrat Ben Nelson is one of them.

AX: Well, nuances won't be enough to get 60 votes. My hope is that the kinds of things I've laid out will be changed and to my satisfaction.

NARR: The Senate bill has a direct effect on how doctors get paid. The bill gives internists, family physicians, and geriatricians a 10 percent bonus payment for 5 years on their Medicare charges for primary care services. General surgeons working in physician shortage areas also get a 10 percent boost for major procedures. But those pay raises come at a cost for doctors in other specialties. For them, payments are cut half a percent across the board to fund the bonuses.

NARR: On the other side of the Capitol, the House passed its bid to permanently replace the Medicare physician pay formula known as the Sustainable Growth Rate. The bill lets spending rise each year at the same rate as the gross domestic product plus one percent.

NARR: Physicians will have a tougher time getting the pay fix passed in the Senate, where a similar bill already failed. Dr. Nancy Nielsen is past president of the American Medical Association. She told reporters last week that the AMA will work hard to convince deficit hawks that passing the pay fix is fiscally responsible. The AMA leadership appears to be holding firm on its commitment to a health overhaul, despite the ups and downs of the pay fix. But if Congress ultimately fails to fix physician pay, Dr. Nielsen thinks it would hurt lawmakers' credibility.

AX Nielsen (11 seconds): "The real issue is can everybody believe Congress in terms of what it's trying to do if they won't fulfill existing obligations."

NARR: Congress is gone for Thanksgiving, but it's not all turkey and football. Negotiations are already underway for a long list of amendments. They're expected to hit the floor next week. And that's the Policy & Practice podcast; I'm Todd Zwillich.

NARR: Congress takes a breather...but the health reform debate continues. Welcome to Policy & Practice, the weekly podcast of Global Medical News. I'm Todd Zwillich.

NARR: While the House and Senate paused for Veterans Day, physician groups were considering their options following a contentious meeting of the American Medical Association. A coalition of physicians opposed to the House-passed health reform bill challenged the AMA's backing of that package. But the AMA's policy-making body voted to continue its support. David Cook, speaking for the group opposing the House bill, said the coalition planned to keep working for changes in the legislation.

AX Cook [14 seconds]: "We're going to continue to do what we've done in the past. We have some significant concerns about the public option and those kinds of things, and we'll continue to voice those concerns as we move forward."

NARR: Cook said the group was pleased with two other votes at the AMA meeting. One backed private contracts between doctors and patients. The other put AMA firmly in opposition to cuts in payments to specialists as a way to increase payments to primary care physicians. That transfer of dollars from specialists to primary care is already a reality for Medicare next year.

NARR: Another contentious issue -- abortion -- did not come up in the AMA discussions. The House agreed to bar federal payment for abortion, even for women in the health insurance exchange. The question of how and whether abortion should be covered is expected to be a major issue in the Senate, also. Alicia Ault has more.

AULT: Pro-choice advocates are still reeling from the passage of the Stupak-Pitts amendment in the House bill. The coverage-barring amendment is "appalling," said Dr. Suzanne Poppema, board chair of Physicians for Reproductive Choice and Health. Dr. Poppema said it wasn't clear if the Senate would adopt the same language. If it does, women would be denied what Dr. Poppema and her colleagues have deemed a safe and often necessary medical procedure. But Dr. Donna Harrison, president of the American Association of Pro-Life Obstetricians & Gynecologists, applauded the House amendment and said that funding abortion has no place in health reform.

NARR: Meanwhile, the Senate has yet to unveil its final bill. Majority Leader Harry Reid of Nevada is waiting for the Congressional Budget Office to provide cost figures on the bill he cobbled together from two Senate committees. A Reid staff member said the senator hopes to hear back from the budget office early this week. He aims to get the bill to the floor for a vote soon after that. But Senate Minority Leader Mitch McConnell of Kentucky said he and his Republican colleagues will take their time in analyzing the bill before they agree to a floor vote. And that's the Policy & Practice podcast. I'm Todd Zwillich.

NARR: What's that snapping sound you hear? It's the sound of coalitions splintering over health reform. Welcome to Policy & Practice, the weekly podcast from Global Medical News. I'm Todd Zwillich.

NARR: After hours of debate, the House passed its health reform bill by a vote of 220 to 215. Only one Republican broke ranks to vote yes for H. R. 3962. But there was a deep divide among Democrats - - over abortion. A bipartisan amendment to bar abortion coverage in the public plan -- with a few exceptions - passed easily with votes from both parties. The amendment also bars private plans operating on a new insurance exchange from offering abortions, if customers use any government subsidies. Pro-choice lawmakers, like Dianna DeGette, of Denver, were furious.

