Doctor in the House: an interview with author Congressman Michael Burgess, M.D.

When Dr. Michael Burgess gave up delivering babies in favor of kissing them, most physicians thought he was crazy.

After reliving the September 11th World Trade Center nightmare in his head for weeks, the successful obstetrician decided to run for Congress in his Republican district of North Texas against the well-funded and well-named son of then Majority Leader Dick Armey.

Not only did Burgess win, but he has quickly become the thought leader of American medicine in the United States Congress.

In his new best-selling book, Congressman Dr. Burgess retells the story of his first years in the House of Representatives where another nightmare unfolded: the Democratic creation of Obamacare.

His work is entitled Doctor In The House and it contains the prescription necessary to heal the ills of American health care.

In this blog we engage in a spirited discussion with Dr. Burgess. Let us know what you think.

Stark Contrast: How the Democrats are missing again on healthcare

Recently Pete Stark told a group that the Republicans were trying to shove a massive bill to repeal the Obamacare Bill down the throats of the Democrats.

The Republicans two-page bill stands in sharp contrast to the 2000-plus page bill pushed through by the Democrats last spring. So Mr. Stark, what's different now?

I had the pleasure of spending an hour with Congressman Stark last March right before the historic vote that changed the way healthcare is financed and delivered in this country. He was adamant at that time that he would never "support" the Senate version of the healthcare bill.

Well he did.

Now this isn't the first time or probably the last that a member of Congress has changed their mind.

But fundamentally the reason he voted for the bill as did most of the Democrats was political: legislation had to be passed regardless if it was good or not. Nancy Pelosi's health care chief told me in a meeting the same day that "we know its not a good bill but we can always fix it later."

The Republicans have taken the position that repeal is the best choice, followed by not funding key elements of the legislation, and probably hoping that the Supreme Court will rule that the Democrats overstepped their interpretation of the commerce clause. The latter is the ruse that allowed them to pass the bill in the first place.

So now the Democrats believe they have to defend the bill they created. And reforming the legislation would be tantamount to failure.

The American Medical Association adopted a recent slogan from their Texan brethren when they started preaching the "Keep what's good. Fix what's broken" mantra. But this lobby tactic would assume that either side would want to fix anything in the first place.

Neither the Democrats nor the Republicans are really motivated to reform the legislation. These polar opposite positions place American patients right in the middle of a stand off -- most likely to be killed by "friendly" fire.

Democrats are missing the boat here by not learning from prior mistakes and following the advice that we talked with Pete Stark about a year ago. Give patients some protections from preexisting illness and right of recision rules from the insurance companies and allow them to keep their doctor.

That's really what patients and taxpayers want.

And, tank the rest of the 2000 pages of the bill.

The 18 thousand new IRS agents, the Independent Medicare Advisory Panel, the criminalization of billing issues, the mandate on individual coverage, the expansion of a broken Medicaid system -- all of this needs to go away. None of it will improve the health of America.

But sadly it is doubtful that anything good will happen in Congress this term related to healthcare.

Yes, the House can refuse to fund key elements of the legislation...they can vote to repeal the bill. But the Democratically controlled Senate and the sitting President will not allow the bill go away.

In the meantime Washington bureaucrats will be turning out millions of pages of rules and regulations that will immortalize Obamacare for millions of patients.




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Conversation with a Health Care Leader: the past and future of health reform with Dr. Susan Rudd Bailey

Today we talked with Susan Rudd Bailey, MD who is the President of the nation's largest state medical society about the genesis of federal health reform and what she expects for the future.  This nationally known leader of the Texas Medical Association is candid in her discussion of the role that physicians and patients play in determining the ultimate outcome of the recent federal health regulation.  She also discusses the implications of the flawed funding mechanism for Medicare -- the so called "SGR".

Is Obamacare unconstitutional?

Is Obamacare unconstitutional?  That's the question we address today on docdano.com.  Darren Whitehurst and Dan Finch from the Texas Medical Association join us today to discuss the Virginia federal judge ruling that the health reform bill is unconstitutional.  What does it mean?  And what effect is it going to have on the upcoming session of Congress?

Is the government telling me if I can see my doctor?

Medicare was touted as the social entitlement program that would forever change health care access for our seniors.

But is it becoming the biggest challenge to seeing the doctor of your choice?

For the first time in the almost 50 years of the program more and more Medicare recipients are facing the challenge of finding a doctor who will take their government sponsored insurance.

Sure, there have recently been problems with the over 65 finding primary care physicians. But these PCP's can be hard for any insurance class of patient to find, though much harder for patients with plans that pay 40 percent of current market rates.

As you have seen from my recent blog posts, we are facing a rapidly approaching meltdown of our Medicare system. With no substantial reimbursement increases since 1997, an expanding older population, and medical costs that are outpacing the rate of growth of GDP, more and more physicians and other health care providers are exiting the market space.

