Take Doctors Off the 'Fee-for-Service Treadmill,' Senator Says

WASHINGTON -- Doctors need to be taken off the "fee-for-service treadmill" so they can give patients better care, Sen. Sheldon Whitehouse (D-R.I.) said Wednesday at a hearing held by the Senate Finance Committee on the role of federal programs in the U.S. health insurance system.

"Once you free up the doctors from having to march to the fee-for-service treadmill, we give them the ability to adapt the way they treat patients to a 'patient-first' way of dealing with the patients, and you then open up this arena in which three things happen at once: patients are happier and healthier, costs go down, and everybody wins," Whitehouse said. He was referring to the idea of having doctors join accountable care organizations, in which clinicians are financially rewarded based on the quality of care they deliver. In addition, "I would note that ... nobody's against accountable care organizations; they're across the states, they are doing really well, and we can make a lot of progress," he said.

Democrats and Republicans on the committee each had different points they wanted to highlight during the hearing. Democrats focused more on what needed to be added to improve Medicare and Medicaid. "We Democrats believe deeply in updating the Medicare guarantee, because we know that seniors need dental care, vision, and hearing assistance," said Finance Committee chair Sen. Ron Wyden (D-Ore.), referring to a proposal to add those benefits in one of two infrastructure bills now being debated in Congress. "It's unthinkable that these gaps in Medicare coverage are allowed to persist. Similarly, we're working on a plan that lets seniors and people with disabilities get the care they need in place where they're most comfortable: at home."

Sen. Mike Crapo (R-Idaho), the committee's ranking member, criticized Democrats' proposals to allow Medicare to negotiate prescription drug prices, also included in the infrastructure bill. "The proposed drug price controls, imposed under the guise of negotiation, pose a threat to our global leadership in biomedical innovation," Crapo said. "A recent University of Chicago study found that the price-fixing policies included in the bill would slash research and development funding by up to 60%, reduce the number of new drugs approved in the next 20 years by as many as 342, and trigger a loss of life as much as 20 times what the COVID 19 pandemic has inflicted on our nation."

Crapo did, however, give a nod to bipartisanship. "I stand ready and eager to work with the administration and members of both parties to pursue policies that improve healthcare outcomes, expand access to life-saving drugs and devices, and drive costs down for both the consumer and the taxpayer," he said. "From telehealth expansion to outcomes-based payment arrangements, there are endless opportunities for us to come together on common ground and meet the needs of the American people."

Committee members disagreed on whether proposals to add Medicare benefits like dental, vision, and hearing care would hurt the program financially. "None of the plans I've talked about will reduce the solvency of Medicare's Hospital Insurance Trust Fund at all -- not one bit," Wyden said. "Those benefits will have different sources of funding; they will not be part of Medicare Part A, which is what the trust fund covers."

Sen. Bill Cassidy, MD (R-La.) disagreed. "Medicare is going bankrupt in 2026, and we have a bunch of people who want to expand coverage to Medicare, which will further strain its finances, so that those who are on it are less likely to get it," he said. If the program does go insolvent that year, "by law it will only pay the providers that [money] which it is currently receiving, which will result in roughly a 25% decrease in what they shall receive. That will be a crisis of access."

Witnesses at the hearing also presented different concerns. "Even recognizing the successes, significant gaps remain in the health insurance system," said Linda Blumberg, PhD, a fellow at the Urban Institute, a left-leaning think tank here. "More than 3 million people living below the poverty line and 1.2 million near-poor people are uninsured and ineligible for any financial assistance because they live in states that have not expanded Medicaid eligibility," said Blumberg, who was speaking for herself. And without the temporary increase Congress passed for subsidies in the Affordable Care Act's insurance marketplaces, "my colleagues estimate [that] the number of uninsured nationally would reach 30 million in 2022."

When the pandemic's public health emergency ends, so will the requirement that states keep people enrolled in Medicaid, she noted, adding that the Urban Institute estimates indicate that Medicaid enrollment could decrease by as many as 15 million people next year. "A permanent enhanced premium tax credit should encourage more people to move from Medicaid to the marketplace," said Blumberg. "Further aggressive outreach and enrollment efforts at the state and federal levels, in addition to streamlining Medicaid re-determination and enrollment processes" are among the options that should be considered.

Douglas Holtz-Eakin, PhD, president of the American Action Forum, a right-leaning organization, urged lawmakers to focus on improvements to government programs. "For the past 15 years I think the coverage discussion has dominated the thinking about government programs, and I would like to urge you to shift the focus somewhat, to make sure that those programs deliver high-value care," he said. With Medicare Advantage plans being seen as a success story, "a system of competition among Medicaid managed care organizations as a foundation for the future of Medicaid would offer the same promises," he said.

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