AX DeGette: "This is a vast expansion of choice restrictions, it's probably the biggest restriction on a woman's right to choose that will have been considered on the House floor in my career."

The Senate's bill - still awaiting a floor vote -- is not as restrictive but does prohibit the use of government funds for abortion. Language on abortion payment will likely present a major hurdle when the House and Senate convene to hash out a compromise.

Meanwhile, Monday, DeGette warned that at least 40 pro-choice Democrats will vote NO on a final version of the bill, if the abortion amendment remains.

NARR: In the days leading up to the vote, the House bill got some high powered support from the AARP and the American Medical Association. In a conference call, AMA President James Rohack said his group was backing H. R. 3962. But he stopped short of a hearty endorsement.

Rohack AX: "H. R. 3962 is not a perfect representation of the AMA's view, but it's consistent with enough of our goals to warrant support to keep the process moving."

NARR: Dissatisfied with the AMA's approach, physician groups have begun splintering off. At the AMA's own policy setting meeting, a handful of state medical and neurosurgical societies, and a general surgical society introduced a resolution to rescind AMA support for the House bill. And the American College of Surgeons led 19 other surgical groups in opposition to the Senate bill. Among their objections to that bill: its failure to permanently fix the Sustainable Growth Rate formula that guides Medicare payment. Joyce Frieden has more.

FRIEDEN: The House has proposed to overhaul th e SGR formula in a stand-alone bill. Physicians will face a 21% pay cut next year unless Congress takes action. House Majority Leader Steny Hoyer of Maryland is pushing for a permanent change, instead of continuing to approve a fix every year.

AX Hoyer [16 seconds]: "We in the House want to do a permanent fix. The doctors very much want a permanent fix so they don't have to try to plan from year to year as to what reimbursement rate they're going to have. And we're hopeful the Senate will adopt our bill."

NARR: Hoyer said the House plans to vote on an SGR fix next week. Meanwhile, President Obama is pushing the Senate to take up its health reform bill as soon as possible. But there's not a lot of time to get it done. The Senate is taking off several days this week for Veterans Day, then a week-long recess for Thanksgiving starting November 23rd. Look for some kind of action on health reform next week. And that's the Policy & Practice podcast. I'm Todd Zwillich.

NARR: Lawmakers inch closer to a showdown on health reform. Welcome to Policy & Practice, the weekly podcast from Global Medical News. I'm Todd Zwillich.

NARR: Congressional Democrats talked a lot about history last week-specifically, the history they plan to make on health reform. House and Senate leaders unveiled the bills they will send to the floors of their chambers. They had added to, and in some cases thrown out, proposals that congressional committees spent the last several months crafting. Mary Ellen Schneider has more.

SCHNEIDER: Senate Majority Leader Harry Reid of Nevada made news early last week when he announced that the Senate bill would include a public option. But it wasn't what liberals had hoped for. Under Senator Reid's plan, states could opt out of a public plan. The opt out was seen as a bid for support from moderate Democrats. But Senator Reid defended his proposal.

Reid AX (15 seconds): "A public option can achieve the goal of bringing meaningful reform to our broken system. It will protect consumers, keep insurers honest, ensure competition and that's why we intend to include it in the bill that will be submitted, that will be submitted to the Senate."

SCHNEIDER: Over in the House, Democratic leaders moved swiftly toward a vote on their bill. It, too, includes a public option, but states cannot opt out. The public plan will compete alongside private health plans and co-ops. In a key win for hospitals and physicians, the bill would block the government from dictating payment rates. Instead, reimbursement will be negotiated. The fees cannot be lower than Medicare or higher than private plans' average rates.

NARR: Neither of the bills includes a permanent fix to the widely criticized Medicare physician pay formula-called the Sustainable Growth Rate, or SGR. The Senate already voted once against considering a separate fix. But House Democrats have stepped into the breach. They introduced a bill to jettison the SGR and recalculate Medicare physician pay with a new formula, starting in 2010.

NARR: But until the fee fix is approved, physicians are stuck with a 21% overall pay cut next year. Some face even deeper reductions. Alicia Ault has more.

AULT: There were no big surprises as Medicare issued its final payment rates late on Friday, only exasperation from some specialists. Primary care doctors are due to receive a 5-8% increase before the mandated SGR cut. But certain specialties will see reductions in addition to that cut. American College of Cardiology CEO Jack Lewin says his members are looking at an average 27% reduction in pay. He predicted that cardiologists will close up shop and move their practices to hospitals. And that will make it harder for patients to find a cardiologist when they need one.

NARR: The pressure is now on for Congress to meet two deadlines before the end of the year: avoiding the fee cut AND moving into the history books by passing health reform. And that's the Policy & Practice Podcast, I'm Todd Zwillich.