"Healthcare Guaranteed"--A Health Care "Solution" Offered Dr. Ezekiel Emanuel

I just received a copy of Dr. Ezekiel Emanuel's new book "Health Care Guaranteed."

I am anxious to get into it as Dr. Emmanuel's health plan has received considerable attention.

In the meantime, Maggie Mahar over at "Health Beat" has put together two posts on the plan, "A Fresh Look at Health Care Reform" you might find useful.

Dr. Emmanuel creates a voucher system enabling everyone to buy a private health insurance policy with the plan funded by a value added tax (VAT). It's a clean sheet approach to health care reform with all of the political advantages and disadvantages starting over would give us.

Maggie summarizes it this way:

If this all sounds too good to be true, you need to read Health Care, Guaranteed by Dr. Ezekiel Emanuel. Published this month, Health Care, Guaranteed offers a bold, refreshing plan for health care in America. The charm of the proposal is four-fold: It faces up to the fact that reform won’t pay for itself, and it offers a funding mechanism that is fair, efficient and could deliver high quality care nationwide. It regulates insurers, forcing them to concentrate on quality. Finally, and perhaps most importantly, this plan insulates our health care system from the lobbyists who, today, have far too much control over our health care system.

You can access both of her posts here and here.

AHP Announces a Health Care Reform Initiative and Tells All of the Other Stakeholders What They Ought to Do

I'd like to propose a new health care reform rule.

You can't announce health care reform proposals unless Part 1 of your plan first tells us just what it is your side is going to sacrifice for the effort.

I don't know about you, but I am getting tired of one vested interest after another in the health care system telling the others what it is they have to do to fix the system. Everyone has to sacrifice to fix the system and each side should start by outlining what it is they are throwing in the pot before they get to play.

Last December, the health insurance industry trade association, AHP announced its plan for ensuring everyone has access to a health insurance plan even if they have a preexisting condition:

Under this plan, states should establish Guarantee Access Plans to provide coverage for uninsured individuals with the highest expected medical costs. If an individual is not eligible for coverage through the Guarantee Access Plan, health plans would then provide coverage to that individual on a guarantee issue basis with premiums capped at one-and-one-half times the standard rate.

AHP's idea for making sure everyone has health insurance is to take the healthy ones and leave the sick to the states.

Today, they announced a cost containment plan. They talked a lot about what others need to do but I didn't see a lot aimed specifically at what insurers are willing to sacrifice to bring costs down.

Here are AHP's five principles from their "Proposal to Reduce Health Care Costs:"

• Principle #1: Patients and their doctors must have the information and tools they need to evaluate treatment options and make health care decisions on the basis of safety, quality and cost.

AHIP Proposal: Access to information that compares the effectiveness and cost of treatments: Give providers, patients and purchasers access to a trusted source where they can find up-to-date and objective information on which health care services are most effective and provide the best value.

• Principle #2: Patients and doctors want an efficient, interconnected health care delivery system that reduces medical errors.

AHIP Proposal: Health information technology: Encourage widespread adoption of tools such as electronic health records (EHRs), personal health records (PHRs), secure e-visits with physicians, and e-prescribing.

• Principle #3: Doctors and nurses need the freedom to practice medicine without worrying about frivolous lawsuits.

AHIP Proposal: Reforming the legal system: Replace the current medical liability system with a dispute resolution process consisting of an objective, independent administrative process to provide quick and fair resolution to disputes while promoting evidence-based medicine.

• Principle #4: Health insurance plans are transitioning to a system that more closely aligns payments with the quality of care patients receive.

AHIP Proposal: Build health care reform around quality improvement by rewarding safety, value and effectiveness: Work for the broader adoption of value-based reimbursement mechanisms and provide consumers with more actionable information about health care value.

• Principle #5: The nation must move towards a system of care that focuses on keeping people healthy, detects disease at the earliest possible stage and rewards chronic care management.

AHIP Proposal: Enhanced disease management, care coordination and prevention programs: Deploy a new generation of strategies that emphasize prevention, improve chronic care and tailor healthcare for patients to help them live longer and stay healthier.

There's nothing wrong with their five principals. They are, perhaps with the exception of legal reform, fairly non-controversial--at least til you get into the details. They are also incremental since much of this is going on in the market anyway.

AHP says that fully implemented our health care expenditures could be $145 billion less than they would have been in 2015 without these things. Since we're already over $2 trillion and likely headed to more than $3 trillion in the next seven years at this rate, that would be a savings of 3% to 5% of overall 2015 costs. Big money at one level but hardly a rounding error in the overall scheme of things.

