[Congressional Record Volume 156, Number 6 (Wednesday, January 20, 2010)]
[Senate]
[Pages S36-S40]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 2009
Mr. COBURN. Mr. President, I ask unanimous consent that these letters
commenting on the Patient Protection and Affordable Care Act of 2009--
the majority's ``health reform bill''--be printed in the Record.
There being no objection, the material was ordered to be printed in
the Record, as follows:
Physician Organizations That Oppose Senate's Patient Protection and
Affordable Care Act
To date 43 state, county and national medical societies,
representing nearly one-half million physicians, have stated
their public opposition to the Senate healthcare overhaul
bill, the Patient Protection and Affordable Care Act (H.R.
3590).
National Medical Associations
American Academy of Cosmetic Surgery, American Academy of
Dermatology Association, American Academy of Facial Plastic
and Reconstructive Surgery, American Academy of
Otolaryngology Head and Neck Surgery, American Association of
Neurological Surgeons, American Association of Orthopaedic
Surgeons, American College of Obstetricians and
Gynecologists, American College of Osteopathic Surgeons,
American College of Surgeons, and American Osteopathic
Academy of Orthopaedics.
American Society for Metabolic & Bariatric Surgery,
American Society of Anesthesiologists, American Society of
Breast Surgeons, American Society of Cataract and Refractive
Surgery, American Society of Colon and Rectal Surgeons,
American Society of General Surgeons, American Society of
Plastic Surgeons, and American Urological Association.
Association of American Physicians and Surgeons, Coalition
of State Rheumatology Organizations, Congress of Neurological
Surgeons, Heart Rhythm Society, National Association of Spine
Specialists, Society for Vascular Surgeons, Society of
American Gastrointestinal and Endoscopic Surgeons, Society
for Cardiovascular Angiography and Interventions, and Society
of Gynecologic Oncologists.
State and County Medical Associations
Medical Association of the State of Alabama, Arizona
Osteopathic Medical Association, California Medical
Association, Medical Society of Delaware, Medical Society of
the District of Columbia, Florida Medical Association,
Medical Association of Georgia, and Kansas Medical
Association.
Louisiana State Medical Society, Missouri State Medical
Association, Nebraska Medical Association, Medical Society of
New Jersey, Ohio State Medical Association, South Carolina
Medical Association, Texas Medical Association, and
Westchester (NY) County Medical Society.
____
December 7, 2009.
Hon. Harry Reid,
Majority Leader, U.S. Senate,
Washington, DC.
Dear Senator Reid: The undersigned state and national
specialty medical societies are writing you on behalf of more
than 92,000 physicians in opposition to passage of the
``Patient Protection and Affordable Care Act'' (H.R. 3590)
and to urge you to draft a more targeted bill that will
reform the country's flawed system for financing healthcare,
while preserving the best healthcare in the world. While
continuance of the status quo is not acceptable, the shifting
to the federal government of so much control over medical
decisions is not justified. We are therefore united in our
resolve to achieve health system reform that empowers
patients and preserves the practice of medicine--without
creating a huge government bureaucracy.
H.R. 3590 creates a number of problematic provisions,
including:
The bill undermines the patient-physician relationship and
empowers the federal government with even greater authority.
Under the bill, 1) employers would be required to provide
health insurance or face financial penalties; 2) health
insurance packages with government prescribed benefits will
be mandatory; 3) doctors would be forced to participate in
the flawed Physician Quality Reporting Initiative (PQRI) or
face penalties for nonparticipation; and 4) physicians would
have to comply with extensive new reporting requirements
related to quality improvement, case management, care
coordination, chronic disease management, and use of health
information technology.
The bill is unsustainable from a financial standpoint. It
significantly expands Medicaid eligibility, shifting
healthcare costs to physicians who are paid below the cost of
delivering care and to the states that are already operating
under severe budget constraints. It also postpones the start
of subsidies for the uninsured long after the government
levies new user fees and new taxes to cover expanded coverage
and benefits. This ``back-loading'' of new spending makes the
long-term costs appear deceptively low.
The government run community health insurance option
eventually will lead to a single-payer, government run
healthcare system. Despite the state opt-out provision, the
community health insurance option contains the same
liabilities (i.e. government-run healthcare) as the public
option that was passed by the House of Representatives. Such
a system will ultimately limit patient choice and put the
government between the doctor and the patient, interfering
with patient care decisions.