But the current state of affairs is about more than money. A whole lot more.

You see money won't necessarily buy you access to your physician if you are a Medicare patient.

For most capitalist oriented folks this doesn't make sense. This land of milk and honey we call America was built on one's ability to buy anything -- including access. Whether it be to the halls of Congress or the waiting rooms of medical specialists, the rich (or even the middle class) in the United States have always been given the golden ticket for access if they could afford it.

But current Medicare rules don't allow for the normal business relationships that have built the rest of our economy.

This stems from the limited participating agreements that physicians are forced to agree with if they desire to see Medicare patients. And, for laws that restrict the payment of benefits to seniors if they see physicians that aren't a part of the Medicare program.

Physicians are really given only two choices if they want to get paid for seeing a Medicare patient. They can either agree to be "participating" where they are paid directly by the government for delivering care, or "non-participating" where they agree to see an over 65 patient but the payment is paid to the patient and the physician is then responsible for collecting the fee.

If a physician "opts out," that is, decides to not be a part of the program at all ("par" or "non-par"), then they can see a Medicare patient only if a complicated set of constantly renewed contracts are completed.

But here's the catch: the patient cannot receive any reimbursement from the government for the cost of the care.

That's right, as a Medicare patient you lose your benefits from the federal government entitlement program if you enter into a contract with a physician who is not part of the system. You won't even get reimbursed for what Medicare would have paid if the physician was a program provider.

Now honestly this has never been much of a problem: most physicians participated in the program and very few were "non-par", much less opted out. A big impediment to even testing the water of opting out has been the mandatory two year waiting period that physicians must survive before they are allowed to rejoin the system.

That was until the post-Obamacare age we live in now.

Funding the Medicare system has become laughable with a recurrent litany of temporary fixes that now provide only a month-to-month operating budget for the program.

It is this uncertainty combined with the decline in overall revenue that is driving physicians to opt out of the program and into the world of direct contracting.

Is it fair for the federal government to get a free ride on the backs of American seniors by no longer being responsible for providing health care dollars?

If you are an entitled Medicare recipient and you see a physician of your choosing who might not be a part of the system, why shouldn't you at least be able to get reimbursed for your out of pocket costs to the limits of the allowable Medicare charge?

So I guess the answer to the question is, that for now, the government is not "telling patients they can't see the doctor of their choice" but they are telling them that they aren't going to pay for it.

As we move forward into the Republican controlled Congress, and free market capitalism begins to rein supreme, we are almost certain to see challenges to the current status quo. Not only will patients begin to demand the right to see the physician of their choice, Republicans may see changes in the law as a way to limit growth of the program and curb the government's responsibility for cost increases.

Of course, with these rights patients risk a higher amount of out-of-pocket costs.

It's unclear if the political winds will blow to enhance the laws surrounding direct contracting -- loosening the restrictions on physicians from offering these deals and for patients electing to sign up -- but it is almost certain to be a part of the discussion very soon.

Follow this story as we chronicle the debate on www.docdano.com.


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Location:32,000 feet over Virginia, AA Flight 730

Should Medicare patients fear creeps

There has been considerable concern recently about the viability of physician's practices as they face a dramatic cut in reimbursement due to the need to slow the growth of health care spending.

No where is that more evident than with Medicare.

This last century era government administered health entitlement program now supplies medical coverage for a growing majority of American citizens. And the cost of this coverage is even exceeding its expected growth rate due to an ever aging and sicker population.

In typical bureaucratic fashion to legislate policy, Congress tied the cap on Medicare expenditures to the sustainable growth rate in an attempt to see that health care costs in the program did not exceed GDP (Gross Domestic Product).

This flawed calculation created in the Balanced Budget Act of 1997 has generally resulted in reimbursement rates to Medicare physicians that have not kept up with the real rate of medical inflation.

Yes, this last measure would have been a better metric to use in the calculation. But who knew in 1997.

Now we get to experience the implementation of this policy decades after the budget sensitive Congress of the 90's have mostly long gone. And the results aren't pretty.

Congress and physicians realized shortly after its passage that the SGR was a flawed system. Rather than solve the problem and change the way the Medicare system is funded, though, they have created temporary "fixes" virtually every year since its inception.

These "fixes" have only served to magnify and put off the eventual point where system implosion is expected to occur.

And that point may be here.

The latest physician hostage crisis of course occurred this year with an impending cut that threatened to throttle the rollout of Obamacare and the new federal health regulation. This fix expires on December 1st.

At that point physician reimbursement will be cut an arbitrary 23.6 percent with another 6.5 percent to follow on January 1.

So will the cut happen? (You can read my prior post: "Dear Santa: I want a Medicare fix")

But more importantly what will physicians do?