It's hard to understand why AHP sees that kind of savings as a big deal. One has to believe a whole lot of bad things would already have happened to America's health care system--and maybe the private health insurance business--well before the $3 trillion mark.

And I don't think state run risk pools will help their cause a lot either.

It's going to take a lot more than this to fix the system and a lot more sacrifice.

Childhood Obesity--The Washington Post's Five Part Series on an Important Issue

Last week, the Washington Post gave us a five part series on childhood obesity.

It made the point, which has been made here a number of times, that for the first time in our history American children are on their way to a shorter life span than their parents.

This comes on the heels of a report last month that 20% of American women have already seen a decline in their life expectancy largely because of obesity and smoking.

The Post series made a number of important points:

• Obesity has tripled among children ages 6 to 11.
• The average weight for boys and girls age 10 is 11 pounds more than it was in 1963.
• Locally, almost a quarter of kids through age 17 in PG County MD, and more than third of kids in Loudoun County VA, are considered obese. In DC, 40% of kids are at least overweight.
• Type 2 Diabetes has increased tenfold among children and teens and gallbladder disease has tripled in children ages 6 to 17.

As I have also said many times before on this topic, we need an offensive against obesity of all ages. Being fat is a dumb thing to let yourself become and letting your kids get just as fat as you are is worse than dumb.

A Post editorial put it more diplomatically: "What is needed is a champion to turn these disparate actions against childhood obesity into a unified campaign...Without clear and focused leadership––the kind that turned smoking from chic to undesirable––rising obesity among America's youth and the health problems that go with it will worsen."

First Year Results in Massachusetts' Health Care Reform Undercut Barack Obama's Health Care Reform Strategy

The Massachusetts health care reform plan is coming up on its first anniversary.

Its costs are now officially out of control.

Those of you who regularly read this blog know that I have been particularly critical lately of what I see as a lack of sophistication in McCain's market-based health insurance proposals.

But with this news, Obama will have some big health care policy questions of his own to answer.

The 2006 Massachusetts Health Insurance Law is looking to be little more than an expensive expansion of Medicaid and that does not bode well for Barack Obama who has used the Massachusetts health reform law as the template for much of his own health care reform plan––as did all major Democratic candidates including Hillary Clinton.

The good news is that the plan, which began on July 1, 2007, has covered 340,000 people who were not insured a year ago––out of around 600,000 when the program started.

Almost all of those people have incomes below 300% of the federal poverty level and are eligible for full or substantial government subsidies to pay for their new health insurance.

The state has seen a gain of only 18,000 Massachusetts residents with incomes above 300% of the poverty level in the Commonwealth Choice plan. That's because it costs $7,000 - 12,000 a year for a family of four to buy the baseline health plan that includes a $2,000 single/$4,000 family deductible before most benefits are available. A family of four with an income of at least $61,000 (300% of the federal poverty level) would not qualify for a subsidy.

Commonwealth Care, the program covering uninsured workers under 300% of poverty, and available at little or no cost to residents, had 176,000 new enrollees as of May 1st and is projected to grow to 255,000 by July of next year--many more than the 136,000 that were estimated for the first year when the law was passed.

It is a good thing that there are 340,000 fewer uninsured in Massachusetts than there were a a year ago and Mass appears on its way to covering about 400,000 of the 600,000 that were uninsured when the program began.

But the Massachusetts Health Insurance Law is doing almost nothing for the middleclass because people can't afford the premiums––leading the state to also back-off on the individual mandate for these people. For example, almost all families would need an income of at least $110,000 a year in order for the mandate to apply to them.

So, Obama is right––you can't enforce an individual health insurance mandate if the coverage isn't affordable.

But that is about the only thing Senator Obama can be happy about when it comes to the state health reform plan that looks a lot like his plan for national reform.

With little or no cost containment in the program, the cost of Massachusetts Health Insurance Law really is out of control.

The cost for the program in its first year––July 1, 2007 to July 1, 2008––was first estimated to come in at $472 million when the bill was passed in 2006. However, that assumed there would be 136,000 low-income residents in Commonwealth Care. Instead, the state now projects that there will be 180,000 in the plan by the end of the fiscal year on June 30th driving first year costs up by 38% to $650 million.

When the law was passed in the spring of 2006, it was estimated that the second year’s costs––2008 to 2009––would increase to $725 million as the enrollment ramped up.