Largely unchecked by Congress or the courts, the federal
government would have unprecedented authority to change the
Medicare program through the new Independent Medicare
Advisory Board and the new Center for Medicare & Medicaid
Innovation. Specifically, these entities could arbitrarily
reduce payments to physicians for valuable, life-saving care
for elderly patients, reducing treatment options in a
dramatic way.
The bill is devoid of real medical liability reform
measures that reduce costs in proven demonstrable ways.
Instead, it contains a ``Sense of the Senate'' encouraging
states to develop and test alternatives to the current civil
litigation system as a way of addressing the medical
liability problem. Given the fact that costs remain a
significant concern, Congress should enact reasonable
measures to reduce costs. The Congressional Budget Office
(CBO) recently confirmed that enacting a comprehensive set of
tort reforms will save the federal government $54 billion
over 10 years. These savings could help offset increased
health insurance premiums (which, according to the CBO, are
expected to increase under the bill) or other costs of the
bill.
The temporary one-year SGR ``patch'' to replace the 21.2
percent payment cut in 2010 with a 0.5 percent payment
increase fails to address the serious underlying problems
with the current Medicare physician payment system and
compounds the accumulated SGR debt, causing payment cuts of
nearly 25 percent in 2011. The CBO has confirmed that a
significant reduction in physicians' Medicare payments will
reduce beneficiaries' access to services.
The excise tax on elective cosmetic medical procedures in
the bill will not produce the revenue projected. Experience
at the state level has demonstrated that this is a failed
policy. In addition, this provision is arbitrary, difficult
to administer, unfairly puts the physician in the role of tax
collector, and raises serious patient confidentiality issues.
Physicians strongly oppose the use of provider taxes or fees
of any kind to fund healthcare programs or to finance health
system reform.
Our concerns about this legislation also extend to what is
not in the bill. The right to privately contract is a
touchstone of American freedom and liberty. Patients should
have the right to choose their doctor and enter into
agreements for the fees for those services without penalty.
Current Medicare patients are denied that right. By
guaranteeing all patients the right to privately contract
with their physicians, without penalty, patients will have
greater access to physicians and the government will have
budget certainty. Nothing in the Patient Protection and
Affordable Care Act addresses these fundamental tenets, which
we believe are essential components of real health system
reform.
Senator Reid, we are at a critical moment in history.
America's physicians deliver the best medical care in the
world, yet the systems that have been developed to finance
the delivery of that care to patients have failed. With
congressional action upon us, we are at a crossroads. One
path accepts as ``necessary'' a substantial increase in
federal government control over how medical care is delivered
and financed. We believe the better path is one that allows
patients and physicians to take a more direct role in their
healthcare decisions. By encouraging patients to own their
health insurance policies and by allowing them to freely
exercise their right to privately contract with the physician
of their choice, healthcare decisions will be made by
patients and physicians and not by the government or other
third party payers.
We urge you to slow down, take a step back, and change the
direction of current reform efforts so we get it right for
our patients and our profession. We have a prescription for
reform that will work for all Americans, and we are happy to
share these solutions with you to improve our nation's
healthcare system.
Thank you for considering our views.
Sincerely,
Medical Association of the State of Alabama,
Medical Society of Delaware,
Medical Society of the District of Columbia,
Florida Medical Association,
Medical Association of Georgia,
Kansas Medical Society,
Louisiana State Medical Society,
Missouri State Medical Association,
Nebraska Medical Association,
Medical Society of New Jersey,
South Carolina Medical Association,
American Academy of Cosmetic Surgery,
American Academy of Facial Plastic and Reconstructive
Surgery,
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American Association of Neurological Surgeons,
American Society of Breast Surgeons,
American Society of General Surgeons, and
Congress of Neurological Surgeons.
Past Presidents of the American Medical Association: Daniel
H. Johnson, Jr., MD, AMA President 1996-1997. Donald J.
Palmisano, MD, JD, FACS, AMA President 2003-2004. William G.
Plested, III, MD, FACS, AMA President 2006-2007.
____
December 1, 2009.
Hon. Harry Reid,
Majority Leader, U.S. Senate,
Washington, DC.
Dear Leader Reid: On behalf of the over 240,000 surgeons
and anesthesiologists we represent and the millions of
surgical patients we treat each year, the undersigned 19
organizations strongly support the need for national health
care reform and share the Senate's commitment to make
affordable quality health care more accessible to all
Americans. As you know, we have been working diligently and
in good faith with the Senate during the past year and have
provided input at various stages in the process of drafting
the Senate's health care reform bill. To this end, we have
reviewed the Patient Protection and Affordable Care Act of
2009.