That is the question that is becoming more and more the topic of not only surgery lounges where physicians commiserate between cases but also the murmur outside the halls of medical meetings.

Certainly I've seen no organized conspiracy. But it is interesting that many physicians across the country are coming to the same conclusion: is it worth it to stay a part of the system.

Booklets and articles have been written about how physicians can leave the Medicare program. Even more concerning are the materials being produced for patients teaching them how to see non-Medicare participating physicians or even to form "direct contracts" with physicians so they can continue their care outside the system.

Historically and currently there doesn't appear to be a wholesale abandonment of Medicare participation. In my home state of Texas, unofficial numbers put the number of physicians that have resigned their Medicare number at less than 500.

But I don't see this as the real problem. I think more likely we are going to see something I like to call "creep."

Let me give you an example. Recently I was asked to provide some strategic review and planning for a practice in another state -- one with a large retired Medicare population. We prepared a detailed analysis of revenue and expense numbers as part of the consultation service, but the physician seemed to gravitate to one report more than the others.

It was a simple calculation that compared the payer mix of the practice based on the number of patient visits. The physician found that 59% of his office visits were Medicare, but that this group only provided 32% of his total revenue.

He became obsessed with the fact that most of his and his staffs work product was only generating a dwindling minority of his revenue. And without my well deserved consultant-paid-advice he reached his own conclusion that if he only made changes in his schedule and payer mix it could start to minimize his Medicare exposure, decrease his work schedule, and likely either see no change or a slight bump in his practice income.

That is the concern. Creep.

As physician practices get tired of the recurrent uncertainty about the future of Medicare payments, will they begin to find the solution may be to limit Medicare patients within their practice, that is to "creep" their schedules -- and not leave the system altogether?

This would have the effect of exaggerating an already access challenged Medicare population. And since we don't have good data on the clinic slots available to Medicare patients it will be difficult to measure the rate of creep until its too late.

Congress will take up the new fix soon, and conventional wisdom dictates that there will be another temporary solution to stabilize physician payments.

But will it satisfy a physician workforce that is tired of the recurrent stress of practice financial viability on an annual or now, even a monthly basis?

I guess we will get see it play out in the health care access of our Seniors.

Creepy.





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Location:Over El Paso, Texas courtesy of American Airlines

Dear Santa: I want a Medicare fix

Well it's that time of year again.

No, not Thanksgiving or Christmas, or even the venerable Interim Meeting of the AMA. It's the time that physicians nationwide anticipate another mandatory cut in Medicare reimbursement rates.

This time the recurrent temporary fix will result in a cut of 23.6 percent on December 1st. Assuming political gridlock the rate will fall another fraction of 6.5 percent on January 1.

History dictates that there will be lobbying, bluffing, puffing and even some "take my toys and go to my room" childish attitude but in the end Congress will create another "fix". In the past this has been to stabilize payment rates to a Victorian-era fee schedule (ok, 1997 or so) and set up an expiration schedule that again is measured in months.

But this year might be different. Or, at least it threatens to be.

American voters stampeded to the polls to vote out the status quo in favor of a new Republican House and a "lack of cloture" Democratically impotent Senate. Many of these new Republicans campaigned on the promise of fiscal responsibility (read: make the Bush tax cuts permanent and curb spending, including entitlement programs).

The Republicans have as a group pledged to cut $100 billion in January.

Now enter the AMA.

This association is again lobbying for a fix -- though now it is not the "permanent fix" but rather a tempered 13-month patch to give physicians at least a year to worry until the next SGR induced armageddon.

But will this new Congress support the AMA proposal? I don't think so.

Rumors abound to the cost of the AMA idea but it ranges between $17 billion to upwards of $20 billion. I'm certainly not an insider, but a new Republican congressman might find it challenging to explain to those tea party goers about why one of his first actions was to vote to support a double digit entitlement extension.

The other options are also mind stretching.

The lame duck Democratic controlled body could pass a 1 month extension and leave it up to the Republicans to spend the money in 2011. Or, they could use the pout strategy and just grind out the final month with the cut in place with Medicare physicians having to deal with a very arduous Christmas present.

So what will happen? It's anybody's guess but a likely outcome will be a compromise of sorts.

It would be fairly easy to disguise a three or four month fix as part of a January revenue bill to add some permanence to the Bush era tax cuts. This would of course create another type of March Madness, but it also would only cost a minuscule five or six billion. Chump change.

There is the issue of raising the debt ceiling that will have to survive a potential Senate filibuster by one of our new freshman Kentucky senators who will be calling for a balanced federal budget. This ophthalmologist turned tea drinker may not see eye to eye with adding more money to a spending bill -- even if it would be good for patients.

But no one said it would be easy.