This past March, Governor Patrick provided an updated estimate of $869 million for next year––fiscal year 2008 to 2009––saying enrollment was higher than expected.

Just a month later, in April, the Governor revised that estimate upward by an additional $100 million to $969 million.

Now, in May, in a statement to bond rating agencies, the Governor has estimated that the fiscal year 2008-2009 costs will be more like $1.1 billion––a 50% increase over the original estimate from less than two years ago!

These costs may themselves be understated because health insurers are saying they are losing money on the program and are charging insufficient premiums that will ultimately have to rise. The Commonwealth Care insurers (100% to 300% of poverty) originally asked for a 15% increase for next year and settled at 10%.

The Commonwealth Choice insurers (over 300% of poverty and also available to small groups) are seeing a 10% trend rate and are being pressured to limit their increases to 5%--which they will do with more benefit reductions and cost sharing making these plans even more unaffordable for the benefits they provide.

It is clear that the Massachusetts Health Insurance Law is not sustainable for the state--and wouldn't be sustainable for the nation.

Until policymakers are ready to have a serious discussion about cost containment, health care reform is an unrealistic objective.

Prior posts on the Mass Health Care Plan from March 2007:
The Massachusetts Health Plan Will Turn Out to Be Little More Than a Fancy Expansion of Medicaid--Bids Come In At $250 Per Person Per Month

The Massachusets Health Plan's Inability to Offer Affordable Health Insurance Premiums Will Stall-Out Other State's Efforts in Health Reform

The CMS Website Comparing Hospital Performance Is a Good Step Forward

With much fanfare, Medicare (CMS) has stepped up the publicity for its website enabling consumers to compare their local hospitals' quality of care and cost data.

So, I went to it and put in the necessary info for my neighborhood. While a number of hospitals came up, I was able to create a side-by-side analysis for three choices. (I suggest you simply ask for all hospitals within a certain distance from your city and then select the three you want.)

When I asked about the hospitals' results for bypass surgery I got some very impressive information about key hospital and surgical health care process criteria as well as a patient satisfaction survey.

When I asked about the same hospitals' performance for diabetes, far less information came up--this is clearly a work in progress. What they did show was the average Medicare payment to the hospital for diabetes and the number of patients Medicare paid for in that hospital over a year. They also showed the results of a patient customer satisfaction survey on items from pain control to how quiet their room was.

Give the site a try--it's a very positive step forward!

While you're at it, don't forget the American Hospital Directory site that provides significant financial information--including profits--by hospital.

Administrative Costs and the Individual Health Insurance Platform for Health Care Reform

A new study by the "Center for American Progress Action Fund" says that Senator McCain's health reform plan based upon individually owned and controlled health insurance would increase administrative expenses by $20 billion.

The Center is an organization headed by former Clinton chief of staff, John Podesta. So, they clearly have an agenda.

But they also have a point.

As I have said many times before, an individual-based health care reform plan can work. But any such plan has to overcome the problems the individual health insurance market has today that include underwriting and expense ratio issues.

You can't just dump millions of Americans on the individual health insurance platform we have today.

It is true that Senator McCain would create a more efficient individual market by enabling insurers to sell across state lines and doing away with many benefit mandates. But the fundamental problem with individual health insurance is that it commonly has a 25% to 30% expense and profit margin--leaving 70% to 75% of premiums for medical costs. McCain's market improvements will make only a small dent on this expense level that is substantially higher than in the employer-based health insurance market that has an expense ratio that averages more like 12%.

But cutting lots of benefit mandates would dramatically reduce costs even further? Which benefit mandates? My experience is that when you take out the egregious benefit mandates what's left are the things most people would want in their policies anyway like regular mammogram screening or letting a new mother spend the night in the hospital. It's one thing to say these things would no longer be required and another to argue that eliminating them would cut insurance costs. You only cut costs if people wouldn't choose to buy them and would avoid the services.

It's interesting that when I am out in the country meeting with insurance execs in their conference rooms--people who do understand the market--it never fails that they all just roll their eyes at the lack of sophistication when we discuss McCain's market-based solution--specifically his individual health insurance product ideas.

McCain needs to address these very legitimate criticisms the likes of John Podesta and Elizabeth Edwards have made before this campaign goes into high gear.

Related posts:

John McCain's Health Care Plan and the Uninsurable--There Are Better Fixes Than the Ones He's Proposed

Elizabeth Edwards Criticizes John McCain's Health Plan--He Needs to Fill in Some Important Gaps

McCain's Lost Opportunity

Joe Paduda has a great post today over at "Managed Care Matters" on the McCain health plan.