As you may recall, on November 4 our coalition sent you a
letter outlining a number of serious concerns that needed to
be addressed to ensure that any final health care reform
package would be built on a solid foundation in the best
interest of our patients. Since those concerns have not been
adequately addressed, as detailed below, we must oppose the
legislation as currently written.
We oppose:
Establishment and proposed implementation of an Independent
Medicare Advisory Board whose recommendations could become
law without congressional action;
Mandatory participation in a seriously flawed Physician
Quality Reporting Initiative (PQRI) program with penalties
for non-participation;
Budget-neutral bonus payments to primary care physicians
and rural general surgeons;
Creation of a budget-neutral value-based payment modifier
which CMS does not have the capability to implement and
places the provision on an unrealistic and unachievable
timeline;
Requirement that physicians pay an application fee to cover
a background check for participation in Medicare despite
already being obligated to meet considerable requirements of
training, licensure, and board certification;
Relying solely on the limited recommendations of the United
States Preventive Services Task Force (USPSTF) in determining
a minimum coverage standard for preventive services and
associated cost-sharing protections;
The so-called ``non-discrimination in health care''
provision that would create patient confusion over greatly
differing levels of education, skills and training among
health care professionals while inappropriately interjecting
civil rights concepts into state scope of practice laws;
The absence of a permanent fix to Medicare's broken
physician payment system and any meaningful proven medical
liability reforms; and
The last-minute addition of the excise tax on elective
cosmetic medical procedures. This tax discriminates against
women and the middle class. Experience at the state level has
demonstrated that it is a failed policy which will not result
in the projected revenue. Furthermore, this provision is
arbitrary, difficult to administer, unfairly puts the
physician in the role of tax collector, and raises serious
patient confidentiality issues.
This bill goes a long way towards realizing the goal of
expanding health insurance coverage and takes important steps
to improve quality and explore innovative systems for health
care delivery. Despite serious concerns, there are several
provisions in the Patient Protection and Affordable Care Act
of 2009 that the surgical community supports, strongly
believes are in the best interest of the surgical patients,
and should be maintained in any final package. Specifically
these include: health insurance market reforms, including the
elimination of coverage denials based on preexisting medical
conditions and guaranteed availability and renewability of
health insurance coverage; strengthening patient access to
emergency and trauma care by ensuring the survival of trauma
centers, developing regionalized systems of care to optimize
patient outcomes, and improving emergency care for children;
well-designed clinical comparative effectiveness research,
conducted through an independent institute and not used for
determining medical necessity or making coverage and payment
decisions or recommendations; and the exclusion of ultrasound
from the increase in the utilization rate for calculating the
payment for imaging services.
Further, while redistribution of unused residency positions
to general surgery is a positive step in addressing the
predicted shortage in the surgical workforce, we believe that
the Senate should look more broadly at the issue of limits on
residency positions for all specialties that work in the
surgical setting that are also facing severe workforce
problems.
Finally, we are pleased that you have accepted our
suggestion and removed language which would reduce payments
to physicians who are found to have the highest utilization
of resources--without regard to the acuity of the patient's
physical condition or the complexity of the care being
provided. We thank you for making this important change.
While we must oppose the Patient Protection and Affordable
Care Act as currently written, the surgical coalition is
committed to the passage of meaningful and comprehensive
health care reform that is in the best interest of our
patients. We are committed to working with you to make
critical changes that are vital to ensuring that this
legislation is based on sound policy, and that it will have a
long-term positive impact on patient access to safe and
effective high-quality surgical care.
Sincerely,
American Academy of Facial Plastic and Reconstructive
Surgery, American Academy of Otolaryngology-Head and Neck
Surgery, American Association of Neurological Surgeons,
American Association of Orthopaedic Surgeons, American
College of Obstetricians and Gynecologists, American College
of Osteopathic Surgeons, American College of Surgeons,
American Osteopathic Academy of Orthopedics, American Society
of Anesthesiologists, American Society of Breast Surgeons,
American Society of Cataract and Refractive Surgery, American
Society of Colon and Rectal Surgeons, American Society for
Metabolic & Bariatric Surgery, American Society of Plastic
Surgeons, American Urological Association, Congress of
Neurological Surgeons, Society for Vascular Surgery, Society
of American Gastrointestinal and Endoscopic Surgeons, Society
of Gynecologic Oncologists.
