Message from the CEO

Major Healthcare Reform on the Agenda
for the United States in 2009

David Julian Martin, CAE
CEO/Executive Vice-President
Society of Critical Care Medicine

As the New Year gets underway, U.S. members of the Society of Critical Care Medicine (SCCM) are becoming keenly attuned to the new political landscape. It appears that 2009 may bring the first meaningful attempt at comprehensive healthcare reform in many years. The Obama Administration, along with lawmakers in the House and Senate, is floating various ideas for healthcare reform, and SCCM is looking closely at which of these proposals may emerge as tangible legislation. One of the most prominent proposals is coming from Sen. Max Baucus, D-Mont., chairman of the Senate Finance Committee, who oversees issues related to Medicare and Medicaid. In November, the senator released an outline of his comprehensive vision, Call to Action: Health Reform 2009. Presented as a white paper rather than a legislative proposal, the Call to Action aims to stimulate debate and offers insight into the issues facing the healthcare system and possible solutions. The Society has not endorsed this or any proposal, but it will continue to stay abreast of these developments in their formative stage, as they certainly will affect members, the healthcare community and patients, if implemented.

Baucus has put together what he deems a “blueprint for action” to address, among other things, the less-thanoptimal quality and value that he believes exists in the current healthcare delivery and payment system as well as rapidly rising healthcare costs and the increasing number of uninsured Americans. The plan envisions a U.S. healthcare system that is sharply competitive and more efficient, delivering better quality and value to patients. The proposal highlights value-based initiatives such as pay for performance and comparative effectiveness research (CER) as well as other initiatives, suggesting the start of a solid effort to move away from a “volume-based” system to one that is “value-based.” CER examines and assesses similar treatments or device protocols and compares their value (in terms of patient care and outcomes) against more costly protocols or treatments.

In addition to discussions with congressional leaders, former Senator Thomas Daschle (President Barack Obama’s appointee for Secretary of Health and Human Services) has reached out to the various stakeholder groups, such as the American Medical Association (AMA) and SCCM, to understand their priorities for health system reform. Daschle is looking to implement healthcare reform from the “grass roots up” and has said that he wants to get input from ordinary Americans on “what's broken about the healthcare system.” The Obama Administration seems poised to tackle far-reaching system reform head-on. It has given Daschle a mandate to overhaul the U.S. healthcare system and even created a new Office of Health Reform, which Daschle will lead. At his formal nomination in Chicago, Illinois, Daschle stressed the job ahead was urgent, saying “growing costs are unsustainable, and the plight of the uninsured is unconscionable.”

Establishing Alternative Payment Systems
Recognizing a flawed formula that inappropriately and inexplicitly links the sustainable growth rate to Medicare physician payments, most current plans circulating to fix the system support the development and implementation of alternative payment methodologies. Alternatives being considered include the “medical home model” – the bundling of services and payments – and the implementation of incentive programs such as pay for performance and gain-sharing. The stated goal of these two latter models is to lower healthcare costs while improving quality. While gainsharing (methods of aligning the fiscal and clinical motivation of hospitals and physicians) is being considered as a viable alternative by the Centers for Medicare and Medicaid Services (CMS), some legal and regulatory challenges may need to be addressed before they can be implemented. Alternatively, the medical home model, which provides patients with a coordinated and comprehensive approach to primary care, may be more likely to gain wide support. Not only have the principles of the medical home model been adopted by the AMA House of Delegates, but they also align with Baucus’ efforts to create a payment system that highlights primary care, prevention, wellness and chronic care management. The medical home model emphasizes payment for the coordination of care and more appropriately reimburses for care management. The specifics related to healthcare provider payments across all specialties are still unclear. Importantly however, the model’s emphasis on primary care, prevention, wellness and chronic care management may bring relief to overcrowded emergency rooms, which often become the first line of healthcare for the uninsured, namely elderly and low-income populations.