The Three Faces of Health Reform

May 6, 2011 - Health reform is suffering from a Dissociative Identity Disorder, better known as Multiple Personality Disorder. There are three health reform personalities at work, each with its own agenda and identity.

First is the physician identity and personality disorder, which calls for more autonomy and freedom to practice as it sees fit. As I write, hearings are being held in the House of Representatives about Medicare physician payment options. Representatives from the AMA, the Coalition of State and National Medical Societies, the American College of Surgeons, and the American Academy of Family Physicians are there. They argue that the Sustainable Growth Rate (SGR) formula, which calls for a 29.5% cut in Medicare doctor payments in 2012, has to be revised or repealed, or the nation will face a massive exodus of physicians from federal programs. The coalition backs a “doc fix” bill allowing doctors to privately contract with patients to charge patients more than Medicare pays for various services without penalties. It would also allow patients to apply Medicare benefits to physicians of their choice and allow physicians to opt out of Medicare on a per patient basis. This approach is known as “balanced billing.” It balances the interests of physicians and patients and allows both to escape the tentacles of Medicare.

Next is the government policy identity and personality disorder, which insists only it knows what is equitable and safe and what constitutes “quality.” Its leaders are Donald Berwick, MD, CMS administrator who may not be long in office, and HHS Secretary Kathleen Sebelius, JD, who together have just unveiled a “Partnership for Patients, “ a $1 billion project targeting hospital safety measures. Before he departs, Doctor Berwick wants to the world to judge his performance of the quality of his service, not the quantity of federal regulations, the growing size of the federal bureaucracy , or the magnitude of physician payment restrictions he has ushered in. The government personality has a superiority complex - a towering super-ego - that genuinely believes one-size-fits-all and it can impose heavy-handed concepts such as Accountable Care Organizations on providers and cut payments to hospitals, doctors, and medical suppliers through a government-appointed "Independent" Payment Advisory Commission- without stifling innovation and economic growth.

Finally, there is the split personality of the states. Some are moving ahead with implementation of the health reform law, others are asking for waivers, and still others, 26 in all, are challenging the constitutionality of the law, saying it infringes on individual freedoms, exceeds Congress’s enumerated powers, and coerces the states in violation of the Tenth Amendment. The state brief, now being argued in federal appeals court in Atlanta, challenges the law’s individual mandate and its vast expansion of Medicaid benefits, which the states say they cannot afford.

Bringing together these personalities to coherently express the mindset of the American people will not be easy. The people themselves are deeply divided on what needs to be done to avoid national and state bankruptcies of Medicaid and Medicare and to retain access to doctors.