____
Alliance of Specialty Medicine,
December 2, 2009.
Hon. Harry Reid,
Majority Leader, U.S. Senate, Washington, DC.
Dear Majority Leader Reid: As the Alliance of Specialty
Medicine (Alliance), our mission is to advocate for sound
federal health care policy that fosters patient access to the
highest quality specialty care and improves timely access to
high quality medical care for all Americans. As patient and
physician advocates, the Alliance believes that true health
reform should be enacted through a responsible and
transparent process. Over the past year, the Alliance has
provided substantive comments on those health reform
provisions that concern specialty physicians and patients in
their care. We are extremely concerned that your substitute
amendment, the ``Patient Protection and Affordable Care
Act,'' to H.R. 3590, fails to address our previously
mentioned concerns. Therefore, we oppose the substitute
amendment in its current form. We stand ready to work with
you to address the issues, outlined below, that continue to
concern us.
Physician Payment Update (Section 3101)
Medicare's sustainable growth rate (SGR) formula needs to
be replaced with a permanent, stable mechanism for updating
Medicare fees to continue to assure Medicare beneficiary
access to high quality care. Rather than come back year after
year, providing a short-term fix to this large problem, we
must stop utilizing band-aid solutions and establish a new
baseline for physician reimbursement. President Obama agreed
with that proposal when he sent this year's budget to the
Congress. The cost of interim updates to the physician fee
schedule should not be shifted to out years, making permanent
SGR reform even more difficult, and costly, to achieve.
Already, as a result of previous interim updates, physicians
currently face a 21% fee reduction beginning in January 2010.
Medicare physician payment rates already are below market
rates. Therefore, any long-term solution should, at the very
least, recognize reasonable inflationary cost increases.
Value-Based Physician Payment Modifier (Section 3007)
Rather than create a stable physician payment schedule,
Section 3007 would dramatically alter the current payment
system by adding a new, untested payment modifier that would
redistribute Medicare payments based on quality and
geographic cost variation, without a more systematic review
of the potential consequences. While the Center for Medicare
and Medicaid Services (CMS) has been testing various models
in this area, CMS does not have the current capability to
implement such a proposal and no valid methodology that
incorporates appropriate risk adjustment factors and outcome
measures even exists. Furthermore, there are many reasons for
geographic cost variation, including differences in
population demographics that merit significantly more study
before such a measure could be implemented. Therefore, rather
than add stability to the physician payment mechanism, the
proposal would create yet more instability with an
unrealistic and unachievable timeline.
CMS should be allowed to fully test models for value-based
payment and determine which system would achieve maximum
benefit before further modification of a flawed Medicare
physician payment formula. There is widespread agreement that
the current SGR process results in arbitrary and damaging
cuts to Medicare physician payment. We cannot achieve a
reliable or stable incentive for quality care by modifying
arbitrarily--and arbitrarily changing--reimbursement rates.
And because this new modifier in Section 3007 would be budget
neutral,
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some providers would face the dual blow of arbitrary SGR cuts
and neutrality-imposed value-based purchasing cuts.
Payment Cuts for Specialty Care (Section 5101)
While we understand the potential need to increase the
payment rates of primary care physicians, many surgical and
specialty medicine disciplines have faced significant cuts
over the years while primary care fees have increased. As
Medicare payments have continued their steady decline over
the past few years, reimbursement for primary care services
has actually increased. For example, CMS recently approved a
more than $4 billion increase in the fee schedule for primary
care services, as well as a 37 percent increase in one key
code used by primary care physicians. In its March 2009
report, MedPAC noted that Medicare payments for primary care
have increased 10.6 percent between 2006 and 2009. And these
changes will continue in the future. Indeed, under the 2010
Medicare Physician Fee Schedule, reimbursement for primary
care physicians will increase between 2-4 percent.
While primary care payments have been increasing, specialty
care payments have been decreasing. Since 1992, specialists
have seen significant reductions in the fees they receive for
procedural services. Although modest increases may have been
provided for physician services in recent years, they have
not kept up with the rate of inflation nor have all
physicians seen increases. In fact, many surgical services
were cut again in 2008 and a number of specialties are facing
additional cuts in 2010 as a result of changes CMS has made
in the fee schedule. Specialists continue to lose more ground
in the fees they receive for serving Medicare beneficiaries
while their practice costs continue to steadily rise. This is
particularly troubling because much of the funding for this
health care reform proposal already relies on cuts to
Medicare and to the physicians that provide those key
services. Additional cuts will likely result in decreased
patient access to critical health care services. With a
shortfall of 49,000 surgeons and other specialists predicted
by the year 2025, we can ill-afford to further exacerbate the
access to care problem.
