If you're anything like me, you did not go into medicine because you had an interest in politics. Like most of us, I suspect your interest in politics is relegated to the time you have left over after you've attended to every other priority in your life. Physicians are scientists; we compile information, examine symptoms, determine diagnoses and use the best evidence-based outcomes information to direct treatment. Politics is anything but scientific. The very nature of politics runs counter to what appeals to us in medicine.
The reality, though, is that physicians' lack of political awareness, preparedness and activity has led us directly to the state of crisis health care is in today. As an example, the recent 5.4% across-the-board Medicare physician reimbursement decrease was an affront to all doctors who already sacrifice up to 30 cents on each dollar spent to treat Medicare patients [1]. During the last 2 years, individual doctors and such medical associations as the North American Spine Society (NASS) reached out to the leaders in Congress to alert lawmakers to the unintended but certain result of this fee cut: our nation's elderly would be denied access to the high-quality health care they need and deserve because doctors were being forced away from the Medicare program in an effort to simply stay in business. When Bill Thomas (R), chair of the House Ways and Means Committee, sat down to tackle the Medicare reimbursement issue, he called on the American Hospital Association (AHA) to assist him in his efforts. Once he and the representatives of the AHA had developed a solution, Mr. Thomas contacted the American Medical Association (AMA) to alert the group to the results. The AMA—viewed as the House of Medicine in the United States—was informed of the outcome, rather than invited to assist in creating the outcome. In other words, unlike hospitals, physicians did not have a seat at the table when the subject was physician reimbursement.
How did we find ourselves being excluded from these critical discussions and decisions? To answer this, we need to take a brief look at how Congress came to control physician reimbursement.
In 1966, in an effort to standardize the description of physician services and to develop a method for compiling actuarial data, the AMA developed and published a list of descriptive terms and associated numerical codes for reporting medical services called the Current Procedural Terminology (CPT). One of the intended applications of CPT was to facilitate communication between physicians and payers. HCFA (now the Centers for Medicare and Medicaid Services) adopted CPT as part of its Common Procedure Coding System in 1983.
In the mid 1980s health-care costs skyrocketed, capturing the attention of both third-party payers and government. As hospitals accounted for more than two-thirds of expenditures, efforts to contain Medicare costs, and the federal government's initial concerted effort to dictate reimbursement levels, first focused on hospital costs that are covered under Medicare Part A expenditures. A diagnosis-related group payment was developed for approximately 500 diseases based on the national average cost for each particular illness. Because the payment to hospitals was capped based on this average, the hospitals had tremendous incentive to improve cost-efficiency, and the annual growth of Medicare expenditures was reduced by more than half between 1975 and 1990.
The government grew increasingly dissatisfied with the existing physician payment and the disparity in reimbursement among different geographical regions. And an alternative method of physician payment emerged for growing Part B expenditures. The new method was a resource-based relative value system (RBRVS). Antitrust concerns precluded direct physician involvement in the development of the RBRVS system and led the AMA to hire the Harvard University School of Public Health to perform a national study of resource-based relative value scales for physician services. On July 1, 1986, Congress passed the Consolidated Omnibus Budget Reconciliation Act, which mandated that the Department of Health and Human Services (which oversees CMS) develop an RBRVS to be submitted to Congress. (Reconciliation bills are special legislative vehicles that cannot be amended or filibustered. Congress often uses the reconciliation process to make major budgetary decisions that can adversely affect various private interest groups.) In December 1989, Congress enacted another Omnibus Budget Reconciliation Act (OBRA 89), which mandated a Medicare payment schedule based on RBRVS from the Harvard study and included geographically adjusted physician work, practice expense and professional liability. The new payment schedule is updated with an annual conversion factor designed to limit annual increases in expenditures to $20 million. RVRBS has been linked to all AMA CPT codes.
Although balancing the national budget is indeed a worthy goal, the congressional mandate to use the RBRVS system for physician reimbursement essentially crammed the proverbial 8 pounds into a 5-pound bag, forcing physicians to accept payment for services based on the cost of providing care that in some cases does not cover the actual cost of providing care. The budget was initially balanced on the backs of doctors who absorbed the increasing losses from treating Medicare patients. However, most private insurers now follow Medicare's lead on which procedures are reimbursable and at what level. As a result, the federal government has replaced usual and customary fees with something that looks a lot like price fixing for health-care costs, driving reimbursement from all payers down perilously close to falling below the cost of providing care.