Barack Obama is vulnerable over health care because his plan will cost a lot more than the $50 to $65 billion a year he has estimated--maybe twice as much.

McCain rightly points that out regularly on the campaign trail.

But what McCain and his advisers are missing is that his plan scares people in its own right--and it doesn't have to.

McCain wants voters to take this big leap away from employer-based health care and then does little to take the worry out of such a leap for those voters. Until he realizes that and tries a lot harder to make his plan one that works for people he's just scaring them. If he's scaring Joe Paduda, he will be scaring lots more people as the presidential finals heat up.

There are very good ways for McCain to make his market-based plan work a lot better for voters. For the life of me I don't understand why the McCain campaign has to make it so hard.

Related post:
John McCain's Health Care Plan and the Uninsurable--There Are Better Fixes Than the Ones He's Proposed

Senator Kennedy's Illness

News that Ted Kennedy is seriously ill sent shock waves through the capital and the country yesterday.

Many think of him as the "liberal lion"--and that is true.

Less well known outside the beltway are his incredible instincts and skills for "cutting a deal."

I know the notion of liberals and conservatives finding a way to come together drives some people on the far right and left nuts but it is in fact how we make progress in a real world where there will always be liberals and conservatives--neither will ever score that knockout blow some of them believe can happen at the next election.

I was in a Senator's office last week talking to him about a very important piece of new legislation on health care. I asked him where Kennedy was on it--a key to its being able to move forward. The response was that Kennedy was thinking about just where the deal would be.

That's Kennedy.

I have said before that health care reform will be very hard to do. Without Kennedy leading the way for conservatives and liberals finding the delicate balance, that will be so important, it will be even harder.

As David Broder pointed out this morning, it may be a McCain presidency that will need Kennedy the most for his skills at bringing together what would be a Democratic Congress and a Republican administration.

Everyone in this town has their Kennedy stories. My own favorite is a day some years ago when I was testifying before Senate HELP when he was chair. He had this elaborate introduction planned for me tied to how I was a former exec with a Mass company and a constituent. Of course he screwed up the pronunciation of my name--a constant Irish problem--and an extended interchange between he and Barbara Mikulski on correct pronunciation ensued. I will always appreciate that C-SPAN video tape.

Let's hope he continues to preside over that committee for many more years.

"Blendon, Laszewski, And Rovner On Health Care Reform In The Election"

Earlier this week I was part of conference call organized by the new Health Affairs editor-in-chief, Susan Dentzer, on the topic of health reform in the presidential election.

The call, and subsequent posting of the transcript by Chris Fleming on the Health Affairs blog, was in connection with the thematic issue of health reform in the May/June Health Affairs.

First, congratulations to Susan on taking over at Health Affairs. They couldn't be in better hands and this issue concentrating on health reform proves it.

My colleagues made a number of really good points.

Bob Blendon, the guy with his "finger on the pulse of the American public" from his perch as director of the Harvard Program on Public Opinion and Health and Social Policy:

• In the eyes of voters the health policy struggle between Clinton and Obama is not about the details but about who can follow through and get it done.
• The health care issue is going to be "bigger than people think."
• Comparing McCain to the Democrat over health care will be about "very big differences in values and beliefs."
• McCain has framed this in a way that people can make choices--Employer or individual?--Do you want something done about the uninsured or not?
• "The differences are so wide that it's going to be easier for people to be interested in the [health care] debate."

Julie Rovner, health policy correspondent from NPR:

• Health care is not wavering as an election-year issue but it is more integrated in the overall concern about the economy--don't write if off as a major issue.
• The idea that the Democrats can pay for their big health care plans by "simply letting the Bush tax cuts expire does not hold up."
• The Wyden-Bennett bill is "the stealth bill." The recent CBO scoring that found it likely to be revenue-neutral very early in its proposed implementation was very significant and the bill bears watching.

There is lots more good stuff in their comments and you can read the whole conversation here: Blendon, Laszewski, And Rovner On Health Reform In The 2008 Election

Against Obama, McCain Has a Lot of Ground To Make Up on Health Care

The latest Washington Post-ABC News poll on health care should give John McCain reason to be concerned.

The early May poll asked voters, "Regardless of whom you may support, whom do you trust more to handle health care?"

The answer was Obama by 55% and McCain by 31%.

And this poll was done a few days after his much-publicized week long health care tour.