Independent Medicare Advisory Board (Section 3403)
Congress should retain proper oversight of the process that
determines how services are provided under Medicare and not
relegate it to another entity. If the goal of a new Advisory
Board is to find new ways to eliminate spending in the
Medicare program, the end result may well be detrimental to
patient care for our nation's elderly. Already, Medicare
reimbursement rates are well below market rates for similar
services. And yet, the solution seems to be to further
ratchet down the costs, without oversight, without care to
ensure that our seniors receive the care that they deserve.
Further, the construct of the Board seems to selectively
exempt certain providers from its purview--placing more
pressure to cut Medicare in those areas under its
jurisdiction. There is no question we need to improve the
Medicare program to make it sustainable well into the future.
However, Medicare cannot be ``fixed'' when we do not look at
the whole program, but rather, chop it up and force program
savings into specific areas, such as provider reimbursement.
We certainly understand and appreciate concerns with the
rising costs of health care. But this is not the way to
approach this problem. Rather than develop a coherent
proposal to appropriately address the issue, the proposal
contained in the substitute amendment abdicates Congress'
fundamental responsibility and instead hopes that others can
develop additional solutions and then allows them to be
implemented. If we go forward with this process, there will
be myriad unintended consequences, including restricting
access to important interventions and services for Medicare
patients. You should not allow important health care
decisions to be made with little clinical expertise,
resources or oversight required to ensure that seniors are
not placed in jeopardy.
Medical Liability Reform (Section 6801)
We remain concerned that the current health care proposal
before us does not address our broken medical liability
system. Medical liability reform will help achieve health
system savings by reducing the incentives for defensive
medicine and it will also protect physicians from
unaffordable liability premiums. Last fall, President Obama
stated in the New England Journal of Medicine that he would
be ``open to additional measures to curb malpractice suits
and reduce the cost of malpractice insurance.'' Earlier
this year, at the American Medical Association's Annual
Meeting, the President also noted that we will not be able
to implement changes in our health care delivery system
that reflect best practices, incentivize excellence and
close cost disparities ``if doctors feel like they are
constantly looking over their shoulder for fear of
lawsuits.'' With a President that understands the need for
medical liability reform, we do not understand why your
proposal only includes a Sense of the Senate on the topic.
We would prefer a more comprehensive approach to this dire
problem, such as federal medical liability reform based on
the California or Texas models, which include, among other
things, reasonable limits on non-economic damages. As you are
aware the Congressional Budget Office recently scored
comprehensive and proven medical liability reforms, similar
to those above, as saving the federal government $54 billion
over the next decade. In addition to this savings, these
reforms will also improve patient access to specialty care,
particularly in rural and underserved areas. However, at the
very least, we should do something in this area, and there
are several bipartisan proposals which we should debate,
consider, and then include within a comprehensive health care
reform package.
Excise Tax on Certain Elective Medical Procedures (Section 9017)
Physicians strongly oppose taxes on distinctive physician
services to fund health care programs or to pay for health
care reform and we therefore are extremely concerned by the
last minute addition of the tax on elective cosmetic surgery
and medical procedures. This is a dangerous precedent to set
as it places physicians in the role of tax collector,
compromises patient safety by encouraging individuals to
circumvent the tax by seeking procedures from non-medical
personnel or providers in other countries, and jeopardizes
patient privacy by opening physician practices up to IRS
audits. Furthermore, once in place, we fear that this tax
could easily be expanded to other health care services. As
demonstrated by New Jersey's experience with a similar tax,
the application of such a tax is arbitrary and confusing to
administer.
Provisions Important to Maintain in Any Health Care Reform
We applaud many of the provisions in your substitute
amendment that improve access to health insurance and believe
a number of provisions must be included in any meaningful
health reform package to improve access to affordable health
insurance and assure access to specialty medicine. Those
provisions included in your substitute amendment that we
believe should be maintained include eliminating pre-existing
condition exclusions, providing adequate access to specialty
care through the benefit package, addressing rescission of
health coverage, ensuring continuity in Medicaid coverage for
children who go in and out of the system, and prohibiting
annual and lifetime coverage limits.