The federal government has not stopped with its involvement in cutting reimbursements for physicians. Its long arm has reached out into many other areas as well. As an example, the Department of Health and Human Services' Office of Civil Rights recently enacted a rule that requires any medical practice that takes “federal financial assistance” (eg, any physician who takes even a single Medicaid payment) to pay for the services of a language translator on demand for any patient with “limited English proficiency.” The federal government's intent was to do the right thing, but achieving that goal needs more than an arbitrary, one-dimensional response to the problem. With recent headlines in papers across the United States reading, “Uninsured Americans on the Rise,” you can be certain that the government will continue to attempt to remedy the ills of the country's health-care delivery programs with more and more legislation. You can also be certain that if we are not a part of the process, if we continue to remain inactive and simply hope that the government will treat health-care providers fairly, we will face one crisis after another. If we fail to act now, we will have only ourselves to blame.
How can we become a part of the process? How can we guarantee our seat at the table when the discussion is physician work and patient care? To begin, we first must recognize ourselves—health-care providers—as the only viable guardians of health care. The hospitals and the drug companies are not going to serve in this role alone. The device manufacturers likely will not serve in this role alone. The Congress is a “sharp elbows” arena where every interest group must fight to get its share of the federal budget. It is up to us to ensure that we will always be able to deliver the best medical care possible by being properly reimbursed for our services.
Clearly, it is imperative to become politically active; we have seen where inactivity has led us. We must work together to reverse much of the damage that has been done and emerge as a key voice in any health-care debate. Recently, a former US representative informed me that there is only one rule in politics: there are no rules. Although there is no specific path with clearly numbered steps that leads to certain victory, there are some proven methods for engaging the decision makers and enhancing physicians' position in the health-care policy debate.
The first step is to identify a single issue to address. NASS members were already struggling to care for Medicare patients before the January 2002 fee cuts. After the January 2002 fee cuts, 49% of NASS members indicated that they had to reduce the number of Medicare patients in their practices because of low reimbursement [2] (up from 26% before the cut [3]). With more cuts expected over the next few years, Medicare reimbursement must be the number one issue for NASS's legislative advocacy efforts in the 108th Congress.
What is the best way to make our elected officials aware of the looming Medicare patient access-to-care crisis? It is actually quite simple. We need to tell them. We need to tell them in a way that lets them see how their increasingly lower physician reimbursements directly affect their constituents.
NASS has recognized the need to communicate with Congress and responded by creating a lobbying organization, the National Association of Spine Specialists (NASS6). NASS6 is actively pursuing meetings with influential policymakers to inform them of the spine care perspective on national legislation. But action needs to be taken at the grassroots level as well.
Many US representatives host town hall meetings. Find out when your congressperson's next town hall meeting is (NASS6 can help you do this, if necessary) and plan to speak up about the issue at the meeting. Ask your colleagues (whether or not they are NASS members) to do the same at other town hall meetings so that the reimbursement issue is raised at each one. If you have patients who can articulate the problems they are facing, invite them to have their concerns heard at a town hall meeting. If the reimbursement issue is repeatedly raised, your elected official is more likely to go back to his or her staff and ask them to research the issue.
After the town hall meeting, approach your elected official and ask him or her if you could meet in the local office sometime soon to discuss further the many implications and unintended consequences of the fee cut. Most elected officials welcome the opportunity to speak to constituents. NASS6 will provide you with all the information and supporting documentation you will need in order to feel confident in this meeting, including the well thought out responses to the arguments of those who stand in opposition to physicians on the reimbursement issue.
Once you are in that meeting, you can let your representative know that you are part of a larger organization, and ask if a NASS6 representative could have a few minutes with him or her in the congressperson's Washington, DC, office in the very near future. Let NASS6 know about your meeting, and one of our lobbyists will contact your representative to advance the discussion.
There are other ways to get the attention of your elected officials and begin to build the relationships necessary for gaining a seat at the table. Gather several physicians from your area and invite your representative for a reception or dinner, indicating that the group has collected some money for his or her campaign fund. Bring those checks to the event. This is an easy way to introduce our legislative issue to your local decision maker. It is also a great way to position yourself as a resource to this person as he or she weighs the costs and benefits of health-care policy.
