First Healthcare Reform Bill Leaves Many Unanswered Questions

It's here. After months of speculation and roundtables and public pledges, the first healthcare reform bill emerged this week from the Senate Health, Education, Labor and Pensions Commission, chaired by Senator Ted Kennedy. It certainly won't be the only bill, but it marks the beginning of what should be an interesting, and probably volatile, few months for the healthcare industry.

But for all of the answers in the 615-page draft of the "Affordable Health Choices Act," many questions remain, particularly for physicians. And the picture becomes less clear when other sources of healthcare reform legislation are considered.

It looks like all Americans will be required to have insurance and there will be greater oversight of the insurance industry, as well as more emphasis on primary care and prevention. But here's what we still don't know:

1. What will replace the Sustainable Growth Rate formula? Kennedy's legislation doesn't even mention the sustainable growth rate, but a memo released by the House Committees on Ways and Means, Energy and Commerce, and Education and Labor calls for replacing the "currently flawed" SGR formula that determines physician pay rates. Replace it with what, it doesn't say. That answer should come later in the process, but I have a feeling that will be one of the most difficult issues to resolve.

2. Will a public plan make it through? The Affordable Health Choices Act calls for new "insurance exchanges" to facilitate universal coverage, in part to avoid the controversy surrounding public plans. Republicans oppose a government-backed insurance plan, and perhaps more importantly, some conservative Democrats want it only as a last resort.

What about doctors? Conventional wisdom (and political pundits) says that physicians are opposed to another government payer, but I think opinions are fairly evenly-divided. Perhaps one of the biggest surprises in our HealthLeaders Media Industry Survey this year was that so many physicians supported some sort of universal coverage, in many cases even single-payer. The AMA has come out against a plan, in part because it could drive out private insurers.

3. Will primary care benefit at the expense of specialists? This is a question I've been exploring for months, and the early legislation doesn't clear up much. As expected, there is more money for training and rewarding primary care in Kennedy's bill. Normally, that would require specialists to take a hit, but we're obviously playing by new rules now. If the SGR formula goes out the window, then anything is possible.

4. What will happen to MedPAC? There is talk of making the Medicare Payment Advisory Commission part of the executive branch and giving it power to enact changes. This could be good or bad. If MedPAC had power in the past, Congress couldn't have blocked the physician reimbursement decreases that the committee recommends on an annual basis. On the other hand, it would have had the authority to tweak the payment system annually instead of waiting until sweeping changes were necessary to prevent a crisis.

There are, of course, many more issues that will be fiercely debated over the summer. This is just the beginning. President Obama wants to sign the final legislation by October, so we have nearly four months of wrangling and politicking before we find out any real answers to the big questions of the day.