In addition, the Alliance is pleased that your legislation
includes a provision to expand comparative effectiveness
research (CER). Like you, the Alliance believes appropriately
designed CER conducted by an independent entity with full
participation of all relevant stakeholders should enhance
information about treatment options and outcomes for patients
and physicians, helping them to choose the care that best
meets the individual needs of the patient. CER needs to
recognize the diversity, including racial and ethnic
diversity, of patient populations and subpopulations and
communicate results in ways that reflect the differences in
individual patient needs. It should not be a vehicle for
making centralized coverage and payment decisions or
recommendations.
The Alliance also appreciates the elimination of a
provision which would automatically reduce payment rates by
5% for physician services if they are deemed ``outliers'',
regardless of patient acuity or other key factors.
Finally, we appreciate that you addressed our concerns
related to imaging services and clarified that the definition
of advanced imaging does not include ultrasound as it relates
to the increase in the utilization rate for imaging services.
Thank you for commitment and leadership on this issue.
Physicians are an integral part of the health care system and
are on the front lines of patient care. The Alliance hopes
you will work with us to improve the Senate health reform
package.
Sincerely,
American Association of Neurological Surgeons; American
Association of Orthopaedic Surgeons; American Society
of Cataract and Refractive Surgery; American Urological
Association; Coalition of State Rheumatology
Organizations; Congress of Neurological Surgeons; Heart
Rhythm Society; National Association of Spine
Specialists; Society for Cardiovascular Angiography and
Interventions.
____
American Academy of Dermatology and AAD Association,
Washington, DC, Nov. 20, 2009.
Hon. Harry Reid,
Majority Leader, U.S. Senate,
Washington, DC.
Hon. Max Baucus,
Chairman, Senate Finance Committee,
U.S. Senate, Washington, DC.
Hon. Tom Harkin,
Chairman, Senate HELP Committee,
U.S. Senate, Washington, DC.
Dear Leader Reid, Chairman Baucus, and Chairman Harkin: On
behalf of the American Academy of Dermatology Association
(AADA), which represents nearly 12,000 dermatologists and our
patients across the country, I am writing to state that we
are opposed to S. 3590, the Patient Protection and Affordable
Care Act (PPACA), in its current form. This legislation
simply contains too many flawed provisions and policies that
will harm vulnerable patient populations, undermine ongoing
quality improvement efforts, leave in place an unstable
physician payment system, and exacerbate physician workforce
shortages--jeopardizing access to quality health care.
We are extremely disappointed to have reached this
decision, because AADA fully supports meaningful and
comprehensive
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health system reform that achieves our shared goals of
improving the health care delivery system and providing
coverage for more Americans. We are serious about achieving
reform--after working closely with leadership on the House
side and finding that H.R. 3961 and H.R. 3962 comport with
most of our principles for reform, we indeed issued letters
supporting the key provisions of those bills. Early this
year, AADA readily embraced the Senate's offer to work as
constructive partners in finding the common ground that would
serve as the foundation of meaningful health system reform.
On several occasions, AADA submitted thoughtful, constructive
comments on numerous proposed reform components, and
subsequent legislative provisions, in an effort to work in a
collaborative fashion. However, PPACA has made it clear that
the majority of our input has been dismissed.
AADA is on record with the Senate in opposition to the
following key provisions:
The Independent Medicare Commission--This commission
removes public accountability and Congressional oversight of
Medicare payment policy. Even more troubling is the exemption
of hospitals from the Commission's jurisdiction, forcing
physicians to bear the costs of Medicare Part A
inefficiencies. It is unreasonable to expect that the cost
curve can be bent solely within the Medicare part B silo.
Misvalued Relative Value Units--This provision creates an
unnecessary, duplicative bureaucratic layer. CMS and the RUC
are already engaged in extensive efforts to review and
correct RVUs that no longer reflect practice realities, and
this existing process continues to bring about substantial
changes without the need for a duplicative and new panel.
Failure to Address Physician Payment--This legislation
seeks to ``transform the health care delivery system,'' which
would require physicians to make substantial changes in their
practices. However, the bill offers yet another short term
solution to a fundamentally flawed physician payment system.