Moreover, all NASS6 members must support SpinePAC. SpinePAC is the fund through which the NASS6 supports federal candidates who champion legislation that benefits spine care patients. Although the PAC in SpinePAC stands for “political action committee,” SpinePAC is a fund. Contributions to SpinePAC are used to support the campaigns of candidates for the US Senate and the US House of Representatives who are sympathetic to the needs of our patients. SpinePAC is “connected” to the National Association of Spine Specialists; therefore, only NASS6 members can contribute to SpinePAC. It is up to us to fund this effort. NASS6 members can contribute $5,000 in personal funds per year in a 2-year election cycle to SpinePAC. Of course, we'll take less, but everyone should contribute a minimum of $250 a year.
SpinePAC serves a critical role in the process of shaping the outcome of important legislation, especially in light of the recent campaign finance reforms. Money that comes from PACs is considered “hard money” because it is fully regulated and tracked by the Federal Election Commission and is subjected to specific limitations and restrictions. This “hard money” will become even more important in future election cycles.
In the last election cycle, the National Association of Realtors' PAC was ranked by the Center for Responsive Politics as number one in contributions to federal candidates with $3.4 million in “hard” contributions. The realtors gave millions more in “soft” money donations. In second place, according to the Center, was the Association of Trial Lawyers of America, which gave $2.7 million in “hard” dollars. Going down the Center's list, one had to look all the way down to tenth place to find the American Medical Association (AMA), which contributed $2 million during the 2000 election cycle.
Although the AMA is supposed to represent the interests of all doctors, on many occasions the AMA's interests and those of specialty medical practices, such as ours, have diverged. Furthermore, the AMA has sometimes been a less-than-effective player in the world of politics. Therefore, if spine care professionals are to be able to have a seat at the table in the legislative process and make certain the interests of our members are fully heard, we must fund our own PAC. To date, we have placed only our big toe in the water. During the 2000 election cycle, SpinePAC contributed only $30,000. To put this in some perspective, even the nurse anesthetists contributed $200,000. With the 108th Congress scheduled to begin in January, it will take a minimum of $100,000 in SpinePAC to be able to help shape the outcome of Medicare reimbursement legislation, the issue that directly affects our ability to care for patients and continue to practice medicine.
NASS6 has developed a strategy for distributing SpinePAC funds in a manner that will have maximum impact. Whereas many organizations give most of their funds to the chairs of congressional committees, NASS6 plans to support many mid-level or junior members of these important committees. NASS believes this approach will pay better dividends. Generous SpinePAC contributions to the campaign funds of these mid-level and junior members of the committees will help ensure that they will make our issues a high priority, bring our issues to the table and fight for what is best for spine care professionals and their patients. To carry out this strategy, we have to have sufficient resources. To date, we are far short of what we need.
Another step toward success in legislative advocacy is to multiply oneself. If the 3,395 members of NASS can have some impact on shaping legislation through grassroots activities and support of SpinePAC, imagine how much more impact 165,000 physicians working together to achieve the same aims would have. To that end, NASS has partnered with the Alliance of Medical Societies to amplify our voice and message in the halls of Congress. The 14 medical specialty societies comprising the Alliance are working collaboratively to make changes that will benefit all of specialty medicine.
Lastly, NASS sends urgent action alerts on an as-needed basis to address time-sensitive legislative issues. Be prepared to respond to urgent action alert faxes or e-mails for either NASS or the Alliance of Medical Societies. NASS makes it easy for you to reach out to your local elected official and respond to an urgent action alert by providing a letter on the NASS web site that you can modify and send directly to your elected officials.
Through this multipronged approach, NASS's influence in the legislative arena will grow substantially. The success of these efforts, however, is dependent on NASS membership. The grassroots efforts, where each of us reaches out to our elected officials and builds a personal relationship, are the key to winning this game. NASS has built the necessary infrastructure through NASS6 and SpinePAC. Outside counsel has been retained to make our case. The rest is up to us. Spine care providers need to get off of the sideline and into the game of politics. Our patients and the future of spine care depend on it.
Tom Faciszewski, MD
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