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Location:37,000 feet over Arizona

Mortgage meltdown or medicine meltdown?

As we enter the final phases of the election cycle you can get a good idea of the spoils of big government just by looking at the rhetoric in the campaign.

Clearly, one issue is dominating the election this fall: the economy, and more specifically the lack of jobs.

So I would like to pose a few questions and ideas on just how government actually performs in creating economic growth and in kick starting job growth. I don't necessarily have the answers, but I'm real good at asking questions.

Did government assisted mortgages help the economy? Certainly by artificially lowering mortgage rates and the creation of investor owned, government back sub-prime mortgage equities, the federal system of assistance in home buying has become the norm.

But given the meltdown in the mortgage industry, did we do a service to Americans by putting people in homes they couldn't afford? Flipping houses became the source for a evening cable television show and the folly of many particularly young home buyers.

As liquidity in the mortgage market disappeared so did the dreams and savings of many Americans -- including those that had invested in the "government" back equities of Fannie Mae and Freddie Mac.

Is government funded healthcare going to be beneficial for our country in the long term? Just like mortgages, are we going to put our country into a health system they can't afford?

Out current federal health legislation creates "coverage" for 85% of our citizens, but does nothing to promote access to care or an improvement in health care choices.

The latter is particularly concerning.

Regardless of the life style choices one makes, there is a guarantee of coverage. There certainly needed to be an improvement in health care services for the uninsured, and there needed to be some limitations on the growth in spending, but wouldn't it have been better to put incentives on the user?

The real question becomes: will we be facing a health care meltdown just like the mortgage industry? As the requirements for health care services rise, there being no limitations on cost, and no impediments to limiting health care decisions, can the system continue to function?

The biggest concern here is whether physicians and other health care industry providers (pharmaceutical companies, insurance companies, hospitals) can continue to function in an economic environment of continued declining reimbursement for services.

This is especially true given the proposed 23%+ cut in Medicare rates next month with more to follow in January.

Will there be a decline in health care liquidity?

Physicians and other health care providers may find themselves in a situation much like the mortgage industry: servicing consumers with health care services they and the government really can't afford.

I guess the real question is will there be a foreclosure on your new sub-prime health coverage?



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Perry-Palin in 2012? Hillary Clinton in 2012?

As we enter the final weekend of this political season I thought I would take a few moments to suggest some possible scenarios for 2012 that will begin as soon as the last ballot is cast on Tuesday.

Here are some thoughts:

Perry-Palin 2012? Could this be the next Republican dream team? Before I get the laugh lines and hate mail let me make my point.

Both of these individuals have been or are Governors from large states with many similarities. Texas and Alaska have faired much better than their counterparts in the latest recession, have enjoyed a relatively friendly tax environment, have benefited from the increase in energy demand, and, lets face it, represent geographically about a third of the United States.

But more importantly both Rick and Sarah correctly identified early on the upswing of the Tea Party movement and latched on. I think this "movement", I don't really think it qualifies as a Party yet, has surprised almost everyone's expectations about its growth and popularity. I'm not sure where it will end up, but these two mavericks have been riding the wave into this election season.

Both have also been able to run as "non-incumbents". This has been easy for Palin (read: jobless), but despite the anti-incumbent rage sweeping the country, Perry has been able to be the outsider in the current Texas governor's race. He has successfully painted his opponent as being part of the "problem" by using his mediocre performance as Houston mayor as the whipping post.

Will I vote for this team? Not sure, but it will make for an interesting discussion as we move into next year and both are not running for President. Right.

Now think about this: Hillary Clinton the Democratic nominee? I know this sounds far fetched.

But think about it for a moment. Assuming President Obama is defeated in his bid for reelection, Hillary would face the risk of a four to eight year stint of being on the outside of a Republican administration. (And she would likely be too old to run at the end of an Obama second term.)

So what would happen (assuming the Democrats get trounced in the Congressional elections) if Clinton resigns her post as Secretary of State, moves back home, and now jobless -- turns into the Palin-type evangelist of change and returns to the Democratic principles that she campaigned on (and remember, almost won).

She could certainly make the argument that the wrong choice was made in selecting Obama and he has moved way outside the mandate for American that swept the D's into power.

If she could somehow manage to recreate the mid-term rehabilitated mode of her husband Bill during his first term (move slightly to the center, fiscal responsibility, make the country's problems those of the Republicans), she might offer hope to the Democratic Party.

Particularly if there isn't a valid Republican nominee (read #1).

Plus, what an exciting political season. We haven't had a sitting President with a primary challenge in a long time.

I know everyone just can't wait to start this circus all over again.


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Location:AA Flight 2324: somewhere over Illinois

My interview with Dr. Michael Burgess, Congressman from Texas, on some provisions of the new federal health plan