Without a stable payment system, physicians will be unable to
make the long-term investments required to implement health
system reform and continue to modernize their practices. The
abject failure to recognize the need for real long- term
reform demonstrates a misunderstanding of physician practice
costs, including the employment of millions of Americans in
these small businesses, and will inhibit transformation in
the health care delivery system. We hope that the Senate will
follow the House's lead and pass a complete repeal of the
Sustainable Growth Rate formula.
While we are appreciative of changes made to the resource
use and PQRI provisions, that positive movement was negated
by the inclusion of new provisions in PPACA that have the
potential to harm patients and conflict with several of our
principles for reform.
Tax on Cosmetic Surgical and Medical Procedures--In an
effort to offset the cost of this legislation, PPACA would
impose a cosmetic procedure tax that disproportionately
affects women and the middle class. Furthermore, this tax
inserts the federal government into the physician-patient
relationship in a new way--specifically, the Internal Revenue
Service will become an arbiter of what is cosmetic and what
is medically necessary. Under the proposed language, an HIV-
infected patient with severe and stigmatizing lipoatrophy
(loss of facial fat) resulting from their antiviral
medications might be taxed for seeking to reduce their social
stigmatization and return their face to a normal shape.
Public Reporting--We have extensively participated in
quality measure development and supported incentives for
physician participation. However, several unresolved problems
still make public reporting of performance results premature.
Our ability to assess comparative quality from claims data
and to risk-adjust any measures to reflect different patient
populations is still in its infancy. Releasing performance
measures to the public before physicians have had the
opportunity to advance this science and build trust in a
system to properly account for variations in patient
populations has substantial risk. In particular, the
physician profiling that will result from such a premature
data release will discourage physicians from taking on the
sickest, most vulnerable patients and those with complex
medical and social conditions. This can only serve to
exacerbate health care disparities and create new barriers
to care for those patients who are most in need.
AADA has previously submitted comments related to
additional policies, including the value-based physician
payment modifier, the lack of any meaningful provision
related to the reform of our nation's unbalanced medical
liability system, and others in its prior communications.
Our nation's doctors and patients are in need of health
care system reform--reform that can happen if we work
together to create a system that embraces the principles of
quality care, efficient use of resources, and a patient-
centered approach to practicing medicine. We are deeply
disappointed to find ourselves with a Senate bill which fails
to address several of the concerns we have raised, and it is
regrettable that our efforts at collaborative dialogue have
not resulted in a bill that we can support.
We urge you to work with us to arrive at a legislative
proposal that is consistent with our specialty's principles
for health system reform--principles which are widely shared
by the physician community. AADA believes it is incumbent
upon every health care provider to commit to being
responsible stewards of the nation's health care resources.
The challenge is finding the balance between fiscal prudence,
delivering high quality care, and preserving the trusted
physician-patient relationship. Please feel free to contact
John Hedstrom ([email protected]) in the Academy's
Washington office at (202) 842-3555.
Sincerely,
David M. Pariser, MD, FAAD,
President.
Mr. COBURN. Mr. President. I ask unanimous consent to have printed in
the Record the following letter I sent to Mr. Alan Frumin,
Parliamentarian of the U.S. Senate, on January 8, 2010, regarding the
ruling that occurred in the Senate on December 16, 2009, during
consideration of the health care reform bill that permitted Senator
Sanders to unilaterally withdraw his amendment during its reading.
There being no objection, the material was ordered to be printed in
the Record, as follows:
U.S. Senate,
Washington, DC, January 8, 2010.
Alan Frumin,
Parliamentarian of the Senate, U.S. Senate, Washington, DC.
Dear Mr. Frumin: I write to express my dismay with the
situation that occurred in the Senate on Wednesday, December,
16th, 2009, regarding Sanders Amendment No. 2837.
Specifically, I refer to the ruling that permitted Senator
Sanders to unilaterally withdraw his amendment during its
reading. This ruling had immediate, untoward, and severe
ramifications for consideration of highly consequential
legislation.
After thorough research into the matter, I firmly believe
the Chair incorrectly applied Senate rules and precedents to
permit Senator Sanders to withdraw the amendment. In doing
so, the Chair cited a 1992 circumstance in which Senator
Adams was allowed to withdraw an amendment during its
reading, without unanimous consent. While this particular
precedent has generated a significant amount of controversy
in its own right, in this case it has only served to distract
from the central issue at hand: even if the 1992 procedure
were a proper precedent, it cannot be used to justify the
withdrawal of the Sanders amendment.
Unlike the situation in 1992, consideration of Senator
Sanders' amendment was governed by a unanimous consent order.
