Humpty Dumpty, Alice, and the SGR, Or, Waiting for The Dough

“When I use a word, “ Humpty Dumpty said in a rather scornful tone, “It means just what I choose it to mean- never more or less.”
“The question is, “ said Alice, “whether you can make words mean so many different things.”
“The question is,” Said Humpty Dumpty, “which is to be master – that’s all.”

Lewis Carroll (1832-1898), Through the Looking Glass

January 6, 2012 - On the current health reform scene, the Obama administration is Humpty Dumpty, vowing to turn the health system upside down, Alice is the status quo, the word is "SGR", and the question is which is to be the master – government or the markets – that’s all.

Right now an uneasy calm exists before the storm – how to pay doctors enough to keep them in practice – preoccupies Washington. The issue at hand, set to be solved in 2 months, is how to fix the Sustainable Growth Rate (SGR), which calls for a 27.5% cut in Medicare pay to doctors.

A doctor pay cut of that magnitude is unthinkable. The cut would cause as many as 50% of doctors, the exact figure is unknowable but it is large, to cease accepting new Medicare patients. One-third of Texas doctors already no longer accept new Medicare patients. Lack of access to doctors would inflame seniors who cannot or could not find a doctor. Seniors, of course, are the single most reliable voting bloc. Two-thirds oppose Obamacare. Not fixing the SGR would be equivalent to pouring gasoline on a smouldering political fire in a windstorm.

Thus the battle is joined – who is to be the boss - the Obama administration, which leans towards government control, or the Republicans, who favor market competition.

The Obama administration’s approach, if I may oversimplify, tends to be socialistic – doing away with fee-for-service, bundling bills in packages determined by government, herding doctors in government sponsored and subsidized accountable care organizations to “save” money in the names of efficiency and quality, controlling ultimate doctor pay through a government-run Independent Payment Advisory Commission, pre-auditing physicians suspected of overusing procedures, and in Massachusetts, contemplating whether to make acceptance of government –based patients a condition for practicing medicine.

Republicans counter by proposing open competition across state lines by health plans, introducing health savings accounts on a widespread scale, maintaining Medicare Advantage plans, voucher or premium support plans allowing patients to choose between traditional Medicare and private options, and allowing patients to privately contract outside of current Medicare boundaries.

In the end, this struggle boils down to who shall have the most political clout- those who tout the virtues of a more equitable distribution of government benefits and entitlements, or those who say the market is more efficient in distributing the more expansive benefits of a dynamic capitalistic society.

Both sides insist it is the principle, and not the money, that counts. Let’s not kid ourselves, given the looming mounting exploding $15 trillion national deficit, it’s the money. I’m reminded of the play, Waiting for Godot, in which the two protagonists are waiting for someone called Godot, who neither of them knows to arrive.

Under current circumstances, a more appropriate title might be Waiting for the Dough. To occupy their time, the two antagonists swap talking points, blame one another, play political games, anything to try to figure out how to pacify doctors, who may bolt out of Medicare, and seniors, who may punish them at the polls no matter what they do.

Tweet: In the next 2 months, Obama, Democrats, and GOP must decide how to pay doctors to keep them in practice seeing Medicare patients.