McCain also did poorly on the other economic issues--although not as badly. On gas prices, it was Obama 48% and McCain 28%. On the economy generally it was 48% to 38%.

McCain did better on the war on terror––55% to 34%. The two were tied over who would do the best in Iraq.

It is still early and polls are notoriously unreliable this far out.

But my sense is that McCain has some big work to do on health care. He has the most far-reaching health care proposal because he proposes the most fundamental change in calling for an end on the reliance upon the employer-based health insurance system in favor of a plan that builds upon the individual. That is in many ways to his credit. But the best health insurance people now have comes through the employer-based system. This can only be a hard sell for him.

But he also has a health care plan with some very troubling gaps in it. The biggest having to do with how those with a low-income, those with pre-existing medical conditions, and older people will be able to access a health insurance plan.

So long as he has these glaring health care gaps McCain can expect to run far behind Obama in health care voter polls.

Recent McCain posts

An Analysis of Senator John McCain's Health Care Reform Plan

Watch the Wyden-Bennett "Healthy Americans Act"--It Could Be the Place Health Care Reform Compromise Takes Place in 2009

Health care reform will be hard to do after the November election. I've even called it a long-shot.

Polls clearly show the voters split evenly between the Democratic and Republican approach to health care reform. I can't tell you who will win the presidency but I am willing to make the bold statement that it will be a close election and neither very different approach to health care reform will enjoy any kind of mandate.

That will mean finding common ground between these very different approaches will be more than tricky.

But we may already have an outline.

Senator Ron Wyden (D-OR) and Senator Robert Bennett (R-UT) have crafted a health care reform plan that gives both sides the most important things each are looking for:

• For the Republicans, it gives them a plan that moves away from the third-party employer-based payment system to one of individual responsibility and the promise of a more vibrant market.
• For the Democrats, it provides a plan that assures everyone will have access to coverage and provides the financing to get about everyone covered in the short-term.

But here's the big one: Last week the Congressional Budget Office and the Joint Committee on Taxation said the Wyden-Bennett plan could be operational by 2012 and would be budget neutral by 2014! In health care terms, parting the Red Sea would be an easier accomplishment.

The key to the individual-based program's financing is an employer contribution. Employers would be required to pay a tax based upon a sliding scale of 3% to 26% of the cost of basic health insurance--tied to their size and revenue per employee. That would convert to a per worker tax of something like $250 to $2,000 for an employer. Employers who now contribute would be required to convert their contributions to higher wages during the first two years and pay the sliding scale tax later.

Under the Wyden-Bennett plan, people with an income of less than 400% of poverty would be eligible for subsidies, everyone would have access to guaranteed and community rated coverage, and the feds would oversee a system of private individual-based insurance and would collect the base-line premiums through the tax system.

In exchange for all of this consumer support, the Wyden-Bennett plan would also require individuals to have health insurance (an individual mandate) and that it must be purchased from a state-run purchasing pool that would require health policies have substantial benefits (rich benefit mandates) and offer a choice of private policies. There would be a flat personal tax deduction ($12,000 for a couple) for consumer insurance payments and low-income subsidies would be tied to the lowest cost policy available.

While employers could offer plans created especially for them by the state purchasing pools it is hard to see why they they would other than to comply with existing labor contracts that required benefits that did not fit the standard state pool offerings.

Those in SCHIP and Medicaid would be converted to this private system. The private insurance sector would clearly have lots more business as they picked up the uninsured and those in these public programs.

Just as there is something for everyone to like there is also something for everyone to dislike.

Conservatives still see too many benefit mandates, too little financial incentive for people to be better health care consumers, and too much federal regulatory control over how the private insurance market would work: See a critical view of the Wyden-Bennett "Healthy American's Act" from the Heritage Foundation.

Liberals, particularly the unions, will be concerned about moving away from the employer-based system. Liberals will also be concerned about continuing to base the system on private insurance--particularly the higher cost individual form and ceding SCHIP and Medicaid to private insurance companies.

Employers will be hard hit to pay for it. Those who provide health benefits today will have to convert their existing health support to wages and pay another tax on top of that.

I would also label the proposal "cost containment lite." It clearly emphasizes access over cost cost control.

It will also be easier to pass this bill since it doesn't directly take on any of the powerful health care special interests--insurers, drug companies, doctors, hospitals, or lawyers. However, the biggest losers would include insurance agents (out of business for health care), Medicaid and SCHIP program bureaucracies, and insurance company employees who do billing and eligibility work.