The order not only sequenced the amendment but provided that
no further amendments could be proposed to the Sanders
amendment. In calling up his amendment, Senator Sanders
expressly stated that he was doing so pursuant to the order.
A 1971 precedent reflects well-established Senate practice:
``when the Senate is operating under a unanimous consent
agreement or setting time for debate of a specific amendment
that is action by the Senate on said amendment and
subsequently it would take unanimous consent to withdraw the
same.'' If this practice had been followed, Senator Sanders
would not have been able to withdraw the amendment as a
matter of right. Instead, he needed to propound a unanimous
consent request, which he did not. Be assured, consent would
not have been granted.
Following the ruling on December 16, your office justified
Senator Sanders' unilateral withdrawal of his amendment, even
in the face of the order, by claiming that the restrictions
under a UC agreement for withdrawing an amendment are not
imposed until after an amendment is pending. And you assert
that the Sanders amendment could not be considered pending
until the reading had been completed. I cannot find a basis
for this explanation in Senate rules or precedents.
The assertion that the Sanders amendment was somehow not
pending is illogical. A well-established practice, as
expressed in a 1943 precedent, states ``the amendment must be
before the Senate to be withdrawn.'' Thus, for the Sanders
amendment to be withdrawn, it had to have been pending. If
the amendment were not pending, and thus not subject to the
order, it should not have been in order to withdraw it.
A 1979 precedent definitively demonstrates when an
amendment must be considered pending. On December 10, 1979,
Senator Roth of Delaware offered a second degree amendment to
an amendment from Senator Stevens of Alaska. Objection was
entered to dispensing with the reading of the Roth amendment.
Upon a parliamentary inquiry during the reading, the Chair
twice affirmatively stated that the amendment being read was
the ``pending amendment'' and the ``pending order of
business.''
Specifically, the Chair expressed the following: ``The
Chair would advise that the amendment offered by the Senator
from Delaware is the pending order of business. A unanimous
consent request that the reading of the amendment be
dispensed with was objected to. Therefore, the amendment is
in the process of being read and now will be read.''
One can clearly draw two inferences from this ruling that
demonstrate once an amendment is offered, it is pending:
1. If the amendment were not pending, the Chair would have
stated that the order of business would be the reading of the
amendment, not the amendment itself. Instead, the Chair
stated that the pending order of business was the amendment,
which was being read.
[[Page S40]]
2. Furthermore, if the Roth amendment were not yet pending,
the Chair would have stated the pending amendment was the
underlying Stevens amendment. However, the Chair announced
that the pending amendment was the Roth amendment.
Based on this precedent, which is directly on point and
controlling, I believe it is conclusive that the Sanders
amendment was, in fact, pending, thereby triggering the
limitations imposed by a consent order. Because an order
applied, ``action'' had been taken on the amendment.
Therefore, Senator Sanders should have needed unanimous
consent to withdraw his amendment.
If the amendment had been fully read, its disposition would
have carried over until the next calendar day. That is what
should have happened if Senate procedures were properly
applied. Senators from both parties vividly understand that
the Parliamentarian's advice in this matter may have been
greatly consequential for the consideration of health care
legislation.
Finally, it is disturbing to know that the only entities
privy to the operative considerations underlying the ruling
were your office and the majority party. Senator Cardin, who
presided at the time of the ruling, submitted into the Record
on December 21, 2009 a statement that mentioned the 1992 and
1950 precedents, supplied by your office, to attempt to
justify his ruling.
Unfortunately, at the time of the ruling, I had no way of
knowing about the 1992 Adams precedent since it occurred
after the latest edition of Riddick's Senate Procedure was
published. Furthermore, the 1950 precedent was inaccurately
depicted in Riddick's, with the text of Riddick's
contradicting the actual precedent cited. Had all the
precedents been commonly available in a reliable and updated
form, Senators could have had a basis to challenge the
Sanders ruling in real time. By the time the dust had settled
after the ruling, as Senators struggled to parse what had
happened, such a challenge was long moot. In any event,
neither of these precedents arose in the context of a consent
order. I therefore believe the precedents were off-point and
inapplicable.
You are a man of integrity, are a dedicated public servant,
and hold the rules and precedents of the Senate in high
regard. However, I believe this ruling was incorrect, and
that it had a major adverse impact on a monumental piece of
legislation.
Sincerely,
Tom A. Coburn, M.D.,
U.S. Senator.
____________________