Current status — House of Representatives

On July 14, 2009, health care reform legislation — H.R. 3200, “American’s Affordable Health Choices Act” (also known as, the TriCommittee bill) was introduced in the U.S. House of Representatives. Immediately following introduction, all three committees of jurisdiction — Ways and Means, Energy and Commerce, and Education and Labor began their mark ups. The Ways and Means Committee and the Education and Labor Committee both voted out a bill on July 17 with some differences as a result of amendments added during the mark-up process.

The Energy and Commerce Committee continued its deliberations on the bill on Monday, July 20. At least 10 Democrats on the full committee, including seven members of the fiscally conservative Blue Dog Coalition, have expressed deep concerns with key provisions of the bill, and said that they would not be able to support the legislation in its current form. Facing a continued opposition the chair of the Energy and Commerce Committee, Henry Waxman (D-CA), announced late Monday night there would be no health care reform markup Tuesday afternoon and left the committee in an indefinite recess. Committee leaders have been having conversations with members and are trying to work out some of the issues. The chairman said he remained hopeful that members will strike a deal on the legislation.

The “Blue Dog” Democrats have been unified in their mission to highlight the overspending in the bill. They met with President Obama on Tuesday to express their concerns. During the meeting a tentative agreement was reached between the Blue Dogs and the President to give an outside panel (such as the Medicare Payment Advisory Commission, also known as MedPAC) the power to reduce health care spending in the government-financed health care program. Rep. Waxman agreed to support this idea; he was previously opposed.

The Heart Rhythm Society is greatly concerned about this proposal. On July 2, the Society, along with the members of the Alliance of Specialty Medicine, wrote a letter to the House and the Senate leadership expressing deep reservatons regarding the expansion of MedPAC's role. The primary concern is that MedPAC has neither the clinical expertise nor the research capacity to examine the national and regional effects of proposed recommendations to ensure patients are not unduly impacted. Read the letter » (PDF, 144K)

Once the Energy and Commerce Committee completes its work, the three committee bills will need to be merged into one complete package for consideration by the full House of Representatives. The House hopes to complete work on the bill before the August recess, which for the House currently is scheduled to begin on August 3, 2009. The Blue Dogs’ actions may delay this goal until September.

Key provisions — House Legislation

A broad range of issues of concern to physicians are addressed in the House legislation. Among these issues are the following:

• The House legislation proposes a long term solution to the Medicare physician payment Sustainable Growth Rate (SGR) formula by rebasing, giving a one-year increase to physicians of 1 to 1.5 percent in 2010, and beginning in 2011 replacing the flawed formula, by creating two major “buckets” expenditure targets:
• • One for evaluation and management services (including office visits, primary care services, emergency services, consultation and home services), primary care and preventive services, which would increase based on the gross domestic product (GDP) +2 percentage points
  • All other services would increase based on the GDP + 1 percentage point.
    
• The plan includes additional bonus payments to primary care physicians that are not budget neutral, at the expense of specialty physicians.
  
• The plan includes a public plan health insurance option which will compete with private plans and that assumes all Medicare providers will participate, but with a provision to allow individual providers to opt out. In addition, for the first three years, the reimbursement rates are explicitly tied to Medicare reimbursement rates for similar services, and the Secretary of HHS is given the authority to set all rates for services not currently under Medicare.
  
• Several other issues are described in the letter sent by the Alliance of Specialty Medicine to the Tri-Committee leadership on July 8. Read the letter »

Additional Amendments
As evidenced by the recent activity by the Blue Dogs, there is quite a bit of unrest among many Democrats with the current health care reform proposal. Of particular note, several Democrats are expressing concern regarding the surtax on “high income individuals.” With the defeat of the amendment by Rep. Paul Ryan [R-WI] in the Ways and Means Committee (ensuring that no one under 250 percent of Federal poverty levels would have an increase in taxes), individuals are becoming concerned with what the next steps may be. In that same category of concern, within the Education and Labor Committee, Rep. Dennis Kucinich (D-OH) won a major victory for many Democrats with the adoption of his amendment by a vote of 27-19 to allow for a single-payer solution.

Several other key health-related amendments are expected within the Energy and Commerce Committee, including these of particular interest to the Heart Rhythm Society —

1. The comparative effectiveness amendment by physician Rep. Donna Christensen (D-VI) to replace the current comparative effectiveness research provisions with more provide-friendly provisions included the bill by Rep. Kurt Schrader (D-OR)
2. An amendment proposed by Rep. Mike Rogers (R-MI) to ensure that comparative effectiveness research is not used for coverage or reimbursement decisions failed by a party-line vote of 23-35 and
3. An amendment by Rep. Phil Gingrey (R-GA) to ensure that comparative effectiveness research would not be used to deny benefits on the basis of a beneficiary’s age, life expectancy, present or predicted disability, or expected quality of life was accepted by voice vote.
4. Rep. Jackie Speier (D-CA) recently introduced HR 2962, the Integrity in Medicare Advanced Diagnostic Imaging Act of 2009, which would close the in-office ancillary service exemption making it much more difficult for cardiology patients to have imaging procedures in their physician’s office. As a supporter of the Speier legislation and members who sit on the Energy and Commerce Committee, Rep. Anthony Weiner (D-NY) has decided to offer HR 2962 as an amendment.

These amendments are expected to come up this week, but as mentioned above, the committee schedule is in flux.

Industry Concerns: Several Proposals Lack Protections for Iinnovative devices

Among industry concerns are the expansion of pilot programs for accountable care organizations (ACOs) — where physicians and hospitals can form collaborative groups that would jointly receive financial incentives from Medicare to lower cost and improve outcomes in a designated group of patients. Another is the expansion beyond the current five hospitals of the “acute care episode” demos, where a single bundled payment is provided to hospitals and physicians for certain cardiac and orthopaedic procedures; as well as expansion of gainsharing allowances currently illegal under anti-kickback statures.

In addition, a proposed National Medical Device Registry is a concern, as well as comparative effectiveness provisions in the House bill that would not result in a transparent research process and could potentially allow a focus on cost comparisons.

Current Status — Senate

In the Senate, the Health, Education, Labor & Pensions (HELP) Committee voted out its health care reform bill by a party line vote on on July 15, and the Finance Committee members continue to deliberate regarding its potentially bipartisan proposal. The latest press reports suggest that they will not unveil their health care reform proposal until late next week, creating a time crunch for the Finance Committee to mark up its legislation before the August recess, which is currently scheduled for the Senate to begin August 10 (one week later than the House).

While the Finance Committee proposal has not been formally unveiled, members have indicated that their health care reform proposal will not include a long-term solution to the SGR formula. Rather, as with previous years, there will be a short-term patch with a modest update (approximately 1 percent). Further, any increases to primary care services likely will come at the expense of specialty care, given their focus on budget-neutral, low-cost provisions.

The Senate HELP bill (no Medicare jurisdiction) included a public plan option in which physicians are not required to participate, but the payment rates will be negotiated by the Secretary and cannot be more than the average reimbursement rates paid by health insurers offering plans through a Gateway providing “one-stop” health insurance shopping for consumers.

According to press reports, the Senate Finance Committee is leaning toward two alternative options: (1) a co-op plan or (2) a fallback option, in which a public plan would be triggered only if there was not enough competition. Unfortunately, to date, little is known about how these Finance Committee options would treat providers.

The Heart Rhythm Society’s Health Policy staff will continue to review the breaking news regarding health care reform and will provide detailed summaries to keep members informed.