In exchange for all of the new business, insurers would be subject to a lot more regulation including minimum loss ratios and a complex bid process that could only narrow premium margins. This would likely be a business model not as kind to Wall Street.

But as a place for a country split right down the middle to come together and begin a health care reform process?

Watch this one.

The Wyden-Bennett "Healthy Americans Act"

There Won't Be Any Health Care Reform Without Physician Payment Reform and There Won't Be Any Physician Payment Reform Unless the Docs Lead The Way

Physicians are facing a 10% Medicare fee cut on July 1st, a total of 15% in cuts on January 1, 2009, a cumulative total of 20% on January 1, 2010, and more each year thereafter.

This spring the Senate Finance Committee is trying to solve the problem. In the short term, the idea is to reach out to future years, when they are betting the Congress would finally fundamentally reform the Medicare physician payment system, and pull those savings back to today in order to stave off the near term cuts. That idea has been referred to as "balloon financing."

In the wake of the subprime fiasco, how any U.S. Senators can come up with so thoroughly dumb an idea is beyond me. At the heart of my disbelief is their notion that the Congress is going to reform the Medicare physician fee schedule a year or two down the line. This problem has been accumulating for years and they have avoided facing it year after year--but don't worry they'll do it next year and be able to make this "balloon payment." And the Congress has refered to the "moral hazard" in subprime lending!

I am coming to the conclusion that it will have to be the docs that break the logjam in health care reform. Please don't misunderstand me, I do not mean to say it is the docs whose fault it is we can't agree on a way to fix the U.S health care system. But fixing physician fees problem may be necessary before any other reform can move forward.

The Medicare physician fee schedule problem has been festering for years. And, what Medicare pays is the basis for what physicians are paid in the private sector--what health plans pay physicians is commonly tied to a percentage of the Medicare fee schedule.

When the Congress created the Medicare Sustainable Growth Rate Formula it was their intention that physician Medicare costs would be controlled. The idea was simple: If doctor costs rise faster than an affordable level, we'll just cut their fees next year to compensate. The hope was that would create an incentive for docs to contain their costs and we wouldn't reward unaffordable Medicare cost trends. Any chance that idea would work, which wasn't much, went by the way when the Congress, year after year, said "never mind" and gave the powerful doctor lobby an increase anyway.

The problem now is that we're out of money. With the Democrats now requiring offsets to any new spending and Medicare about to welcome millions of baby boomers, something has to give in order to keep the docs happy.

About everyone agrees that the Medicare physician payment system is long overdue for an overhaul. So, Senate Finance Committee Chair Max Baucus (D-MT) is now saying we need to just fix the mess and stop dodging the issue--a couple of years from now.

One of the biggest problems in physician payment--first in Medicare and therefore de facto in the rest of the market-- is that the balance between primary and family care on the one end, and specialty care on the other, is out of balance. The primary care guys are hurting and we are on our way to a serious shortage there while the specialties are doing much better and all the new docs are heading for the better money.

The Congress is not going to impose a "solution" to the Medicare physician fee problem without the various medical specialties buying into it. The only thing all the docs can agree on right now is that none of them should get any kind of cut. Congress is afraid of the docs. The doctors have a great lobby--better than hospitals and insurers--and have a knack for manipulating the patient/voter lobby to their benefit.

The fix has to be bottom up--not top down. This physician fee problem is not going to be fixed until the docs--that is the various specialty groups--get together and figure it out. There isn't a lot of chance that will happen anytime soon either.

But until that happens, there will be no Congressional fix. The docs also know this. That is why it will be the docs that block the "balloon" idea. They know that is a slippery slide to an even bigger payment hole.

That is also why there will be big Medicare Advantage payment cuts in 2009. The docs truly need the money, they have the best lobby, the Congress is not going to fix the physician fee problem anytime soon and the "balloon" idea is full of hot air.

And, just as no Medicare physician fee fix is possible without physician payment reform, no big health reform plan can take place either. It isn't that it's the docs fault health care reform can't take place as much as it is they have to be the first of the tough hurdles we have to cross before it can happen. How can any budget scoring of a health reform plan take place without a sustainable physician fee structure?

So far the work between the medical specialties that has to occur hasn't even begun. The AMA itself is hamstrung by what amounts to a low intensity civil war within the ranks between the physician specialties over how to divide the loot.

It will take some key players from the various powerful physician specialties to see an imperative to settle this, and do it, before any real progress can be made.

The sooner the better.